Rational Physician Coding for Emergency Department E/M Services and Critical Care

Full text

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Peter R. Jensen, MD, CPC

For clinically driven E/M coding education, go to www.EMuniversity.com

Rational Physician Coding

for Emergency E/M

Services

ER E/M Coding

ƒ

E/M = Evaluation and Management

ƒ

How patient encounters are translated into 5

digit numbers to facilitate billing

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Goals

ƒ

Learn the documentation requirements

for ED E/M services and critical care

ƒ

Ensure compliance

ƒ

Streamline the documentation process

ƒ

Identify the highest ethical level of care

ƒ

Maintain the focus on patient care

ER E/M Documentation

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

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E/M = Cognitive Labor

=

The E/M Guidelines

ƒ

Developed by the AMA and CMS

ƒ

First set released in 1995

ƒ

Second set released in 1997

ƒ

Based on three “Key Components”

– History

– Physical Exam

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History

Physical

Problem Focused

Expanded Problem Focused Detailed Comprehensive

MDM

Straightforward Low Complexity Moderate Complexity High Complexity

History

Physical

MDM

We think of the key components as being random, but they’re really not……

This is how auditors look at the E/M guidelines. They view the history, MDM

History Physical

Straightforward Problem Focused

Expanded Problem Focused Detailed

Comprehensive

Problem Focused Expanded Problem Focused

Detailed Comprehensive

Low Complexity Moderate Complexity

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Physical Physical ROS HPI PMH FH SH Exam Bullets Organ Systems Diagnoses Data Reviewed Risk

Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on

over-documentation or getting distracted from our real job of taking care of patients.

Rational Physician Coding

2

Target

E/M Code

MD M Physical History

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Rational Physician Coding is a simple three step process:

1. Calculate the medical decision-making

2. Identify the target code

3. Perform and document the required elements of history/exam

MDM Target E/M Code History Physical Exam Step 1 Step 2 Step 3 The E/M Documentation Guidelines Risk Data Problems

Primacy of Medical Decision-Making

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Medical Necessity

“Correct” Level of Care

=

The Importance of Medical Necessity

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Risk Data

Problems

The quote above is taken directly from the Medicare carrier manual and it points out the fact that there must be sufficient medical necessity to support the intensity of the history and exam performed and documented. The key component of medical decision-making can act as an objective index of medical necessity and help us identify the highest ethical level of care based on the clinical circumstances of the patient.

Cognitive Labor Medical Necessity

+

“Correct” Level of Care

The Secret of True E/M Compliance

If you can find the level of care which matches both the cognitive labor provided and the intrinsic medical necessity of the encounter, you can find the “correct” level of care. If you let the key component of MDM lead the way, you can find this level of care each and every time. This is the secret of true E/M compliance because it allows you to avoid

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MDM Points

High 4 4 High Moderate 3 3 Moderate Low 2 2 Low Minimal 1 1 Straight Forward Risk Data Problems MDM Complexity

Need 2 out of 3 to qualify for given level of MDM

Determining the MDM

High Complexity High Extensive Extensive Moderate Complexity Moderate Moderate Multiple Low Complexity Low Limited Limited Straight-Forward Minimal Minimal Minimal Level of MDM Risk Data Reviewed Number of Diagnoses

Need 2 out of 3 to qualify for given level of MDM

Given the importance of the MDM, it is essential that we be able to quan-tify this key component in an objective and repeatable manner. Unfortu-nately, the official table of MDM from both the 1995 and 1997 E/M guide-lines (shown above) makes this a very difficult thing to do. The problem is that the terms used to stratify the dimensions of MDM are too vague.

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Points for Data Reviewed

1

Decision to obtain old records

2

Independent review of image, tracing, or specimen

1

Review/order clinical lab tests

2

Review and summation of old records

1

Discussion of test results with performing MD

1

Review/order tests in the medicine section (echo, EKG, LHC, PFTs)

1

Review/order X-rays

Points

Data Reviewed

Problem Points

1 Self limited or minor (Max 2)

4 New problem, additional work-up

planned

3 New problem, no additional work-up

planned

2 Established problem, worsening

1 Established problem, stable

Points Problems/DDx

The problem points are tabulated by referring to this table. You add up all the problems you are addressing during the encounter and come up with the final number of total problem points. “New” problems are defined relative to the physician, not the patient.

The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your

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Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected Minimal • One self-limited or minor

prob-lem, e.g., cold, insect bite, tinea corporis • Laboratory tests • Chest X-rays • EKG/EEG • Urinalysis • Ultrasound/ Echocardiogram • KOH prep • Rest • Gargles • Elastic bandages • Superficial dressings

Low • Two or more self-limited or minor problems

• One stable chronic illness, e.g., well controlled HTN, DM2, cata-ract

• Acute uncomplicated injury or illness, e.g., cystitis, allergic rhini-tis, sprain

• Physiologic tests not under stress, e.g., PFTs

• Non-cardiovascular imag-ing studies with contrast, e.g., barium enema

• Superficial needle biopsy

• ABG

• Skin biopsies

• Over the counter drugs

• Minor surgery, with no identi-fied risk factors

• Physical therapy

• Occupational therapy

• IV fluids, without additives

Moderate • One or more chronic illness, with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic ill-nesses

• Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast

• Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis

• Acute complicated injury, e.g., head injury, with brief loss of consciousness

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies, with no identified risk factors

• Deep needle, or incisional biopsies

• Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization

• Obtain fluid from body cavity, (e.g., LP or thora-centesis)

• Minor surgery, with identified risk factors

• Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors

• Prescription drug manage-ment

• Therapeutic nuclear medicine

• IV fluids, with additives

• Closed treatment of fracture or dislocation, without ma-nipulation

High • One or more chronic illness, with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe res-piratory distress, progressive se-vere rheumatoid arthritis, psychi-atric illness, with potential threat to self or others, peritonitis, ARF

• An abrupt change in neurological status, e.g., seizure, TIA, weak-ness, sensory loss

• Cardiovascular imaging, with contrast, with identi-fied risk factors

• Cardiac EP studies

• Diagnostic endoscopies, with identified risk factors

• Discography

• Elective major surgery (open, percutaneous, endoscopic), with identified risk factors

• Emergency major surgery (open, percutaneous, endo-scopic)

• Parenteral controlled sub-stances

• Drug therapy requiring inten-sive monitoring for toxicity

• Decision not to resuscitate, or to de-escalate care because of poor prognosis

Table of Risk

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Calculating the Overall MDM

High

4

4

High

Moderate

3

3

Moderate

Low

2

2

Low

Minimal

1

1

Straight

Forward

Risk

Data

Problems

MDM

Complexity

Need 2 out of 3 to qualify for given level of MDM

The overall level of MDM is determined by referring to the table above. Only two out of three elements are needed to qualify for any given level of MDM. The example above would qualify for moderate complexity MDM based on the presence of three problem points and three data points, even though the level of risk is only low.

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ƒ Problem Focused ƒ Expanded Problem Focused ƒ Detailed ƒ Comprehensive CC HPI ROS PFSH

History

Levels of History

None

1

Brief

EPF

1 out of 3

2 – 9

Extended

Detailed

None

None

Brief

PF

3 out of 3

10

Extended

Comp

PFSH

ROS

HPI

History

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HPI

ƒ A narrative of the patient’s symptoms or illnesses since onset or since the previous encounter

ƒ Every level of history requires and HPI, which may be referred to as an “interval history” for follow-up encounters

ƒ The HPI is the only component of history which MUST be personally obtained and documented by the provider

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HPI Elements

ƒ

Location

ƒ

Quality

ƒ

Severity

ƒ

Duration

ƒ

Timing

ƒ

Context

ƒ

Modifying Factors

ƒ

Associated Signs/Symptoms

Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/10 in severity, is worse with exertion and is associated with SOB and nausea.

Location Severity Quality Timing Modifying Factors Duration Context Associated Signs or Symptoms

Example of an extended HPI using all eight of the HPI elements.

Levels of HPI

Brief HPI

ƒ Requires only one to three HPI elements

Extended HPI ƒ Requires four HPI

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ROS

ƒ Constitutional ƒ Eyes

ƒ Ears, nose, mouth, throat ƒ Cardiovascular ƒ Respiratory ƒ GI ƒ GU ƒ Musculoskeletal ƒ Skin ƒ Neurological ƒ Psychiatric ƒ Endocrine ƒ Hem/Lymphatic ƒ Allergic/Immunologic

The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

Without a specific somatic complaint, it may be difficult or outright impossible to qualify for any level of HPI using the HPI elements. This problem was addressed in the 1997 E/M guidelines. If there are no somatic complaints, the 1997 E/M guidelines allow you to qualify for extended HPI by commenting on the status of three or more chronic or inactive problems.

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PFSH

ƒ Past Medical History

– Previously existing illnesses, prior operations, current medications, allergies, immunizations

ƒ Family History

– Health status of parents/siblings/children including relevant or hereditary diseases

ƒ Social History

– Marital status, employment, DOA, education, sexual history

The PFSH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

Levels of History

None

1

Brief

EPF

1 out of 3

2 – 9

Extended

Detailed

None

None

Brief

PF

3 out of 3

10

Extended

Comp

PFSH

ROS

HPI

History

The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation.

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History Tips and Shortcuts

1. You need a chief complaint for each and every encounter. It may be a symptom or it may be a state-ment such as “follow-up HTN.”

2. The physician must always complete the HPI. However, it is acceptable to have the patient or a member of your staff fill out a questionnaire for the past medical, family, and social history (PFSH). However, in order for this information to be counted in your history, you must initial the document and include any pertinent positive and negative information in the body of your note. You should also mention that you reviewed the form in its entirety. Finally, you must keep the questionnaire as a permanent part of the medical record.

3. You don’t have to list out the ROS; it is acceptable to have the patient fill out a form and then initial it, but that form must remain in the chart and you must refer to it in the body of your note. For ex-ample, “Complete 10 system ROS performed and documented, with pertinent findings included in the interval history.”

4. A Complete ROS requires that at least 10 systems be documented. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a nota-tion indicating “all other systems are negative” is permissible. In the absence of such a notanota-tion, at least 10 systems must be individually documented. (This shortcut is NOT accepted by ALL Medi-care carriers, so check before you use it.)

5. When doing a comprehensive history on a follow-up patient in the office, you do not need to re-dictate a previous PMFSH if it is already in the chart. It is acceptable to refer to the earlier PMFSH and make any additions as needed. For example: “The comprehensive past medical, family, and social history obtained during our initial encounter was re-examined and reviewed with the patient. For details, please refer to my dictated note in this chart, dated September 23, 2003. Nothing more to add at this time.”

6. If the patient is too ill or confused to give a reliable history or ROS , you do not need to include this information in the documentation, but you must explain why the data is missing, e.g., “Unable to obtain ROS or past medical, family and social history due to patient’s mental status”

7. At least one element from EACH of family, medical, and social history (PFSH) are required for a complete PFSH for the following categories: Office New Patient, Hospital Observation Care, Initial inpatient services, Consults, Comprehensive Nursing Facility Assessments (new patient), domicili-ary care (new patient), and home care (new patient).

8. Only 2 out of 3 elements of PFSH are required to qualify for Comprehensive History for established

office patients, ER visits, and established domiciliary or home patients.

9. PFSH Exemption: hospital progress notes require only an interval history. These encounters are officially exempt from the requirement for any elements of PFSH. Therefore a level 3 hospital pro-gress note (99233)--which requires a Detailed History--does not require documentation of any ele-ments of PFSH.

10. When using time as a determining factor, you must see the patient face to face for the entire time allotted for that particular level of care (for instance 25 minutes for a level 4 office follow-up visit.) You MUST document in the time spent AND the fact that OVER half of that time was devoted to counseling and/or coordination of care.

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Physical Exam

ƒ

1997 Physical Exam

ƒ

15 Organ Systems and 59 bullets

6 - 11

EPF

12

Detailed

1 - 5

PF

18

Comp

Bullets

Exam

1997 Physical Exam Organ Systems

• Constitutional • Eyes

• Ears, nose, mouth and throat • Neck • Respiratory • Cardiovascular • Chest (breasts) • Gastrointestinal • GU (male, female) • Musculoskeletal • Lymphatic • Skin • Neurologic • Psychiatric

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The 1997 Multi-System Exam Bullets

Constitutional

• Three vital signs

• General appearance

Eyes

• Inspection of conjunctiva and lids

• Examination of pupils and irises (PERRLA)

• Ophthalmoscopic discs and posterior segments

Ears, Nose, Mouth, and Throat

• External appearance of the ears and nose

• Otoscopic examination of the exter-nal auditory

canals and tympanic membranes

Assessment of hearing

• Inspection of nasal mucosa, septum and turbinates

Inspection of lips, teeth and gums

• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and pos-terior pharynx

Neck

• Examination of neck (e.g., masses, overall appearance, symmetry, tra-cheal position, crepitus)

Examination of thyroid

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions)

Percussion of chest

• Palpation of chest (e.g., tactile fre-mitus)

• Auscultation of the lungs

Cardiovascular

• Palpation of the heart (PMI)

• Auscultation of the heart

• Assessment of lower extremity edema

• Examination of the carotid arteries

• Examination of abdominal aorta

• Examination of the femoral pulses

• Examination of the pedal pulses

Chest (Breasts)

Inspection of the breasts

Palpation of the breasts and axillae

Lymphatic

Palpation of lymph nodes two or more areas • Neck • Axillae • Groin • Other Skin

• Inspection of skin and subcutane-ous tissue (e.g., rashes, lesions, ulcers)

• Palpation of the skin and subcuta-neous tissue (e.g., induration, subcutaneous nodules, tighten-ing)

Neurologic

• Test cranial nerves with notation of any deficits

• Examination of DTRs with nota-tion of any pathologic reflexes (e.g., Babinksi)

• Examination of sensation (e.g., by touch, pin, vibration, proprio-ception)

Psychiatric

• Description of patient’s judgment and insight

Brief assessment of mental status, which may include:

• Orientation to time, place, and person

• Recent and remote memory

• Mood and affect

Gastrointestinal (Abdomen)

• Examination of the abdomen with notation of presence of masses or ten-derness

Examination of the liver and spleen

• Examination for the presence or ab-sence of hernias

• Examination of anus, perineum, and rectum, including sphincter tone, pres-ence of hemorrhoids, rectal masses

Obtain stool for occult blood testing

Genitourinary (Male)

• Examination of the scrotal contents (e.g., tenderness of cord)

• Examination of the penis

• DRE of the prostate

Genitourinary (Female)

• Examination of the external genitalia

• Examination of the urethra

• Examination of the bladder (e.g., full-ness, masses, tenderness)

• Examination of the cervix

• Examination of the uterus (e.g., size, contour, position, mobility)

• Examination of the adnexa (e.g., masses, tenderness, nodularity)

Musculoskeletal

Examination of gait and station

• Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, ischemia) Examination of the joints, bones, and muscles of one or more of the following six areas:

1. Head and neck 2. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any mis-alignment, asymmetry, crepita-tion, defects, tenderness, masses or effusions

• Assessment of range of motion with notation of any pain, crepi-tation or contracture

• Assessment of stability with notation of any dislocation, sub-luxation, or laxity

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1995 Exam Rules

Head/face Neck Chest/breast/axillae Abdomen Genitalia/groin/buttocks Back/spine Each extremity Constitutional Eyes ENMT Cardiovascular Respiratory GI GU Musculoskeletal Skin Neuro Psychiatric Hematologic-lymphatic

Problem Focused: a limited exam of affected body area or organ

system

Expanded Problem Focused: a limited exam of the affected body

area or organ system and other symptomatic or related organ sys-tems

Detailed: an extended exam of the affected body area or organ

sys-tem and other symptomatic or related organ syssys-tems

Comprehensive: a general multi-system exam or complete exam of

a single organ system

Organ Systems Body Areas

The 1995 exam rules are included here for the sake of completeness.

We recommend using the 1997 physical exam rules because they are

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1. What level of care is

supported by the MDM?

2. What documentation is

required?

3. Is it reasonable to do

what the documentation

asks?

History Physical MDM

ER E/M Services

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

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ƒ

By far the least

frequently used

code for these

encounters

ƒ

Reimbursement is

about $19.00

3 out of 3 key components must qualify

99281

NA SF PF PF

99281

Time

MDM

Exam

History

E/M Code

99281

.64%

99282

4.5%

99283

25.1%

99284

30.0%

99285

39.6%

3 out of 3 key components must qualify

99281

NA SF PF PF

99281

Time

MDM

Exam

History

E/M Code

6 – 11 from any systems EPF

12 from any systems Det

1 – 5 from any systems PF 2 from 9 systems Comp Bullets Exam None 1 Brief EPF 1/3 2 – 9 Ext Det None None Brief PF 3/3 10 Ext Comp PFSH ROS HPI Hx High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

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What Does a 99281 Look Like?

ƒ

A 42 year old male presents for removal

of sutures from a well-healed,

uncomplicated laceration on the left arm

ƒ

You remove the sutures and clean and

dress the wound

ƒ

The patient is discharged with no further

follow-up required

MDM Points

1 Self limited or minor (Max 2)

4 New problem, additional

work-up planned

3 New problem, no additional work-up planned

2 Established problem,

worsening

1 Established problem, stable

Pts

Problems/DDx

1 Decision to obtain old records

2 Independent review of image, tracing, or specimen

1 Review/order clinical lab tests

2 Review of old records

1 Discuss test results with MD

1 Review/order medicine tests

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•Parenteral controlled substances

•Drug therapy requiring intensive monitoring for toxicity

•Obtain DNR or de-escalate care •Cardiovascular imaging, with

contrast, with identified risk factors

•Cardiac EP studies

•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation •Acute or chronic illness or injury, which poses a threat to life or bodily function

•An abrupt change in neurological status

High

•Prescription drug management •IV fluids, with additives •Cardiac stress test

•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation,

•Two stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis

Moderate

•Over the counter drugs •Minor surgery, with no risk factors

•PT/OT

•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs

•Non-cardiovascular imaging studies with contrast

•ABG

•Skin biopsies •Two or more self-limited or

minor problems

•One stable chronic illness •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Low •Rest •Gargles •Superficial dressings •Laboratory tests •Chest X-rays •EKG/EEG, Echocardiogram •One self-limited or minor

problem, e.g., cold, insect bite, tinea corporis. Minimal Management Options Diagnostic Procedures Presenting Problems

Risk

Calculating the Overall MDM

(27)

Selecting the Target Code

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

3 out of 3 key components must qualify

99281

PF History

PF Exam

Straightforward MDM

Plan Out the Documentation

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3 out of 3 key components must qualify

None None Brief

PF

PFSH ROS HPI History SF PF PF

99281

MDM Exam History Target Code

HPI: The patient is here to have sutures removed from a left arm laceration. CC: Follow-up for suture removal

One HPI Element Location

History

E/M Insight: Problem Focused History

The requirements for a problem focused history are so minimal, it’s diffi-cult (but not impossible) not to qualify for this level of history.

The only requirement is a brief HPI, which must contain one HPI element OR the status of one to three chronic or inactive problems.

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Physical Exam

Constitutional Eyes ENMT Neck

Chest/Breasts CV Skin Musculoskeletal Neurologic Psychiatric GI GU Lungs

4 cm well healed linear laceration; wound edges clean; no fluctuance

1 2

Requires only 1 - 5 bullets from ANY organ systems

3 out of 3 key components must qualify

SF PF PF

99281

MDM Exam History Target Code

Exam

E/M Insight: Problem Focused Exam

Similar to the problem focused history, the requirements for a problem fo-cused history are so minimal, it’s difficult (but not impossible) not to qualify for this level of exam.

The only requirement is one to five bullets from any organ systems. In the example above, we included the following bullets:

• Inspection of skin • Palpation of skin

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Plan: No further follow-up required

Assessment: Well-healed, uncomplicated laceration

SF PF PF

99281

MDM Exam History Target Code High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

Medical Decision-Making

E/M Insight: Straightforward MDM

It literally is impossible not to qualify for this level of complexity. All you need is two out of three:

• One problem point • One data point • Minimal risk

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99281

Requires three out of three qualifying key components

One HPI Element Location

(qualifies as a problem focused history)

This example qualifies as straightforward MDM based on one problem point and minimal risk.

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min Low 2 2 Low Mod 3 3 Mod High ≥ 4 ≥ 4 High Bullets Used • Inspection of skin • Palpation of skin

(Qualifies as a problem focused exam)

SF

PF

PF

99281

MDM

Exam

History

Target

4 cm well healed linear laceration; wound edges

clean; no fluctuance

Plan:

No further follow-up required

Assessment: Well-healed, uncomplicated laceration

HPI: The patient is here to have sutures removed

from a left arm laceration.

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ƒ

Second least

frequently used

code for these

encounters

ƒ

Reimbursement is

about $37.00

3 out of 3 key components must qualify

99282

NA Low EPF EPF

99282

Time

MDM

Exam

History

E/M Code

99281

.64%

99282

4.5%

99283

25.1%

99284

30.0%

99285

39.6%

3 out of 3 key components must qualify

99282

NA Low EPF EPF

99282

Time

MDM

Exam

History

E/M Code

6 – 11 from any systems EPF

12 from any systems Det

1 – 5 from any systems PF 2 from 9 systems Comp Bullets Exam None 1 Brief EPF 1/3 2 – 9 Ext Det None None Brief PF 3/3 10 Ext Comp PFSH ROS HPI Hx High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

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What Does a 99282 Look Like?

ƒ

You see a 19 year old college student

with a rash on both legs after hiking in

the woods

ƒ

You diagnose Toxicodendron dermatitis

ƒ

You recommend Calamine lotion, PRN

benadryl and Burrow's solution

MDM Points

1 Self limited or minor (Max 2)

4 New problem, additional

work-up planned

3 New problem, no additional work-up planned

2 Established problem,

worsening

1 Established problem, stable

Pts

Problems/DDx

1 Decision to obtain old records

2 Independent review of image, tracing, or specimen

1 Review/order clinical lab tests

2 Review of old records

1 Discuss test results with MD

1 Review/order medicine tests

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•Parenteral controlled substances

•Drug therapy requiring intensive monitoring for toxicity

•Obtain DNR or de-escalate care •Cardiovascular imaging, with

contrast, with identified risk factors

•Cardiac EP studies

•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation •Acute or chronic illness or injury, which poses a threat to life or bodily function

•An abrupt change in neurological status

High

•Prescription drug management •IV fluids, with additives •Cardiac stress test

•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation,

•Two stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis

Moderate

•Over the counter drugs •Minor surgery, with no risk factors

•PT/OT

•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs

•Non-cardiovascular imaging studies with contrast

•ABG

•Skin biopsies •Two or more self-limited or

minor problems

•One stable chronic illness •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Low •Rest •Gargles •Superficial dressings •Laboratory tests •Chest X-rays •EKG/EEG, Echocardiogram •One self-limited or minor

problem, e.g., cold, insect bite, tinea corporis. Minimal Management Options Diagnostic Procedures Presenting Problems

Risk

Calculating the Overall MDM

High

4

4

High

Mod

3

3

Moderate

Low

2

2

Low

Min

0 - 1

1

SF

Risk

Data

Problems

MDM

Complexity

(35)

Selecting the Target Code

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

3 out of 3 key components must qualify

99282

EPF History

EPF Exam

Low Complexity MDM

Plan Out the Documentation

(36)

History

E/M Insight: Expanded Problem Focused History

The only difference between a problem focused history and an expanded problem focused history is one element of ROS.

A problem focused history requires a brief HPI and review of one system.

Brief HPI: Requires one to four HPI elements or the status of one to three

problems. The above example qualifies with documentation of two HPI elements (Location, Duration).

ROS: One ROS is required for this history. The example qualifies by

re-viewing the CV system.

ROS CV: Negative for palpitations, chest tightness

Two HPI Elements Location, Duration HPI: The patient is a 19 YOF who was out hiking yesterday and developed a painful and intensely pruritic rash on both legs this morning.

Review of One System Cardiovascular

CC: “My legs are really itchy”

(37)

Exam

E/M Insight: Expanded Problem Focused Exam

An expanded problem focused exam requires six to 11 bullets from any organ systems.

The example above qualifies based on the following seven bullets:

• General appearance • Three vital signs

• Examination of the oropharynx • Auscultation of the lungs • Auscultation of the heart • Inspection of the skin • Palpation of the skin

Physical Exam

Lungs: No wheezes

Constitutional Eyes ENMT Neck

Chest/Breasts CV Skin Musculoskeletal Neurologic Psychiatric GI GU Lungs Vitals: 125/75, 18, 82, 98.6 OP: Clear; no pharyngeal edema CV: RRR, no MRGs

1 2 3

Requires only 6 - 11 bullets from ANY organ systems

6

4 5

General: NAD, conversant, well nourished WF looks stated age

Skin: Warm and dry; normal turgor; multiple streak-like

edematous papular lesions on an erythematous base located on both lower extremities below the knees

7

3 out of 3 key components must qualify

(38)

Assessment: Toxicodendron Dermatitis Plan: 1. Calamine lotion

2. PRN Benadryl

3. Burrow’s solution for weeping blisters

3 out of 3 key components must qualify Low EPF EPF

99282

MDM Exam History Target Code High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

Medical Decision-Making

E/M Insight: Low Complexity MDM

The acuity of care required for this level of MDM is very low. All you need is two out of three:

• Two problem points • Two data points • Low risk

(39)

99282

Low

EPF

EPF

99282

MDM

Exam

History

Target

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min Low 2 2 Low Mod 3 3 Mod High ≥ 4 ≥ 4 High

This exam includes seven bullets:

• General appearance • Three vital signs • Exam of oropharynx • Auscultation of lungs • Auscultation of heart • Inspection of skin • Palpation of skin

(Qualifies as a n EPF exam)

Two HPI Elements

Location, Duration

One ROS

Cardiovascular

CC: “My legs are really itchy”

HPI: The patient is a 19 YOF who was out hiking yesterday and developed a painful and intensely pruritic rash on both legs this morning.

ROS CV: Negative for palpitations/chest tightness

Physical Exam

NAD, conversant, well-nourished WF; looks stated age

Vitals: 125/75, 18, 82, 98.6

OP: Clear; no pharyngeal edema Lungs: No wheezes

CV: RRR, no MRGs

Skin: Warm and dry; normal turgor; multiple streak-like, edematous popular lesions on an erythematous base on both lower extremities

Assessment: Toxicodendron dermatitis Plan:

1. CALAMINE lotion 2. PRN BENADRYL

3. Borrow’s solution for weeping blisters MDM qualifies as being of low

(40)

ƒ

Third most

frequently used

code for these

encounters

ƒ

Reimbursement is

about $61.00

3 out of 3 key components must qualify

99283

NA Mod EPF EPF 99283

Time

MDM

Exam

History

E/M Code

99281

.64%

99282

4.5%

99283

25.1%

99284

30.0%

99285

39.6%

3 out of 3 key components must qualify

99283

NA Mod EPF EPF 99283

Time

MDM

Exam

History

E/M Code

6 – 11 from any systems EPF

12 from any systems Det

1 – 5 from any systems PF 2 from 9 systems Comp Bullets Exam None 1 Brief EPF 1/3 2 – 9 Ext Det None None Brief PF 3/3 10 Ext Comp PFSH ROS HPI Hx High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

(41)

What Does a 99283 Look Like?

ƒ

You see a 34 YOF who complains of

one day of dysuria

ƒ

UA shows 20 WBCs

ƒ

The patient is afebrile, hemodynamically

stable and otherwise healthy

ƒ

After diagnosing uncomplicated cystitis,

you prescribe Bactrim DS BID for three

days

MDM Points

1 Self limited or minor (Max 2)

4 New problem, additional

work-up planned

3 New problem, no additional work-up planned

2 Established problem,

worsening

1 Established problem, stable

Pts

Problems/DDx

1 Decision to obtain old records

2 Independent review of image, tracing, or specimen

1 Review/order clinical lab tests

2 Review of old records

1 Discuss test results with MD

1 Review/order medicine tests

(42)

•Parenteral controlled substances

•Drug therapy requiring intensive monitoring for toxicity

•Obtain DNR or de-escalate care •Cardiovascular imaging, with

contrast, with identified risk factors

•Cardiac EP studies

•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation •Acute or chronic illness or injury, which poses a threat to life or bodily function

•An abrupt change in neurological status High

•Prescription drug management •IV fluids, with additives •Cardiac stress test

•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation,

•Two stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis

Moderate

•Over the counter drugs •Minor surgery, with no risk factors

•PT/OT

•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs

•Non-cardiovascular imaging studies with contrast

•ABG

•Skin biopsies •Two or more self-limited or

minor problems

•One stable chronic illness •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Low •Rest •Gargles •Superficial dressings •Laboratory tests •Chest X-rays •EKG/EEG, Echocardiogram •One self-limited or minor

problem, e.g., cold, insect bite, tinea corporis. Minimal Management Options Diagnostic Procedures Presenting Problems

Risk

Calculating the Overall MDM

High

4

4

High

Mod

3

3

Mod

Low

2

2

Low

Min

0 - 1

1

SF

Risk

Data

Problems

MDM

Complexity

(43)

Selecting the Target Code

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

Moderate complexity MDM goes along with EITHER a 99283 or a 99284. Which of these is the correct target code?

99283 vs. 99284

The Three Questions

1. What level of care is supported by the MDM? 2. What documentation is required?

(44)

99283 vs. 99284

“Medical necessity of a service is the overarching criterion for payment in addition to the individual

requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Medicare Carrier Manual

99283 vs. 99284

Detailed History Requires 4 HPI elements or the status of three chronic or inactive problems, plus 2 – 9 ROS, plus at least one element of PFSH

Detailed Exam Requires at least 12 bullets from any organ systems

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

(45)

Target Code: 99283

NA

High

Comp

Comp

99285

NA

Mod

Det

Det

99284

NA

Mod

EPF

EPF

99283

NA

Low

EPF

EPF

99282

NA

SF

PF

PF

99281

Time

MDM

Exam

History

E/M Code

3 out of 3 key components must qualify

99283

EPF History

EPF Exam

Moderate MDM

Plan Out the Documentation

(46)

ROS Constitutional: Negative for fevers/chills/anorexia GU: Negative for flank pain, hematuria

HPI: The patient complains of burning with urination since yesterday.

Review of Two Systems

Constitutional GU CC: “Burning with urination”

3 out of 3 key components must qualify Mod EPF EPF

99283

MDM Exam History Target Code

One HPI Element Duration None 1 Brief

EPF

PFSH ROS HPI History

History

E/M Insight: Expanded Problem Focused History

Requires a brief HPI (using one to three HPI elements or the status of one to three problems), plus one ROS. No elements of PFSH are required. This example qualifies as follows:

HPI: One HPI element (Duration)

(47)

Exam

Physical Exam

Lungs: CTA

Constitutional Eyes ENMT Neck

Chest/Breasts CV Skin Musculoskeletal Neurologic Psychiatric GI GU Lungs Vitals: 120/65, 18, 77, 98.7 CV: RRR, no MRGs 1 2 3 Requires only 6 - 11 bullets from ANY organ systems

6

4 5

General: NAD, conversant, well nourished WF looks stated age

Skin: Warm and dry, well-perfused Abd: Soft, non-tender; no CVAT

3 out of 3 key components must qualify

Mod EPF EPF

99283

MDM Exam History Target Code

E/M Insight: Expanded Problem Focused Exam

An expanded problem focused exam requires six to 11 bullets from any organ systems.

The example above qualifies based on the following six bullets:

• General appearance • Three vital signs

(48)

Assessment: Uncomplicated acute cystitis Plan: 1. Bactrim DS BID X 3 days

2. Push PO fluids

3. RTC if flank pain or high fever UA shows 20 WBCs

3 out of 3 key components must qualify

Mod EPF EPF

99283

MDM Exam History Target Code High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

E/M Insight: Moderate Complexity MDM

Requires two out of three:

• Three problem points • Three data points • Moderate risk

The example above qualifies based on three problem points (for the new problem with no additional w/u of cystitis) and the presence of moderate risk (based on the use of prescription medications).

(49)

Chief Complaint: “Burning with urination.”

HPI: The patient complains of burning with urination since yesterday. ROS Constitutional: Negative for fevers/chills/anorexia

GU: Negative for flank pain or hematuria

Physical Exam

Vitals: 120/65, 18, 77, 98.7

Gen: NAD, well-nourished WF; looks stated age Lungs: CTA

CV: RRR, no MRGs

Abd: Soft, non-tender; no CVAT Skin: Warm and dry; well-perfused

UA shows 20 WBCs

Assessment: Uncomplicated acute cystitis Plan:

1. Bactrim DS times three days 2. Push PO fluids

3. RTC if flank pain or high fever

99283

One HPI Element

Duration

Two ROS

Constitutional, GU

This exam includes six bullets:

• General appearance • Three vital signs • Auscultation of lungs • Auscultation of heart • Abdominal exam • Palpation of skin

(Qualifies as a n EPF exam)

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min Low 2 2 Low Mod 3 3 Mod High ≥ 4 ≥ 4 High

MDM qualifies as being of moderate com-plexity based on three problem points and the presence of moderate risk.

(50)

ƒ

Second most

frequently used

code for these

encounters

ƒ

Reimbursement is

about $110.00

3 out of 3 key components must qualify

99284

NA Mod Det Det 99284

Time

MDM

Exam

History

E/M Code

99281

.64%

99282

4.5%

99283

25.1%

99284

30.0%

99285

39.6%

3 out of 3 key components must qualify

99284

NA Mod Det Det 99284

Time

MDM

Exam

History

E/M Code

6 – 11 from any systems EPF

12 from any systems Det

1 – 5 from any systems PF 2 from 9 systems Comp Bullets Exam None 1 Brief EPF 1/3 2 – 9 Ext Det None None Brief PF 3/3 10 Ext Comp PFSH ROS HPI Hx High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

(51)

What Does a 99284 Look Like?

ƒ

You see a 58 YOM who complains of

abdominal/flank pain and hematuria

ƒ

The pain responds to IV Ketorolac

ƒ

CT renal colic shows a 2 mm

non-obstructing stone in the distal left ureter

ƒ

UA shows RBCs, but all other labs are

WNL

ƒ

You prescribe Lortab and fluids and

discharge the patient with a strainer

MDM Points

1 Self limited or minor (Max 2)

4 New problem, additional

work-up planned

3 New problem, no additional work-up planned

2 Established problem,

worsening

1 Established problem, stable

Pts

Problems/DDx

1 Decision to obtain old records

2 Independent review of image, tracing, or specimen

1 Review/order clinical lab tests

2 Review of old records

1 Discuss test results with MD

1 Review/order medicine tests

(52)

•Parenteral controlled substances

•Drug therapy requiring intensive monitoring for toxicity

•Obtain DNR or de-escalate care •Cardiovascular imaging, with

contrast, with identified risk factors

•Cardiac EP studies

•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation •Acute or chronic illness or injury, which poses a threat to life or bodily function

•An abrupt change in neurological status

High

•Prescription drug management •IV fluids, with additives •Cardiac stress test

•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation,

•Two stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis

Moderate

•Over the counter drugs •Minor surgery, with no risk factors

•PT/OT

•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs

•Non-cardiovascular imaging studies with contrast

•ABG

•Skin biopsies •Two or more self-limited or

minor problems

•One stable chronic illness •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Low •Rest •Gargles •Superficial dressings •Laboratory tests •Chest X-rays •EKG/EEG, Echocardiogram •One self-limited or minor

problem, e.g., cold, insect bite, tinea corporis. Minimal Management Options Diagnostic Procedures Presenting Problems

Risk

Calculating the Overall MDM

High

4

4

High

Mod

3

3

Mod

Low

2

2

Low

Min

0 - 1

1

SF

Risk

Data

Problems

MDM

Complexity

(53)

Target Code: 99284

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

3 out of 3 key components must qualify

99284

Detailed History

Detailed Exam

Moderate MDM

Plan Out the Documentation

(54)

ROS CV: Negative for SSCP/orthopnea/PND

GU: Negative for obstructive sx, dysuria, urgency, nocturia GI: Negative for N/V/D, melena, hematemesis

Pertinent PFSH: Positive for ongoing tobacco abuse; negative ETOH

HPI: The patient is a pleasant a 58 YOWM who presents with intermittent left flank and abdominal pain associated with blood in the urine, which began this morning at 0200. The pain is described as 8/10 in severity.

CC: Abdominal pain Mod Det Det

99284

MDM Exam History Target Code

3 out of 3 key components must qualify 1/3 2 – 9 Extended

Detailed

PFSH ROS HPI History

History

E/M Insight: Detailed History

Requires an extended HPI (using four HPI elements or the status of three problems), plus 2-9 ROS and one out of three components of PFSH. This example qualifies as follows:

HPI: Five HPI elements (timing, location, associated signs/symptoms,

du-ration, severity)

ROS: Three systems reviewed (CV, GU, GI)

(55)

Physical Exam

Lungs: Clear to auscultation and percussion bilaterally

Constitutional Eyes ENMT Neck

Chest/Breasts CV Skin Musculoskeletal Neurologic Psychiatric GI GU Lungs Vitals: 148/90, 18, 96, 98.6 CV: RRR, no MRGs

Ext: No peripheral edema

1 2 3 7 11 12

Requires AT LEAST 12 bullets from ANY organ systems

6

4 5

General: Somewhat agitated non-toxic WM; looks stated age

Abd: Soft, non-tender; NABS; no HSM, masses, hernias or bruits Rectal: Normal tone; no masses; heme

-Eyes: Anicteric sclerae

8 9 10 Mod Det Det

99284

MDM Exam History Target Code

3 out of 3 key components must qualify

Exam

E/M Insight: Detailed Exam

An detailed exam requires 12 bullets from any organ systems. The example above qualifies based on the following 12 bullets:

• General appearance • Three vital signs • Exam of sclerae

• Auscultation of the lungs • Percussion of lungs • Auscultation of the heart

• Brief abdominal exam • Exam of liver/spleen • Exam for hernias • Rectal exam

• Obtain stool for occult blood • Assessment of peripheral

(56)

Assessment: Acute non-obstructing left ureteral nephrolithiasis Plan: 1. D/C patient home with a strainer

2. Push PO fluids at home

3. Lortab 7.5/500 PO Q 4 hrs, PRN for pain

137 101 1498 12

4.1 24 0.7 36 CT renal colic was reviewed and showed a 2 mm non-obstructing stone in the distal left ureter UA: No WBCs; RBCs TNTC Mod Det Det

99284

MDM Exam History Target Code

3 out of 3 key components must qualify

High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

E/M Insight: Moderate Complexity MDM

Requires two out of three:

• Three problem points • Three data points • Moderate risk

In the example above, there are three problem points, four data points and moderate risk. Since two out of three dimensions are needed, this adds up to moderate complexity MDM.

(57)

Chief Complaint: Abdominal pain.

HPI: The patient is a pleasant 58 YOWM who presents with intermittent left flank and abdominal pain associated with blood in the urine, which began this morning at 0200. The pain is described as 8/10 in severity.

Pertinent PFSH is remarkable for ongoing tobacco abuse; negative ETOH. ROS CV: Negative for SSCP/orthopnea/PND

GU: Negative for obstructive sx/dysuria/nocturia GI: Negative for N/V/melena/hematemesis

Vitals: 148/90, 18, 96, 98.6

Gen: Somewhat agitated, non-toxic WM Eyes: Anicteric sclerae

Lungs: CTA and percussion CV: RRR, no MRGs

Abd: Soft, NABS, no HSM, hernias, masses or bruits Rectal: Normal tone; no masses; heme -

Ext: No peripheral edema

Assessment: Acute non-obstructing left ureteral nephrolithiasis Plan:

1. D/C patient to home with a strainer 2. Push PO fluids at home

3. Lortab 7.5/500 PO Q 4H, PRN

99284

Five HPI Elements

• Timing • Location • Assoc. Signs/Sx • Duration • Severity Three ROS CV, GU, GI 12 Bullets • General appearance • Three vital signs • Exam of slcerae • Auscultation of lungs • Percussion of lungs • Auscultation of heart • Abdominal exam • Exam of liver/spleen • Exam for hernias • Rectal exam

• Obtain stool for occult blood • Assessment of extremity edema

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min Low 2 2 Low Mod 3 3 Mod High ≥ 4 ≥ 4 High

(58)

ƒ

Most frequently

used code for these

encounters

ƒ

Reimbursement is

about $166.00

3 out of 3 key components must qualify

99285

NA High Comp Comp*

99285

Time

MDM

Exam

History

E/M Code

99281

.64%

99282

4.5%

99283

25.1%

99284

30.0%

99285

39.6%

3 out of 3 key components must qualify

99285

NA High Comp Comp*

99285

Time

MDM

Exam

History

E/M Code

6 – 11 from any systems EPF

12 from any systems Det

1 – 5 from any systems PF 2 from 9 systems Comp Bullets Exam None 1 Brief EPF 1/3 2 – 9 Ext Det None None Brief PF 3/3 10 Ext Comp* PFSH ROS HPI Hx High ≥4 ≥4 High Mod 3 3 Mod Low 2 2 Low Min 0 - 1 1 SF Risk Data Pts Prob Pts MDM

Requires two out of three

Comprehensive* History Comprehensive Exam High Complexity MDM

(59)

What Does a 99285 Look Like?

ƒ

You see an elderly NH resident brought

to the ER for “confusion”

ƒ

The patient is obtunded and cannot give

any history, but there is an old chart

available, which you review

151 4.0 124 88 17 2.1 101 15 40

After reviewing the labs and the CXR, you make the diagnosis of RML pneumonia. You send sputum and blood cultures, start IV fluids and empiric ATBs. You also arrange for the patient to be admitted.

MDM Points

1

Self limited or minor (Max 2)

4 New problem, additional

work-up planned

3 New problem, no additional work-up planned

2 Established problem,

worsening

1 Established problem, stable

Pts

Problems/DDx

1 Decision to obtain old records

2 Independent review of image, tracing, or specimen

1 Review/order clinical lab tests

2 Review of old records

1 Discuss test results with MD

(60)

•Parenteral controlled substances

•Drug therapy requiring intensive monitoring for toxicity

•Obtain DNR or de-escalate care •Cardiovascular imaging, with

contrast, with identified risk factors

•Cardiac EP studies

•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation •Acute or chronic illness or injury, which poses a threat to life or bodily function

•An abrupt change in neurological status

High

•Prescription drug management •IV fluids, with additives •Cardiac stress test

•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation,

•Two stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis

Moderate

•Over the counter drugs •Minor surgery, with no risk factors

•PT/OT

•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs

•Non-cardiovascular imaging studies with contrast

•ABG

•Skin biopsies •Two or more self-limited or

minor problems

•One stable chronic illness •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Low •Rest •Gargles •Superficial dressings •Laboratory tests •Chest X-rays •EKG/EEG, Echocardiogram •One self-limited or minor

problem, e.g., cold, insect bite, tinea corporis. Minimal Management Options Diagnostic Procedures Presenting Problems

Risk

Calculating the Overall MDM

High

4

4

High

Mod

3

3

Mod

Low

2

2

Low

Min

0 - 1

1

SF

Risk

Data

Problems

MDM

Complexity

(61)

Target Code: 99285

NA High Comp Comp 99285 NA Mod Det Det 99284 NA Mod EPF EPF 99283 NA Low EPF EPF 99282 NA SF PF PF 99281 Time MDM Exam History E/M Code

3 out of 3 key components must qualify

99285

Comprehensive History

Comprehensive Exam

High Complexity MDM

Plan Out the Documentation

(62)

HPI: This is a 79 YOWM NH resident with multiple medical problems, including well controlled HTN, stable IRDM and CAD who presents with increasing somnolence over the past few days. The patient is confused and unable to give any history. All the information contained in this note was obtained from my review of the medical record.

SH: Long time NH resident; no history of etoh/tobacco abuse ROS: Cannot be reliably obtained due to the patient’s confusion

Current Medications Lisinopril 10 mg QD Lipitor 20 mg QD Imdur 30 mg QD 70/30 inslulin 20 BID CC: Altered mental status

3 out of 3 key components must qualify

PMH: per HPI, plus dyslipidemia and CABG in 1992

High Comp Comp*

99285

MDM Exam History Target Code 2/3 10 Extended

Comp*

PFSH ROS HPI History

History

E/M Insight: Comprehensive* History

Requires an extended HPI (four or more HPI elements or the status of three or more problems) plus the review of at least 10 systems. Usually, a comprehensive history also requires at least one item from all three com-ponents of PFSH, but for ER visits, only two out of three comcom-ponents are needed.

This example qualifies as follows:

HPI: Status of three problem (HTN, DM, CAD)

PFSH: The past medical and social history are documented.

ROS: Cannot be reviewed due to patient’s mental status. In these

Figure

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References

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