Evaluation & Management 101 for Clinicians

Transcription

1 Evaluation & Management 101 for Clinicians Kerin Draak, MSN, WHNP BC, CPC, CEMC, COBGC, CPC I System Director of Clinical & Financial Integration Hospital Sisters Health System This is the Full Title of a Session Green Bay, WI 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify the seven components of E/M along with the three key components used to support E/M code Articulate the difference between 1995 and 1997 documentation guidelines Provide constructive feedback to clinicians on appropriate verbiage to support the three key components Describe who can document the three key components Use an audit tool to review a progress note for the appropriate level of E/M 2

3 Background E/M guidelines introduced in 1994 Revised in 1997 Some practicing providers were educated prior to introduction of documentation guidelines Purpose of medical record has evolved Paper electronic Provider to provider communication 3

4 Reasons for E/M Education Varied reasons for teaching E/M Compliance Financial Fear Voluntary 4

5 Expectations of E/M Educational Session Varied expectation of educator & provider Time expectations Clear and concise Confirm date/time Goals Compliance More money Attitude 5

6 Evaluation & Management 101 Medical necessity Overcoding vs. overdocumenting Undercoding vs. underdocumenting 6

7 Tools for Successful Educational Session Documentation guidelines CPT manual Educational handout Pens/pencils/paper Examples of progress notes Reports Positive attitude 7

8 Tools Purchased learning tools ACDIS Customized learning tools Authoritative sources CMS Local National Documentation guidelines NCCI AMA 8

9 Tools Purchased Reliable and creditable source vs. opinion Google Wikipedia Outside consultant Software Seminars, webinars, conferences 9

10 Tools Customized Flexible Meet needs of compliance plan Consistency Individualized Specialty Primary care 10

11 Tools Authoritative CMS p#topofpage Chapter 1, General Correct Coding Policies and Guidance/Guidance/Manuals/Downloads/clm104c12.pdf IOM, , Chapter 12, Section

12 Educational Session Organize handouts/reference material User friendly format Simple and concise Customize to specialty Avoid wrongful assumptions Avoid information overload 12

13 Building Blocks for E/M Service Seven components used in defining the levels of E/M services History Examination Key components Medical decision making Counseling Coordination of care Nature of presenting problem Time 13

14 History 14

15 Educational Tool History Chief complaint (CC) EVERY note must have a CC Who can obtain and document? History of present illness (HPI) Who can obtain and document? Can one element be counted more than once? 1997 DG for chronic conditions Review of systems (ROS) What is acceptable documentation? Past medical, family, & social history (PFSH) 15

16 History History of Present Illness HPI Location, duration, quality, severity, modifying factor, timing, context and associated S/S Remember to document positive and negative responses ROS No such thing as a 14 point ROS What is a point??? Past medical, family, & social history (PFSH) Avoid verbiage such as family hx noncontributory or unremarkable Ancillary staff can document 16

17 HPI for 1997 Documentation Guidelines Includes the status of three chronic conditions No mention if listing the status of less than three chronic conditions Example: Patient presents today for follow up on her stable coronary artery disease, medication controlled stable hypertension, and worsening hyperlipidemia 17

18 Example of HPI Brief HPI: Pt has had leg (location) pain (CC) for 3d (duration) Extended HPI: Pt has had a constant (timing), throbbing (quality) pain in her leg (location) since falling (context) 3d (duration) ago. Not acceptable CC documentation The patient is here for follow up HPI: annual exam 18

19 Review of Systems An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced (CPT, 2018) DG: The patient s positive responses and pertinent negatives for the system related to the problem should be documented Can you use patient completed forms? Ancillary staff can obtain as long as the provider documents that they reviewed and verified all information 19

20 Review of Systems Constitutional symptoms Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic 20

21 Good Examples of ROS Documentation The patient denies having a fever, chills, ear pain, or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain. Her appetite has been okay. (Detailed ROS) The patient denies having a fever, chills, ear pain, or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain. Her appetite has been okay. She is voiding in normal amounts. All other systems were reviewed and negative. (Comprehensive ROS) 21

22 Bad Examples of ROS Documentation The complete ROS was performed in detail and was negative A 12 point ROS was performed in detail with the patient and is negative Patient has a runny nose and sore throat and the remainder of the ROS is negative The patient wears glasses and is diabetic and all other systems are negative ROS per history form in chart ROS per the HPI, otherwise negative 22

23 Educational Tools History History unobtainable Document why What level of history when unobtainable Tools to make documenting history easier DG: A ROS and/or PFSH obtained during an earlier encounter does not need to be re recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting there has been no change in the information; and Noting the date and location of the earlier ROS and/or PFSH 23

24 Past Medical, Family, and Social History Past history Prior major illnesses and injuries Prior operations Prior hospitalizations Current medications Allergies (e.g., drug, food) Age appropriate immunization status Age appropriate feeding/dietary status 24

25 Past Medical, Family, and Social History Family The health status or cause of death of parents, siblings, and children Specific diseases related to problems identified in the chief complaint or history of present illness, and/or system review Diseases of family members that may be hereditary or place the patient at risk 25

26 Past Medical, Family, and Social History Social history Marital status and/or living arrangements Current employment Occupational history Use of drugs, alcohol, and tobacco Level of education Sexual history Other relevant social factors 26

27 History Prob Foc Exp Prob Detail Comp HPI status of chronic conditions HPI elements Brief Brief Extend Extend Location Severity Quality Duration Timing (1 3) (1 3) ( 4) ( 4) Context Modifying Factors Associated S/S ROS Constitutional Eyes ENMT Cardio Resp GI GU MS Skin Neuro Psych None Prob Pert (1) Extend (2 9) Comp ( 10) Endocrine Hem/Lymph Allerg/Immun PFSH Past: Prior illness/injuries/operations/hosp; meds, allergies, immunization/dietary status Family: Health status or cause of death of parents, sib., children; review of med. events in pt s family Social: Marital status, employment, level of educ., use of drugs/alcohol/tob., sexual hx None None Pert Est. 1 New 1 Comp Est. 2 New 3 27

28 Examination 28

29 Examination 1995 vs DGs Vague General provider Potential risk 1997 DGs Specific Specialty driven Defensible Can use whichever guidelines are most advantageous to the provider 29

30 Examination 1995 vs documentation guidelines Descriptions needed for the difference between an expanded exam and a detailed exam if using 1995 Focused = 1 body area or 1 organ system Comprehensive = 8 organ systems Expanded vs. detailed is somewhere in the middle?? 2 4/5 7 NGS 2 5/6 7 What is your organization s definition?? Extent of examination Provider discretion Medically necessary to presenting problem 30

31 Examination Example Expanded? VSS HEENT neg Detailed? T 99.7, R 24, P 24 HEENT: Head: normocephalic; Eyes: clear; Ears: TMs clear with good light reflexes; Nose: turbinates pink, no drainage; Throat: pink, no tonsillar enlargement or exudate 31

32 Examination Tips Examination HEENT is not an organ system, but an acronym Avoid stating HEENT negative Hepatosplenomegaly vs. organomegaly Unremarkable or noncontributory Musculoskeletal exam: no edema (edema is considered exam of cardiovascular system) Alert and oriented = Constitutional exam Alert and oriented x 3 = Psychological exam 32

33 Examination More Documentation Tips Examination Neck supple = Body area Extremities/joints without swelling Extremities normal Extremities neg Neuro: nonfocal No CVAT: what system is being examined? MS? GI? Or GU? Use approved abbreviations/acronyms 33

34 Examination Comparison 34

35 Medical Decision Making 35

36 Medical Decision Making Easy Ø Straightforward complexity Hard Ø High complexity Medical decision making Ø Level of service Medical decision making Ø Diagnosis driven 36

37 Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and The risk of significant complication, morbidity, and/or mortality, as well as comorbidities, associated with the patient s presenting problem(s), the diagnostic procedure(s), and/or the possible management options (CPT, 2018) 37

38 Number of Diagnosis or Management Options = A 38

39 Table of Risk Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Minimal One self limited or minor problem eg. cold, insect bite, tinea corporis Lab tests requiring venipuncture Chest x rays EKG/EEG Urinalysis Ultrasound KOH prep Rest Gargles Elastic bandages Superficial dressings 39

40 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Low Two or more selflimited or minor problems One stable chronic illness Acute uncomplicated illness or injury Physiologic test not under stress Noncardiovascular imaging studies with contrast Superficial needle biopsies Clinical lab test requiring arterial puncture Skin biopsies Over thecounter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids w/o additives 40

41 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of tx Undiagnosed new prob. with uncertain prognosis Acute illness with systemic symptoms Physiologic tests under stress Diagnostic endoscopies with no risks Deep needle or incisional bx Cardiovascular imaging studies with no risks Obtain fluid from body cavity Minor surgery with identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed tx of fracture or dislocation without manipulation 41

42 Level of Risk Presenting Problem Diagnostic Proc. Ordered Management Opts. Selected High Acute or chronic illnesses or injuries that may pose a threat to life or bodily function One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment An abrupt change in neurologic status Cardiovascular imaging studies with contrast with risks Cardiac electrophysiological tests Diagnostic endoscopies with risks Discography Elective major surgery with risks Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to deescalate care b/c of poor prognosis 42

43 Data to Be Reviewed = C 43

44 Final Result for Complexity 44

45 Medical Decision Making Definitions Additional workup Clearly link why a test is being ordered New problem New to patient or new to provider Independent review Per my read Per my personal review of the x ray Summarization of records 45

46 Medical Decision Making: Documentation Guidelines DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. For a presenting problem with an established diagnosis, the record should reflect whether the problem is: a) improved, well controlled; resolving, or resolved; or b) inadequately controlled, worsening, or failing to change as expected. 46

47 Other Contributing Factors Counseling Coordination of care Nature of presenting problem Time 47

48 Counseling Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) and/or follow up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education (CPT, 2018) 48

49 Counseling When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face to face time in the office or other outpatient setting, floor/unit time in the hospital or nursing facility), then time is considered the key or controlling factor to qualify for a particular level of E/M services (CPT, 2018) 49

50 Billing Based on Time DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face to face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care The extent of the counseling and/or coordination of care must be documented in the medical record (CPT, 2018) 50

51 Examples of Documenting Based on Time I spent 30 minutes with the patient, and 20 of the 30 minutes were spent in counseling the patient on I spent 30 minutes with the patient, and greater than 50% of the visit was spent in counseling the patient/family member on The entire visit of 30 minutes was spent counseling the patient on 51

52 Coordination of Care Coordination of care with other providers or agencies in the office setting must occur with the patient present 52

53 Nature of Presenting Problem A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter CPT recognizes 5 types Minimal Self limiting or minor Low Moderate High 53

54 Putting It All Together 54

55 New Patient or Consult (3 of 3) Element Level I Level II Level III Level IV Level V History HPI ROS PFSH Chronic Prob. Foc (1 3) None None Exp Prob (1 3) (1) None Detailed (4+) (2 9) (1) 3 Comp (4+) (10+) (all 3) 3 Comp (4+) (10+) (all 3) 3 Exam Prob. Foc Exp Prob Detailed Comp Comp (1995) (1) (2 7) (2 7) (8+) (8+) Medical Decision Making Straightforward Straightforward Low Moderate High Code min min min min min 55

56 Established Patient (2 of 3) Element Level I Level II Level III Level IV Level V History Prob. Foc Exp Prob Detailed Comp HPI ROS PFSH Non MD Service (1 3) None None (1 3) (1) None (4+) (2 9) (1) (4+) (10+) (2 of 3) Chronic 3 3 Exam Non MD Service Prob. Foc (1) Exp Prob (2 7) Detailed (2 7) Comp (8+) Medical Decision Making Non MD Service Straightforward Low Moderate High Code min min min min min 56

57 Initial Hospital Care (need 3 of 3) 1995 Guidelines Element Level I Level II Level III History HPI ROS PFSH Detailed (4+) (2 9) (1) Comprehensive (4+) (10+) (all 3) Comprehensive (4+) (10+) (all 3) Exam Detailed (2 7 organ systems) Comprehensive (8 organ systems) Comprehensive (8 organ systems) Medical Decision Making Straightforward to low Moderate High Code Time min min min 57

58 Subsequent Hospital Care (need 2 of 3) 1995 Guidelines Element Level I Level II Level III History HPI ROS PFSH Prob Foc Interval (1 3) None None Exp Prob Interval (1 3) (at least 1) None Detailed Interval (4+) (2 9) None Exam Prob Foc (1 organ system) Exp Prob (2 7 organs) Detailed (2 7 organs) Medical Making Decision Straightforward to low Moderate High Code Time min min min 58

59 Resources National Government Service E/M audit tool Highmark E/M audit tool Trailblazer E/M audit tool 1995 Documentation Guidelines 1997 Documentation Guidelines CMS Evaluation and Management Guide 59

60 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 60