Chapter 7 (p. 193) Evaluation and Management Page | 2
Physicians report codes for their services, located in the front of the manual. Dr sees a pt, generates charges.
· Evaluation of the pt
· Decision making process
· How they manage that pt
Format of E/M Codes (p. 194)
1. Unique code begins w/ 99
2. Place or type of service (phys office, out-pt service, initial/subsequent hospital care)
3. Extent or level of service (detailed history and detailed examination)
4. Nature of presenting problem (moderate severity)
5. Amount of time typically required to provide a service.
Eval/Mgmt Document Guidelines (99201-99496)
Developed by AMA and CMS to help clarity code assignment. Posted on CMS website.
Code Assignment for E/M Services
· What type of Pt? (New/Old)
· New Pt not seen by group in same (sub)specialty w/in 3yrs in
· What is the location of the service? (Office, Observation unit, Consult, LTC, Home Services, etc) (p. 193-4)
· What level of care?
Concurrent Care
Limit of 1 physician per day in same specialty. Consultants can submit claims.
Transfer of Care: Explicitly given responsibility for Pt care to another Pt. Not consulting.
Key Factors to determine appropriate E/M code assignment (3) and drive code selection of new pt
· History
· Examination
· Medical Decision Making
Contributing Factors (4) (when > 50% time w/Pt or family)
· Counseling
· Coordination of care
· Presenting problem
· Time
Documentation Guidelines (DG) provide requirements and definitions to help make determinations of levels in each of the 3 Key Factors/Elements so the coder may assign the correct E/M code.
History (p. 198)
· Problem-focused: CC + brief HPI or condition
· Expanded problem-focused: CC + brief HPI + problem pertinent ROS (subjective by Pt)
· Detailed: CC + expanded HPI + problem pertinent ROS + pertinent PSFH
· Comprehensive: CC + extended HPI + ROS directly related to problem ID'd in HPI + complete ROS + complete PSFH
ROS = Review of Systems
PFSH = Past, Family, Social History
As long as Dr has attested and signed off on having reviewed a system (nurses notes of review) then it can be used in the coding process. If it is covered in the Pt's intake forms, if Dr. signed off on it, it can be used. It does not have to be repeated in dictation.
Chief Complaint (CC) must be on each record somewhere. It may not say 'chief complaint', but the information must be presented. Not real helpful in determining level of visit. It locates a position for data to collect.
See Table 7.3 (at end) to understand determination of History Type.
Examination (p. 202)
1997 Guidelines (expanded single system exams) used below. 1995 Guidelines may also be used.
· Problem-focused: Limited to affected body area (aba) or organ system (os) -- 1-5 elements
· Expanded problem-focused: Exam of aba/os, as well as symptomatic or related (s/r)os –atleast6 elements
· Detailed:Extended exam of aba(s) and other s/ros – 2 elements in each of 6 areas or 12 elements in 2+ areas/systems
· Comprehensive: A gen’l multisyst exam or complete exam of a single-organ system and s/raba/os – All elements in at least 9 os/aba and documentation of at least 2 elements in those 9 areas/systems.
· Need at least specific system "Normal" to count a body system. Can't use "____ system abnormal" without an explanation.
See Table 7.4 (at end) to understand Examination Determination
Medical Decision Making (p. 205)
Use Figure 7.1/2000 Decision Table (p. 207).
· # of Dx (Number X Points)
· Amt/Complexity of the data
· Risk of complications, morbidity, mortality Tableof Risk on pg. 50 of guidelines
Highest 2 of 3:
· Straightforward: 1 or none (each) Minimal
· Low Complexity: 2 (each) Low
· Moderate Complexity: 3 (each) Moderate
· High Complexity: 4+ (each) Extensive
Counseling and Coordination of Care (p. 206)
Discussion of Pt care w/Pt or Pt’s family. Includes diagnositic studies, Tx options, instructions.
· Dr. documents total time of visit
· Dr includes specific time spent in counseling/coordination of care activities
Nature of Presenting Problem (p. 208)
Reason for the encounter, with or without established Dx. 5 types of presenting problems:
· Minimal: Dr not needed to be present for care (BPcheck)
· Self-limited or Minor: Temporary problem. Condition is transient. (upper resp. infection)
· Low Severity: Problem with low risk of morbidity and little or no risk of mortality. Expected full recovery (acne)
· Moderate Severity: With no Tx, Pt’s prognosis may be uncertain or prolonged functional impairment increased.
· High Severity: With no Tx, risk of morbidity high and possible severe, prolongued functional impairment.
Time (p. 210)
Face-to-Face Time
Unit/Floor Time
Hospital Observ. Services
In-Pt Hospital Care
Initial In-pt Hospital Consultants
Nursing Facility Care
Instructions for Selection and/or Validation of E/M Service Levels (p. 211)
1. ID category and subcategory of service
2. Review specific notes and instructions for the selected category and subcategory
3. Review narrative descriptors and 7 components should be reviewed for appropriate level of service code
4. Using definitions under each level of service:
a. determine extent of history obtained
b. determine extent of exam performed
c. determine complexity of medical decision making (MDM)
5. Select or verify the appropriate level of E/M Services.
(Tables below)
Chapter 7 (p. 193) Evaluation and Management Page | 2
Chapter 7 (p. 193) Evaluation and Management Page | 2
3 Key Elements that Define E/M Services (Tbl 7.1): Use 1997 Guidelines for exams
History / Examination / Medical Decision MakingProblem Focused / Problem Focused / Straightforward
Expanded Problem Focused / Expanded Problem Focused / Low Complexity
Detailed / Detailed / Moderate Complexity
Comprehensive / Comprehensive / High Complexity
Determining the Type of History (Tbl 7.3)
Components of a History
History Component(equal to lowest category documented) / Problem-Focused / Expanded Problem-Focused / Detailed / Comprehensive
Chief Complaint ______
*(CC required for all history types)
HPI--History of Present Illness
__Location __Severity __Timing
__Duration __Quality __ Context
__ Modifying factors __Assoc. signs/symptoms / Brief:
1-3 HPI elements documented / Brief:
1-3 HPI elements documented / Extended:
4+ HPI or status of 3+ chronic conditions documented / Extended:
4+ HPI or status of 3+ chronic conditions documented
ROS--Review of System(s)
__Constitutional __Integumentary
(wt loss, etc) __Endocrine
__Eyes __GI __ Neurologic
__ENT, mouth __GU __ Psychiatric
__Cardiovascular __MS __ Hem/Lymph
__Respiratory __Allergy/immun / None / Problem specific:
1 system / Extended:
2-9 systems
Need specific system "Normal" and can't use system "abnormal" without explanation / Complete:
>10 systems or some with all other negative
PFSH (past medical, family, and social history)
__Previous medical (past experience w/illness, injury, surgery, medical Tx, and so on)
__Family medical history (diseases, which may be hereditary or w/increased risk of occurrence)
__Social (relationships, diet, exercise, occupation, and so on) / None / None / Pertinent:
At least 1 item from at least one history area / Complete: specifics of at least two history areas documented
Determining the Type of Examination (Tbl 7.4)
Components of an Examination (Using ’97 Guidelines)
Examination Component / Problem-Focused / Expanded Problem-Focused / Detailed / ComprehensiveBody Areas Organ Systems
__Head, face __Const (vitals, gen'l appearance)
__Neck __Eyes __GU
__Chest, breasts __ENT, mouth __Skin
__Abdomen __Respiratory __Integumentary
__Genit, groin __Cardiovascular __MS
__Back, spine __Gastrointestinal __Neurological
__Each extremity __Lymph/hem/immun __Psychiatric / 1-5 elements identified by a bullet / At least 6 elements identified by a bullet / At least 2 elements id’d by a bullet from each of 6 aba/os
OR
at least 12 elements id’d by a bullet in 2 or more aba/os / All elements id’d by a bullet in at least 9 aba/os and document at least 2 elements id’d by a bullet from each of 9 aba/os
Determining the Type of Examination (Tbl 7.4)
Components of an Examination (Text version (’95 Guidelines?))
Examination Component / Problem-Focused / Expanded Problem-Focused / Detailed / ComprehensiveBody Areas Organ Systems
__Head, face __Const (vitals, gen'l appearance)
__Neck __Eyes __GU
__Chest, breasts __ENT, mouth __Skin
__Abdomen __Respiratory __Integumentary
__Genit, groin __Cardiovascular __MS
__Back, spine __Gastrointestinal __Neurological
__Each extremity __Lymph/hem/immun __Psychiatric / 1 body area or system / 2-4 body syst or
2-7 basic systems, including affected area / 2-7 detailed systems, including affected area / 8+ systems