2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder!

Full text

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2014 E&M Oncology

Documentation & Coding

Basics

Working Smarter, Not Harder!

West Virginia Oncology Society

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This presentation is offered as an educational tool. E&M Consulting Inc. does not bear any responsibility or liability for the results or consequences of using the tools

found in this presentation. This presentation was current as of the date presented; nevertheless, we encourage

readers to review the specific laws, regulations and rulings for up-to-date detailed information. Providers are

responsible for the correct submission of claims and response to any remittance advice in accordance with

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Off-Label Use Disclosure(s)

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Financial Disclosure(s)

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 New Patient Codes  99201: 0.26%  99202: 1.12%  99203: 7.91%  99204: 31.61%  99205: 59.10%

 Initial Hospital Visit

 99221: 8.09%  99222: 29.99%  99223: 61.91%  Return Visits  99211: 2.92%  99212: 3.52%  99213: 31.60%  99214: 49.48%  99215: 12.47%

 Subsequent Care Visits

 99231: 16.29%  99232: 51.41%  99233: 32.30%

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Topics

 The E&M Philosophy  History

 HPI  ROS  PMFSH

 Physical Exam: 95 vs. 97

 Medical Decision Making Documentation  Time

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Consult/New Patient: Count all 3 COLUMNS

Return Visit:

2 out of 3 COLUMNS Subsequent Care Visit:

2 out of 3 COLUMNS History Level: 3 out of 3 BOXES

Medical Decision Making: 2 out of 3 BOXES

History Physical Exam Med Decision Making

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E & M Key Components

History

 Physical

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History (Hx)

 Chief Complaint (CC)

 History of Present Illness (HPI)  Review of Systems (ROS)

 Past Medical, Family and/or

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Chief Complaint

 Must Be In Documentation or Service

Code Does Not Exist (cannot bill)

 Diagnosis IS NOT a chief complaint

“Follow-Up for…” or

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History of Present Illness

Cover Each:  Location  Quality  Severity  Duration  Timing  Context  Modifying Factors  Associated Signs & Symptoms

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Review of Systems

 Systems

 Constitutional  Eyes

 Ears, Nose, Mouth,

Throat  Cardiovascular  Respiratory  Gastrointestinal  Allergic/Immunologic  Genitourinary  Musculoskeletal  Integumentary  Neurological  Psychiatric  Endocrine  Hematological/ Lymphatic

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Review of Systems

“For the remaining systems, a

notation indicating all other systems

are negative is permissible. In the

absence of such a notation, at least

ten systems must be individually

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PFSH

 Family History

 Patient Medical &/Or Surgical History

 Social History

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Family History

“Non-contributory”

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History

Capturing Information

 Collect From Any Source

 Patient information form

 Update Old History (ROS/PFSH only)

 Review history

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E & M Key Components

 History

Physical

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Single System Exam

General Multi-System

 1995 Exam  1997 Exam

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1995 or 1997 Guidelines

“CMS has made clear that we cannot replace content found in the 1995 Documentation

Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for

Evaluation and Management Services. During the review process, WPS Medicare will continue to

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Comprehensive (Level 5/3 Admit): 8 systems Detailed (Level 3): 5-7 systems

Expanded Problem Focused (Level 2):

2-4 systems

Problem Focused (Level 1): 1 system

*Return Visit:

Only what is medically necessary

Physical

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Documentation of Physical Exam

 “the use of examination templates/checklists

is acceptable documentation.”

 “A notation of "abnormal" without elaboration

is insufficient.”

 “A brief statement or notation indicating

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Consult/New Patient: Count all 3 COLUMNS

Return Visit:

2 out of 3 COLUMNS Subsequent Care Visit:

2 out of 3 COLUMNS History Level: 3 out of 3 BOXES

Medical Decision Making: 2 out of 3 BOXES

4

10

3/2

8

History Physical Exam Med Decision Making

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E & M Key Components

 History  Physical

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Medical Decision Making

 Diagnosis

 Data

 Risk

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Medical Decision Making:

Diagnosis

Hospital Level Office Level Total Points

Minimum 1 2 0-1 Limited 1 3 2 Multiple 2 4 3 Extensive 3 5 4 A B X C = D

Diagnosis Number Point Value Result

Self-limiting or minor problem (2 max) 1 Established problem, stable or improving 1 Established problem, worsening 2 New problem, no additional workup (1 max) 3 New problem, with additional workup 4

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Medical Decision Making:

Data

Hospital Level Office Level Total Points

Minimum 1 2 0-1 Limited 1 3 2 Multiple 2 4 3 Extensive 3 5 4 A B X C = D Categories # Points

Review (max 1)/Order clinical lab tests (per puncture) Bloodwork 1 Review (max 1)/Order radiology tests [X-ray, imaging (except echocardiography &

cardiac cath)] Reports 1

Review(max 1)/Order medical tests (EEG, echocardiography, cardiac cath., non-invasive

vascular studies, psychological tests, endoscopy) Reports 1

Independent visualization of image, tracing, or specimen interpreted by another

physician 2

Discussion of test results with performing physician 1 Decision to obtain old records and/or history from someone other than patient. 1 Review & summarize old records 2 Obtain history from someone other than patient. 2 Extensive discussion with another physician or outside provider 2 Personal involvement of physician in testing (i.e. Bone Marrow Biopsy) 2

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Key Medical Decision Making

Documentation Required

NUMBER OF PROBLEMS/DIAGNOSIS

 Document all primary AND secondary problems

being addressed by you and status of each.  DATA

 All Tests Reviewed  All Tests Ordered

 All Discussions w/ Other Physicians

 All Tests Requiring Physician Personal

Involvement (Bone Marrow Biopsy)

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Medical Decision Making

Table of Risk

Risk Columns

 Presenting Problem

 Diagnostic Procedure(s) Ordered

 Management Options Selected

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Risk Level

Level of

Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected

2 Insect Bite Bloodwork Rest Chest x-rays Gargle

3 1 Stable Disease Barium Enema Hydration Therapy

4 2+ Stable Diseases Bone Marrow Biopsy Prescription Drug

Lump In Breast Thoracentesis Radiation Therapy

5

Disease w/ Major Progression

Cardiovascular imaging studies w/ contrast w/

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Time

 Documentation Requirements

 Total time of visit (determines level)  More than 50% of visit spent

counseling/coordinating care

 Content of discussion

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Time

 How to determine the level

 Established Office Visit (total time)

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Same Day Visit/Chemo

 Chemo/Visit on Same Day (-25 modifier)

 Georgia Cancer Specialists (Atlanta)

 $4.1 million settlement (False Claims Act)

 Chief Complaint

 “Here for chemo” vs. “Here for reevaluation & chemo”

 Chief Complaint drives what you can bill

 Visit note pertains to chemo, not disease.

 Data

 Medicare Manual: Chapter 12, Section 30.5,

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James Leach, MBS

E&M Consulting Inc. 810-560-2512

jhleach@eandmconsulting.com

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