Rational Physician Coding for E/M Consult Services. Redacted Version. Peter R. Jensen, MD, CPC
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1 Rational Physician Coding for E/M Consult Services Peter R. Jensen, MD, CPC
2 Rational Physician Coding for E/M Consult Services Peter R. Jensen, MD, CPC For clinically driven E/M coding education, go to Goals Know the definition of a consult Learn the documentation requirements for consult services Understand how to identify the highest ethical level of care Streamline your documentation to save time Maintain the focus on patient care 1
3 O q A f tr C m p What is a Consult? 2
4 Types of Consults E/M Code Outpatient Consults History PF EPF Detailed Comp Comp Exam PF EPF Detailed Comp Comp MDM Low Mod High 3 out of 3 key components must qualify PF SF Time
5 E/M Code Outpatient Consults Inpatient Consults History PF EPF Detailed Comp Comp Exam PF EPF Detailed Comp Comp MDM Low Mod High out of 3 key components must qualify SF SF s Time ts 4
6 Inpatient Consults ted only per ing the es Outpatient vs. Inpatient 5
7 Inpatient Outpatient Outpatient vs. Inpatient Outpatient Consults E/M Code E/M Code Documentation History PF EPF Detailed Comp Comp History PF EPF Exam PF EPF Detailed Comp Comp Exam PF EPF Inpatient Consults MDM Low Mod High MDM Detailed Detailed Low Comp Comp Mod Comp Comp High 110 PF SF SF SF Time Time 3 out of 3 key components must qualify
8 Coding Based on Time Inpatient Outpatient 7
9 8
10 Hx PF E/M Co Thi fre cod enc Rei abo E/M Co o Comprehensive HPI Brief T R N EPF Brief Det Ext 2 Comp Ext 9
11 What Does a Look Like? You You sulin Fina ons and The min
12 Self li Establ Establ worse New p work- New p work-up planned Decision to obtain old records 1 Review of old records 2 Total Points = 4 Total Points = 4 11
13 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Need 2 out of 3 to qualify for given level of MDM 12
14 Selecting the Target Code E/M Code Inpatient Consults History Exam MDM Time 13
15 History History Comp HPI Extended ROS 10 PFSH 3/3 Req thre item This HPI PFS RO are cut, Reason for consult: Pre-op clearance Requesting Physician: John Doe, MD HPI: This is a 77 YOWM with multiple medical problems, including well controlled HTN, stab bein requ PM SH: FH: thre RO Ta E/M Insight: Comprehensive History 14
16 Exam GI GU E/M Insight: Comprehensive Exam 14 hest/breasts Skin sculoskeletal 19 Neurologic Psychiatric DM High Requires at least two bullets from EACH of NINE organ systems. The example above qualifies based on the following bullets and organ systems:
17 Medical Decision-Making Assess Plan: Targ 99 Requires Four o Four o High ri The exam points, ev EKG: NSR; no diagnostic ST changes 16
18 Reaso Doe, MD HPI: T well controlled ht hip early t orthopedic se and risk asses PMH: FH: M SH: M ROS Vitals: Gen: Eyes: HENT Neck: Lungs CV: R Abd: Ext: N Skin: Asses Plan: 1. Wil 2. Sta 3. D/ 4. Co 5. En 6. Ec 7. Ok rent Medications nopril 10 mg QD formin 500 mg BID ur 30 mg QD tor 20 mg QD diagnostic ST changes 17
19 99245 E/M Code History Exam MDM Time Co Hx PF EPF Det Comp Comp Comp High 80 18
20 Yo cre Aft U/S foll The Prob Self limited Established Established worsening New proble work-up pla New proble work-up pla Outpatient Renal Consult 19
21 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast ABG Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without Need 2 out of 3 to qualify for given level of MDM 20
22 Selecting the Target Code e y tal nly of DM gh 21
23 H C History Rea HPI: cont incr elev RO Pert occ dys Com of a no fi dise Tar 9 E/M Insight: Comprehensive History Requires an extended HPI (four or more HPI elements or the status of 22
24 GI GU Requires at least E/M Insight: Comprehensive Exam Chest/Breasts 15 Skin Musculoskeletal 19 Neurologic Psychiatric MDM High 16 23
25 Review of old records: We have a note from Dr. Hayes office dated six months ago, which showed a creatinine of 1.9. At that time, the patient s BP was 160/80. Lisinopril was increased from 10 to 20 mg QD. Patient was l d A P Req F F H The deci Medical Decision-Making
26 Reason for consult: CKD Requesting Physician: Richard Hayes, e, no lid-lag, PERRLA ormal hard/soft palate thyromegaly on /nodules ropriate affect 25
27 EPF E/M Co M us en Re ab E/M Co o Comprehensiv Hx PF Det Comp HPI Brief Brief Ext Ext
28 What Does a Look Like? You ar patient He is p cholec You di hypern meq o Total ti minute What s Problem Self limited or Established pro Established pro worsening New problem, work-up planne New problem, work-up planne 27
29 Risk Presenting Problems Diagnostic Procedures Management Options Need 2 out of 3 to qualify for given level of MDM 28
30 Selecting the Target Code E/M Code Inpatient Consults History Exam MDM Time 29
31 History History HPI ROS PFSH Re thr of Th HP as PF RO ca yo. R H c y in P S F fa R E/M Insight: Comprehensive History 30
32 l Exam GI 14 GU hest/breasts Skin sculoskeletal 19 Neurologic Psychiatric DM Mod s. d organ Lungs Auscultation of lungs Percussion of lungs Assessment of orientation Assessment of affect 31
33 Medical Decision-Making Assessm Plan: 15 3 Target 992 E/M Insight: Moderate Complexity MDM Requires two out of three: 32
34 Vitals: 120/80, 28, 111, 99.6 Gen: Well-nourished middle-aged WM; confused Eyes: Anicteric
35 Hx PF EPF Det Comp E/M Code E Det History Exam MDM Time Det Low 55 34
36 What Does a Look Like? You are consulted for Problems Self limited or mi Established probl Established probl worsening New problem, no work-up planned New problem, ad work-up planned To MDM Points 35
37 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging Over the counter drugs Minor surgery, with no risk factors 36
38 Selecting the Target Code Inpatient Consults History Exam MDM Time 37
39 History History Detailed HPI Extended ROS 2 9 PFSH 1/3 Reason for consult: Post-op HTN spontaneous somatic complaints. ROS Requir three from o This e HPI: C PFSH: ROS:. Target Code Requesting physician: John Doe, MD sional knee pain, he has no 3 out of 3 key components must qualify History Det Exam Det E/M Insight: Detailed History MDM Low 38
40 Exam Constitutional Eyes ENMT Neck Lungs CV GI GU Target Code History Det Exam Det E/M Insight: Detailed Exam MDM Low A detailed exam requir The example above contains the 39
41 Medical Decision-Making Asse Plan Tar Low complexity MDM requires E/M Insight: Low Complexity MDM 40
42 Vitals: 148/90, 18, 82, 98.6 Gen: NAD, conv 41
43 E/M Code EPF History Exam MDM EPF SF Time 40 42
44 What Does a Look Like? Suppose you are consulted to see the Pro Self limited Establishe Establishe worsening New proble work-up pl New proble work-up pl MDM Points 43
45 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings 44
46 Selecting the Target Code 45
47 History History HPI ROS PFSH ROS Target Code 99 An expanded CV: Negative for SSCP/orthopnea/PND History Exam MDM E/M Insight: Expanded Problem Focused History 46
48 Exam Constitutional Eyes ENMT Neck Lungs CV GI GU Chest/Breasts 1. A Vit Ge Ne Lun CV Ab T E/M Insight: Ex 6. Abdominal exam This adds up to exactly 47
49 Medical Decision-Making Target Code E/M In History risk is actually more then enough.) Exam MDM all three dimensions of MDM. (The 48
50 Vitals: 125/75, 18, 82, 98.6 Gen: NAD, QD 49
51 E/M Code PF History Exam MDM Time PF SF 20 50
52 Sel Est Est wor Ne wor Ne wor Example You are asked to evaluate a patient for 51
53 Risk Presenting Problems Diagnostic Procedures Management 52
54 Selecting the Target Code 53
55 History HPI: The Target Code A problem focused History Exam E/M Insight: Problem Focused History MDM 54
56 Exam Constitutional Eyes ENMT Neck Lungs CV GI GU It is difficult (but not impos E/M Insight: Problem Focused Exam Chest/Breasts Skin Musculoskeletal Neurologic Psychiatric MDM SF 55
57 Medical Decision-Making La As Pla Ta Straig On On Min The e 56
58 99251 Reason for consult: three days. Vitals: 125/75, 18, 82, 98.6 Gen: NAD, conversant; labs for the last 57
59 History Physical MDM Perform the documentation in a purpose-driven manner Don t document more than is necessary to take care of the patient and maintain compliance Three out of three key components are always Peter R. Jensen, MD, CPC Online and On-site Physician-to-Physician E/M Coding Education U-EM-CODE pjensen@emuniversity.com Practical E/M Coding Education 58
Rational Physician Coding for Hospital Progress Notes. Redacted Version. Peter R. Jensen, MD, CPC
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