Evaluation & Management

Documentation and Coding

Guidelines
Presented by:
Kristi A. Gutierrez CCS-P, CPC, CEMC
Objectives
• Participants will gain a working knowledge of
Medicare’ss 1995 Evaluation & Management
Medicare
Documentation Guidelines.

• Participants will be able to apply the knowledge

in everyday
y y situations while seeing gppatients in
order to utilize the correct level of Evaluation &
Management Service and document that service
to meet Medicare’s
di ’ Guidelines.
id li
Agenda
• Medicare’s ‘95 Documentation Guidelines (DG) for
Providers

• New and Established Patient Visits

• Consultations

• Hospital Services

•C
Coding
di an Evaluation
E l i & Management
M S
Service
i B Based
d
on Time
Overview
• Medicare’s 1995 guidelines were developed to
assist providers in choosing a level of service
service.
Per Medicare’s DG the visit is made up of three
(3) key components:
▫ History;

▫ Physical Exam; and

▫ Medical
M di l Decision
D i i M Making.
ki
What does Medicare need documented to
bill a level of service?
• History
▫ Chief Complaint (CC)
▫ History of Present Illness (HPI)
▫ Review of Systems (ROS)
▫ Past, family and/or social history (PFSH)
• Examination
• Medical Decision Making (MDM)
Medical Decision Making (MDM)
• Medical Decision Making refers to the
complexity of establishing a diagnosis and/or
selecting a management option as measured by:
MDM Cont’d
• Number of possible diagnoses and/or 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 complications, morbidity
and/or
d/ mortality,
t lit as wellll as co-morbities,
biti associated
i t d
with the patients presenting problem(s), the
diagnostic
g p
procedure(s)
( ) and/or
/ the p
possible
management options.
Number of Management Options/Diagnoses
• Self limited/minor (max 2 problems) or
Est prob stable/improved = 1 point
• Established Problem worsening = 2 points
• New problem; no additional work up planned
(max 1 prob) = 3 points
• New p problem;
b ; additional work up
ppplanned ((max
1 prob) = 4 points
Scoring the Number of Diagnoses or
Management Options
• 1 point = Minimal

• 2 points = Limited

• 3 points = Multiple

• 4 points or more = Extensive

Amount or complexity of data reviewed
• Review and/or order of clinical lab tests =1 point (max)

• Review and/or order radiology tests =1 point (max)

• Review
R i and/or
d/ order
d 90000 series
i tests
t t =11 point
i t (max)
( )

• Discussion of test results w/performing physician =1 point

• Decision to obtain old records and/or obtain history

from someone other than the patient =1 point

• Review and summarization of old records and/or

obtaining history from someone other than
the
h patient
i and/or
d/ di discussion
i off case with
ih
another health care provider =2 points

• Independent visualization of image, tracing or

specimen itself (not simply reviewing report) =2 points
Scoring the Amount or Complexity of Data
Reviewed
• 1 point = Minimal

• 2 points = Limited

• 3 points = Moderate

• 4 points or more = Extensive

Table of Risk
Presenting Problem(s) Diagnostic Proc.Ordered Management Option(s) Level of Risk
Selected
One self limited or minor problem e.g. Lab tests req. venipuncture, Rest
cold insect bite,
cold, bite tinea corporis.
corporis chest X
X-rays
rays, EKG
EKG-EEG
EEG, UA,
UA G l
Gargles
Minimal
Ultrasound, e.g. echo, KOH Elastic bandages
prep.
Superficial dressings

2 or more self-limited or minor Physiologic tests not under OTC drugs

problems stress Minor surg no risks
Low
1 stable chronic illness Non-cardiovascular imaging PT/OT
Acute uncomp illness or inj Superficial needle biopsies IV fluids no additives

1 or more chronic illnesses w/ mild Physiologic tests under stress Minor surg w/ risks
exacerbation Diagnostic endoscopies Elective major surg
Moderate
2 or more stable chronic illnesses Deep needle biopsies Rx drug manage
IV fluid w/ additives

1 or more chronic illnesses w/ severe Cardiovascular imaging Elec. major surg w/ risks
exacerbation Cardiac EP studies Emerg major surg
High
g
Acute or chronic illness w/ threat to Diagnostic endo w/risks Parenteral controlled Rx
life/limb Discography

**** This is an abbreviated Table of Risk. Use Medicare guidelines for full Table of Risk
Scoring the Table of Risk
• The highest level of risk from any column is the
level to choose.
choose
Scoring the Overall MDM

Number Amount or
Diagnoses or Complexity of Risk MDM Level
Management Data Reviewed
p
Options
Minimal Minimal Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate

Extensive Extensive High High

Circle the score for each area of the MDM. Two (2) out of three (3) must meet
or exceed the level chosen.
History
• The history portion of the chart is made up of
four (4) components
▫ Chief Complaint (CC)
▫ History of Present Illness (HPI)
▫ Review of Systems (ROS)
▫ Past, Family and/or Social History (PFSH)
• The HPI, ROS and PFSH must all meet or
exceed the scoring for the overall level chosen
f the
for h History
i portion
i off the
h chart.
h
Chief Complaint (CC)
• Every patient visit needs to list a CC.
• The CC is a concise statement describing the
symptom, problem, condition, diagnosis,
provider recommended return or other factor
that is the reason for the encounter.
Scoring the CC
• Per Medicare’s DG there is no “scoring” of the
CC although the guidelines do state that the CC
needs to be present.
History of Present Illness (HPI)
• The HPI is a chronological description of the
development of the patient’s
patient s present illness from
the first sign and/or symptom or from the
previous encounter to the present.
HPI Cont’d
• Per Medicare DG the HPI includes:
▫ Location
▫ Quality
▫ Severity
▫ Duration
▫ Timing
▫ Context
▫ Modifying factors
▫ Associated
d signs and
d symptoms.
Scoring the HPI
• Count the number of elements the provider
documented for the HPI.
HPI

▫ One (1) to three (3) elements constitutes a Brief

HPI

▫ Four (4) or more elements constitutes an

Extended HPI
Review of Systems (ROS)
• A ROS is an inventory of the body systems
obtained through a series of questions seeking to
identify signs and/or symptoms which the
patient may be experiencing or has experienced.
• The
h ROS may b be obtained
b i db by ancillary
ill staff
ff or b
by
a form the patient fills out (this may also be
obtained by Medical Students.)
• It must be evidenced that it was reviewed by the
provider and any information supplementing or
confirming
fi i the h ROS must b be ddocumented. d
ROS Cont’d
Per Medicare DG the following systems are recognized:
▫ Constitutional ▫ Musculoskeletal
▫ Eyes ▫ Integumentary
▫ Ears, nose, mouth, ▫ Neurological
throat
h ▫ Psychiatric
▫ Cardiovascular ▫ Endocrine
▫ Respiratory ▫ H
Hematologic/Lymphatic
t l i /L h ti
▫ Gastrointestinal ▫ Allergic/Immunologic
▫ Genitourinary
ROS Cont’d
• If a template is used to document the ROS, each
box must be individually marked and all positive
systems must be commented on.

• When documenting the patient record, the

statement “all other systems reviewed and
negative” is considered a complete ROS after
negative
commenting on the systems with positive
responses. The statement “non contributory” is
not sufficient
ffi i d
documentation
i off a ROS.
Scoring the ROS
• Count the number of elements documented in
the ROS.
ROS
▫ One (1) element is a Problem Pertinent ROS
▫ Two (2) to nine (9) elements is an Extended ROS
▫ Ten (10) or more elements is a Complete ROS
Past, Family, Social History (PFSH)
• The PFSH consists of a review of three areas:
▫ Past history (the patient’s
patient s past experiences with
illnesses, surgeries, injuries, etc)
▫ Familyy historyy ((the p
patient’s review of significant
g
family medical events)
▫ Social history (an age appropriate review of past
andd current activities)
i ii )
PFSH Cont’d
• The PFSH may be obtained by ancillary staff or
through a form the patient fills out (this too may
be obtained by a Medical Student.)

• It must be evidenced that it was reviewed by the

provider and anyy information supplementing
p pp g or
confirming the PFSH must be documented.
Scoring the PFSH
• Count the number of elements documented for the
PFSH
▫ One (1) element from any of the three (3) areas
constitutes a Pertinent PFSH
▫ One (1) element from two (2) of the three (3) areas
constitutes
tit t a C Complete
l t PFSH ffor:
x established patients, ED, subsequent nursing facility care,
domiciliary care (est. pt),or home care (est. pt)
▫ One (1) element from all of the three (3) areas
constitutes a Complete PFSH for:
x new patients, hospital observation services, hospital
inpatient services initial care, consults, comprehensive
nursing facility evals, domiciliary care (new pt) or home
care (new pt)
 Scoring the Overall History
HPI ROS PFSH Overall History
Brief N/A N/A Problem Focused

Brief Problem Pertinent N/A Expanded Problem Focused

Extended Extended Pertinent Detailed

Extended Complete Complete Comprehensive

Circle the score in each column.

All three ((3)) must meet or exceed the level of service chosen.
Exam
Medicare’s DG recognize the following body areas and organ
systems:
▫ Head, including the face ▫ Constitutional (e.g. vitals,
▫ Neck appearance)
▫ Chest, including the breasts & ▫ Eyes
axillae ▫ Ears, nose, mouth and throat
▫ Abdomen ▫ Cardiovascular
▫ Genitalia, groin, buttocks ▫ Respiratory
▫ Back, including spine ▫ Gastrointestinal
▫ Each extremity
Exam Cont’d
▫ Genitourinary
▫ Musculoskeletal
▫ Skin
▫ Neurologic
▫ Psychiatric
▫ Hematologic/lymphatic/immunologic
Exam Cont’d
• Specific abnormal and relevant negative findings
of the affected area should be documented.
documented
• A notation of abnormal without elaboration is
not sufficient.
• A brief statement or notation noting negative or
normal is sufficient for
unaffected/asymptomatic areas.
Scoring the Exam
• Count the number of elements documented as
examined by the p
provider:
▫ Problem Focused Examination - limited exam of
affected body area or organ system (1)
▫ Expanded Problem Focused Examination - limited
exam of affected body area or organ system and other
symptomatic related organ systems (2-7)
▫ Detailed - extended exam of affected body areas or
organ systems and other symptomatic or related organ
systems (2-7)
▫ Comprehensive
C h i - a generall multi-system
lti t exam or
complete exam of a single organ system (8 or more)
Scoring the Overall Chart
• New patients
▫ 3 out of 3 areas must meet or exceed the level of service chosen
• Established
E t bli h d patients
ti t
▫ 2 out of 3 areas must meet or exceed the level of service chosen
• Consultations
▫ 3 out of 3 areas must meet or exceed the level of service chosen
• Initial Observation Services
▫ 3 out of 3 areas must meet or exceed the level of service chosen
• Initial Hospital
p Services
▫ 3 out of 3 areas must meet or exceed the level of service chosen
New Patient Office Visits
• New Patient – A new patient is a patient who has
not had a face to face encounter in the last three
years:
▫ By the same provider

▫ By a provider of the same specialty in the same

group
New Patients
History Exam MDM CPT

Problem Focused Problem Focused Straightforward 99201

Expanded Expanded
Problem Focused Problem Focused Straightforward 99202

Detailed Detailed Low 99203

Comprehensive Comprehensive Moderate 99204

Comprehensive Comprehensive High 99205

** All three must meet or exceed the level of service you have chosen
Established Patients
History Exam MDM CPT
NA NA NA 99211
Problem Focused Problem Focused Straightforward 99212
Expanded Problem Expanded Problem Low 99213
Focused Focused
Detailed Detailed Moderate 99214
Comprehensive Comprehensive High 99215

** Two out of the three elements must meet or exceed the level of service you have chosen
Consultations
• A consultation is distinguished from a visit
because it is done at the request of a referring
provider and the consultant prepares a report of
his/her findings that is provided to the referring
provider for his or her use in treatment of the
patient.
The three “R”s of a Consultation
• Request - Documentation of the Request for
consultation from the referring provider

• Reason - The Reason for the consult which must

be medically reasonable and necessary

• Report - The written Report by the consultant

which was provided back to the referring
physician
Outpatient Consultations
History Exam MDM CPT
Problem Focused Problem Focused Straightforward 99241
Expanded
p Problem Expanded
p Problem Straightforward
g f 99242
Focused Focused

Detailed Detailed Low 99243

Comprehensive Comprehensive Moderate 99244
Comprehensive Comprehensive High 99245
**Three out of the three must meet or exceed the level of service you have chosen
Inpatient Consultations
History Exam MDM CPT
Problem
bl Focusedd Problem
bl Focusedd Straightforward
hf d 99251
Expanded Problem Expanded Problem Straightforward 99252
Focused Focused

Detailed Detailed Low 99253

Comprehensive Comprehensive Moderate 99254
Comprehensive Comprehensive High 99255
**Three out of the three must meet or exceed the level of service you have chosen
Initial Hospital Observation Services
History Exam MDM CPT

Detailed/ Detailed/ Straightforward/

Comprehensive
p Comprehensive
p Low
99218

Comprehensive Comprehensive Moderate 99219

Comprehensive Comprehensive High 99220

**Three out of the three must meet or exceed the level of service you have chosen
Initial Hospital Services

Historyy Exam MDM CPT

Detailed/ Detailed/ Straightforward/

C
Comprehensive
h C
Comprehensive
h L
Low
99221

Comprehensive
p Comprehensive
p Moderate 99222

Comprehensive
p Comprehensive
p High
g 99223
**Three out of the three must meet or exceed the level of service you have chosen
Subsequent Hospital Services

Historyy Exam MDM CPT

Detailed/ Detailed/ Straightforward/

C
Comprehensive
h i C
Comprehensive
h i L
Low
99231

Comprehensive
p Comprehensive
p Moderate 99232

Comprehensive Comprehensive High 99233

**Two out of the three must meet or exceed the level of service you have chosen
Observation or Inpatient Care Services
History Exam MDM CPT

Detailed/ Detailed/ Straightforward/

Comprehensive
p Comprehensive
p Low
99234

Comprehensive Comprehensive Moderate 99235

Comprehensive Comprehensive High 99236

**Three out of the three must meet or exceed the level of service you have chosen
These codes are for patients that are admitted and discharged on the same day.
Time Based Evaluation & Management
Services
• Time may be the controlling factor when
determining a level of service
service. In order to use
time as the controlling factor, the provider must
document the following:
▫ The total face-to-face time spent with the patient
▫ That over 50% of that time was spent in
counseling or coordination of care for the patient
▫ The nature or content of the counseling and
coordination of care
Time Based Evaluation & Management
Services cont’d
cont d
• Medicare expects that coding based on time is
the exception to the rule not a regular
occurrence.
• In order to determine what level of service was
provided based on time, look at the average time
spent for that level of service.
• For example, the average time spent (according
to the CPT manual) for a 99214 is 25 minutes.
 Now that I know how to document to
support coding based on time. Where can I
find the average time spent for each visit?
Thank You

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h quiz ffor this
h course.