1

1

E/M Auditing

Shannon O. Smith, CPC, CPC-I, CEMC, CMSCS, CPMA

DoctorsManagement/NAMAS

2

Today’s Session

• Auditing Basics

• Teaching the Provider

• E&M Documentation Guidelines

• Documentation Components

• Difference Between 1995 & 1997 Guidelines

2

3

Auditing Basics

• Why are you performing the audit?

– Compliance

– Risk Management

– Reimbursement

– Combo

• Should it matter?

4

The Well-Rounded Audit

• Random dates

– Don’t pull all of your charts from one date of service

• Random services

– Provider specialty specific

– Don’t forget IP services

• Make sure you obtain all forms referred to

– Initial history forms

– Consult letters

• Services other than E/M

3

5

The Well-Rounded Audit

• Review of what to look at:

– Patient encounter

– Any forms the provider refers to

– Encounter form

– CMS-1500 claim form

– EOB

– Productivity

6

The Well-Rounded Audit

• Remember to audit for the “HOT” issues

– Provider signatures

– Incident-to services

– Providers legibly identified name

– Date documentation produced (dictated/EMR)

– Diagnosis

– Orders

4

7

The Auditor’s Job

• NOT TO ASSUME!

• Give credit were credit is due, but don’t put your back against the fence.

• Do NOT second guess the providers medical care.

• Educate. Educate. Educate.

• Cover yourself.

8

The Report• Contents

– Findings

– Grids

– Productivity

– Comparisons

– Educational Resources

• What about the Compliance Plan?

5

9

Be specific in your findings to the provider.

Do not be afraid to tell them what they did not do correctly.

10

6

11

Grade each provider you audit.

Show them approximately how much they are costing themselves annually.

12

Show the provider what level of service the documentation is and the medical necessity supported.

Also show the financial impact- AGAIN!

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13

Show the provider specifics regarding their documentation.

For specialty providers, show that you scored the documentation under 95 and 97 guidelines.

14

E/M Components• Chief Complaint

– In the patient’s own words

– Documented on all encounters

– Make sure to educate the nursing staff

– The driving force of the medical complexity of the service

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15

E/M Components• History of Present Illness

– Symptoms the patient is having caused by the chief complaint

– 4 is the maximum number needed

– “Mommy Questions”

– How hard is it to get 4 elements on every patient, every encounter

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E/M Components

History of Present Illness

– Timing

– Context

– Modifying Factors

– Associated Signs and Symptoms

–Location–Quality–Severity–Duration

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17

E/M Componentscc: Diabetes

The patient has a 20-year history of diabetes. He has been on Glucophage and currently his diabetes is stable although he does note shifts in sugar levels first thing in the morning.

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E/M Componentscc: Diabetes

The patient has a 20 year history of diabetes. He has been on Glucophage and currently his diabetes is stable although he does note shifts in sugar levels first thing in the morning.

10

19

E/M Components

• History of Present Illness

– These guidelines are pertinent to 1995 & 1997 Documentation Guidelines

– 1997 Guidelines do allow for documenting the HPI in another manner

– STATUS of the 3 chronic or inactive conditions

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E/M Components

• History of Present Illness

– Key to the documentation is the inclusion of the status of each

– Can be documented anywhere in the medical record

– May be used in lieu of 4 HPI elements

11

21

E/M Components

Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems:

Diabetes: Stable on the Glucophage

Depression: Mood swings noted especially at work- he continues to take Prozac

Eczema: Flares have been occurring since the onset of the winter months.

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E/M ComponentsMr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems:

Diabetes: Stable on the Glucophage

Depression: Mood swings noted especially at work- he continues to take Prozac

Eczema: Flares have been occurring since the onset of the winter months.

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E/M Components

• Review of Systems– The review of systems is a required portion of the

documentation because it tells what other systems have been affected by the chief complaint.

– Simply asking the patient if they are having any other problems today will satisfy that all ROS have been reviewed. (LCDs may override)

– Guidelines are the same regardless of 1995 or 1997 Documentation Guidelines

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E/M Components

• Constitutional

• Eyes

• ENT

• Card/Vasc

• Resp

• GI

• GU

• Musculo

• Endo

• Integumentary

• Neuro

• Hem/lymph

• All/Immuno

• Psych

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• Past Family Social History

– PFSH should be reviewed with every patient on every visit because items in their history may help explain the reasons for the patient’s chief complaint.

– A key point to remember is that you may refer to any form in the patient’s chart, as long as this referred to documentation is also reviewed. We recommend that each time you refer to this sheet that you initial and date it to prove that you did review this information.

E/M Components

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• After reviewing the documentation you may now, within the current days documentation incorporate a statement of, “PFSH has been reviewed as per the intake form, at this time there are no changes to note,” or “PFSH has been reviewed as per the intake sheet and the pertinent changes/updates are as follows…”

• Documenting in this way will support a comprehensive level of service in this portion of the documentation.

• No rule regarding content volume

• PFSH is the same for 1995 and 1997 Guidelines

E/M Components

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Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems:

Diabetes: Stable on the Glucophage

Depression: Mood swings noted especially at work- he continues to take Prozac

Eczema: Flares have been occurring since the onset of the winter months.

ROS: - for N/V/D, fever, headaches, coughs, and muscle aches.

PFSH: Family history- (+) Diabetes

Social history- Smoker

Past history- (-) Skin cancer

E/M Components

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Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems:

Diabetes: Stable on the Glucophage

Depression: Mood swings noted especially at work- he continues to take Prozac

Eczema: Flares have been occurring since the onset of the winter months.

ROS: - for N/V/D, fever, headaches, coughs, and muscle aches.

PFSH: Family history- (+) Diabetes

Social history- Smoker

Past history- (-) Skin cancer

E/M Components

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E/M Components

• Exam

– 1995 vs. 1997 Documentation Guidelines

– 1995 body systems

– 1997 bullets

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E/M Components

• 1995 Documentation Guidelines will have an exam which falls into one of these categories:

– Problem Focused: Exam of the affected system

– Expanded Problem Focused: Exam of the affected system and other related systems

– Detailed: Detailed exam of the affected body system and other related systems (some carriers allow 5-7 systems instead)

– Comprehensive: 8 or more systems

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E/M Components

• Under 1995 Documentation Guidelines, qualifying body systems are:

– Cardiovascular

– ENT

– Eyes

– Genitourinary

– Lymph/immunologic

– Musculoskeletal

– Neurological

– Psychiatric

– Respiratory

– Skin

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E/M ComponentsOn exam, Mr. King is mildly agitated by his pain, alert and oriented X 3. His back has good range of motion.

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E/M ComponentsOn exam, Mr. King is mildly agitated by his pain, alert and oriented X 3. His back has good range of motion.

Based on 1995 Documentation Guidelines

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E/M Components1997 Exam Documentation Guidelines will have exams that fall into one of the following categories:

– Problem Focused: 1-5 bullets

– Expanded Focused: 6 bullets

– Detailed: 12 bullets

– Comprehensive: 18 bullets

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E/M ComponentsMr. Star is in no apparent distress today, alert and oriented X 3. Patient’s gait appears good, with good range of motion. On palpation, no tenderness was noted over the L3-L4 area. No swelling was noted in the feet, and the skin appears normal in nature.

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E/M ComponentsMr. Star is in no apparent distress today, alert and oriented X 3. Patient’s gait appears good, with good range of motion. On palpation, no tenderness was noted over the L3-L4 area. No swelling was noted in the feet, and the skinappears normal in nature.

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E/M Components• Medical Decision Making

– Same for 1995 and 1997 Guidelines

– 3 sections to Medical Decision Making

• Number and treatment level of diagnoses

• Tests ordered, records interpreted or reviewed

• Level of risk

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E/M Components• Number and treatment level of diagnoses

– Improved

– Worsening

– New Patient w/o additional work up

– New Patient w/ additional work up

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E/M Components

Test Reviewed/Ordered, Summarization

Ordering Labs/X-rays/Medicine Tests: 1 point per testSummarization/Decision to obtain Records: You must give an overview of records for the summarization and you must document you are requesting for decision: 2 pointsIndependent Reading of Films: Interpreting X-ray films will give you 2 points.

Discussion with another provider

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Risk of Complications and/or Morbidity or Mortality

Levels of

ServiceLevel of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options

99201

99241

99202

99212

99242

Minimal

O One self-limited or minor problem, e.g. cold, insect

bite, Tinea Corporis

O Laboratory tests requiring venipuncture

O Chest x-rays

O EKG/EEG

O Urinalysis

O Ultrasound, e.g., echo

O KOH prep

O Rest

O Gargles

O Elastic bandages

O Superficial dressings

99203

99213

99243

Low

O Two or more self-limited or minor problems

O One stable chronic illness, e.g. well controlled

hypertension or non-insulin dependent diabetes, cataract,

BPH

O Acute uncomplicated illness or injury, e.g. cystitis,

allergic rhinitis, simple sprain

O Physiologic tests not under stress, e.g., pulmonary function tests.

O Non-cardiovascular imaging studies with contrast, e.g., barium

enema

O Superficial needle biopsies

O Clinical laboratory tests requiring arterial puncture

O Skin biopsies

O Over-the-counter drugs

O Minor surgery with no identified risk factors

O Physical therapy

O Occupational therapy

O IV fluids

99204

99244

99214

Moderate

O One or more chronic illnesses with mild exacerbation,

progression, or side effects of treatment

O Two or more stable chronic illnesses

O Undiagnosed new problem with uncertain prognosis,

e.g., lump in breast

O Acute illness with systematic symptoms,

e.g.pyelonephritis, pneumonitis, colitis.

O Acute complicated injury, e.g., head injury with brief

loss of consciousness

O Physiologic tests not under stress, e.g. cardiac stress test, fetal

contraction stress test

O Diagnostic endoscopies with no identified factors

O Deep needle or incisional biopsy

O Cardiovascular imaging studies with contrast and no identified

risk factors, e.g. arteriogram cardiac cath

O Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis,

culdecentisis

O Minor surgery with identified risk factors

O Major surgery (open, percutaneous or endoscopic)

with no identified risk factors

O Prescription drug management

O Therapeutic nuclear medicine

O IV fluids with additives

O Closed treatment of fracture or dislocation without

manipulation

99215

99205

99245

High

O One or more chronic illnesses with severe

exacerbation, progression, or side effects of treatment

O Acute or chronic illnesses or injuries that may pose a

threat to life or bodily function, e.g. multiple trauma, acute

MI, pulmonary embolus, severe respiratory distress,

progressive severe rheumatoid arthritis, psychiatric illness

with potential threat to self or others, peritonitis, acute

renal failure

O An abrupt change in neurologic status, e.g., seizure,

TIA, weakness or sensory loss

O Cardiovascular imaging studies with contrast with identified risk

factors

O Cardiac electrophysiological tests

O Diagnostic endoscopies with identified risk factors

O Discography

O Elective major surgery (open, percutaneousor

endoscopic with identified risk factors).

O Emergency major surgery (open, percutaneous or

endoscopic)

O Parenteral controlled substances

O Drug therapy requiring intensive monitoring for

toxicity

O Decision not to resuscitate or de-escalate care

because of poor prognosis

Table of Risk

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E/M ComponentsImpression: Low Back Pain

Plan: Patient should continue on current treatment of Oxycontin 10 mg b.i.d. and return to our clinic in 2 weeks.

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Let’s Put It All Together

Start with Case #1

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Case #1• CHIEF COMPLAINT: Knee pain

– Valid chief complaint?

– May I use this as location as well?

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Case #1• HISTORY OF PRESENT ILLNESS: This 42 year-old female

presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a “wedge” heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee.

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Case #1• HISTORY OF PRESENT ILLNESS: This 42 year-old female

presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a “wedge” heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee.

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Case #1• HISTORY OF PRESENT ILLNESS: This 42 year-old female

presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a “wedge” heel and stepped on some uneven groundand she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee.

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Case #1• HISTORY OF PRESENT ILLNESS: This 42 year-old female

presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a “wedge” heel and stepped on some uneven groundand she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee.

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Case #1• HISTORY OF PRESENT ILLNESS: This 42 year-old female

presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a “wedge” heel and stepped on some uneven groundand she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee.

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Case #1• REVIEW OF SYSTEMS: She complains of knee joint pain and

headaches. She denies any allergy symptoms, chest pain, chills, nasal congestion, blurred vision, diarrhea/constipation, nausea/vomiting, painful urination, easy bruising, new skin lesions, or shortness of breath.

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Case #1• REVIEW OF SYSTEMS: She complains of knee joint pain and

headaches. She denies any allergy symptoms, chest pain, chills, nasal congestion, blurred vision, diarrhea/constipation, nausea/vomiting, painful urination, easy bruising, new skin lesions, or shortness of breath.

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Case #1• ALLERGIES: No known medical allergies

• MEDICATIONS: Midrin capsules, Motrin 800 mg every 6 hours

• PAST MEDICAL HISTORY: Positive for migraines and skin cancer on her forehead

• PAST SURGICAL HISTORY:

1. Left knee ACL repair

2. Left knee PCL repair

3. Appendectomy

4. Left knee arthroscopy

• FAMILY HISTORY: Mother had uterine cancer. Father has prostate cancer. Heart attack and stroke is associated with her maternal grandfather.

• SOCIAL HISTORY: Patient is employed as a hairstylist. She is divorced and currently single. She admits to alcohol consumption of 0-2 beverages per week. She denies illegal drug use and denies tobacco use.

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Score It Up!O O

O Location O Severity O Timing Brief (1-3) Extended

O Quality O Duration O Context (4 or more)

ROS (review of Systems): O O O O

O ConstitutionalO All/Immuno

O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc.

O GU O Resp O GI O Psych O Endo

PFSH (Past, Family, Social History): O O O O

PROBLEM

FOCUSED

99201

99212

EXP.

PROBLEM

FOCUSED

99202

99213

DETAILED

99203

99214

COMPREHEN

SIVE

99204/99205

99215

N/A

Final History requires all 3 components

above met or exceeded

* Complete PFSH

2 history areas: a) established patients- off ice (outpatient) care, domiciliary

care, home care; b) emergency department; c) subsequent nursing facility

care; and, d) subsequent hospital care.

3 history areas: a) new patients-off ice (

O Assoc. signs

O Modifying Factors

O Past history (the patient's past experiences w ith illnesses, operations,

injuries and treatments)

Pertinent

1 history

item

*Complete

2-3 history

areas

O Ears, nose, mouth throat O Integumentary

N/A

Pertinent to

problem

(1 system)

O Family history ( a review of medical events in the patient's family,

including diseases that may be hereditary or place the patient at risk)

O Social history (an age appropriate review of past and current activities) N/A

Extended

(pert &

others)

(2-9 syst.)

Complete

(pert & all

others)

(10

1995 HPI Guidelines

X

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Score It Up!O O

O Location O Severity O Timing Brief (1-3) Extended

O Quality O Duration O Context (4 or more)

ROS (review of Systems): O O O O

O ConstitutionalO All/Immuno

O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc.

O GU O Resp O GI O Psych O Endo

PFSH (Past, Family, Social History): O O O O

PROBLEM

FOCUSED

99201

99212

EXP.

PROBLEM

FOCUSED

99202

99213

DETAILED

99203

99214

COMPREHEN

SIVE

99204/99205

99215

N/A

Final History requires all 3 components

above met or exceeded

* Complete PFSH

2 history areas: a) established patients- off ice (outpatient) care, domiciliary

care, home care; b) emergency department; c) subsequent nursing facility

care; and, d) subsequent hospital care.

3 history areas: a) new patients-off ice (

O Assoc. signs

O Modifying Factors

O Past history (the patient's past experiences w ith illnesses, operations,

injuries and treatments)

Pertinent

1 history

item

*Complete

2-3 history

areas

O Ears, nose, mouth throat O Integumentary

N/A

Pertinent to

problem

(1 system)

O Family history ( a review of medical events in the patient's family,

including diseases that may be hereditary or place the patient at risk)

O Social history (an age appropriate review of past and current activities) N/A

Extended

(pert &

others)

(2-9 syst.)

Complete

(pert & all

others)

(10

1995 HPI Guidelines

X

X

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Score It Up!O O

O Location O Severity O Timing Brief (1-3) Extended

O Quality O Duration O Context (4 or more)

ROS (review of Systems): O O O O

O ConstitutionalO All/Immuno

O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc.

O GU O Resp O GI O Psych O Endo

PFSH (Past, Family, Social History): O O O O

PROBLEM

FOCUSED

99201

99212

EXP.

PROBLEM

FOCUSED

99202

99213

DETAILED

99203

99214

COMPREHEN

SIVE

99204/99205

99215

N/A

Final History requires all 3 components

above met or exceeded

* Complete PFSH

2 history areas: a) established patients- off ice (outpatient) care, domiciliary

care, home care; b) emergency department; c) subsequent nursing facility

care; and, d) subsequent hospital care.

3 history areas: a) new patients-off ice (

O Assoc. signs

O Modifying Factors

O Past history (the patient's past experiences w ith illnesses, operations,

injuries and treatments)

Pertinent

1 history

item

*Complete

2-3 history

areas

O Ears, nose, mouth throat O Integumentary

N/A

Pertinent to

problem

(1 system)

O Family history ( a review of medical events in the patient's family,

including diseases that may be hereditary or place the patient at risk)

O Social history (an age appropriate review of past and current activities) N/A

Extended

(pert &

others)

(2-9 syst.)

Complete

(pert & all

others)

(10

1995 HPI Guidelines

X

X

X

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Score It Up!O O

O Location O Severity O Timing Brief (1-3) Extended

O Quality O Duration O Context (4 or more)

ROS (review of Systems): O O O O

O ConstitutionalO All/Immuno

O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc.

O GU O Resp O GI O Psych O Endo

PFSH (Past, Family, Social History): O O O O

PROBLEM

FOCUSED

99201

99212

EXP.

PROBLEM

FOCUSED

99202

99213

DETAILED

99203

99214

COMPREHEN

SIVE

99204/99205

99215

N/A

Final History requires all 3 components

above met or exceeded

* Complete PFSH

2 history areas: a) established patients- off ice (outpatient) care, domiciliary

care, home care; b) emergency department; c) subsequent nursing facility

care; and, d) subsequent hospital care.

3 history areas: a) new patients-off ice (

O Assoc. signs

O Modifying Factors

O Past history (the patient's past experiences w ith illnesses, operations,

injuries and treatments)

Pertinent

1 history

item

*Complete

2-3 history

areas

O Ears, nose, mouth throat O Integumentary

N/A

Pertinent to

problem

(1 system)

O Family history ( a review of medical events in the patient's family,

including diseases that may be hereditary or place the patient at risk)

O Social history (an age appropriate review of past and current activities) N/A

Extended

(pert &

others)

(2-9 syst.)

Complete

(pert & all

others)

(10

1995 HPI Guidelines

X

X

X

X

56

Case #1• PHYSICAL EXAM:

• VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus.

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57

Case #1• PSYCHIATRIC: Psychiatric exam reveals orientation x 3

with mood and affect appropriate to situation.

• HEAD AND FACE: Examination of head and face is unremarkable.

• EXTREMITIES: Nail of finger and toes do not demonstrate pitting or any other changes. There is no clubbing, cyanosis or edema noted at either the legs or arms. Her left knee does show some mild bony exuberance. There are medical and lateral longitudinal scars from prior surgeries. There is warmth and mild effusion. She has no significant laxity on provocative tests of the ACL, PCL, MCL or LCL. McMurray’s is negative. She has mild tenderness over the posterior aspect of the lateral meniscus.

58

Case #1• HEART: Regular rate and rhythm

• LUNGS: Clear to auscultation

30

59

Case #1• PHYSICAL EXAM:

• VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus.

60

Case #1• PHYSICAL EXAM:

• VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus.

31

61

Case #1• PSYCHIATRIC: Psychiatric exam reveals orientation x 3 with

mood and affect appropriate to situation.

• HEAD AND FACE: Examination of head and face is unremarkable.

• EXTREMITIES: Nail of finger and toes do not demonstrate pitting or any other changes. There is no clubbing, cyanosis or edema noted at either the legs or arms. Her left knee does show some mild bony exuberance. There are medical and lateral longitudinal scars from prior surgeries. There is warmth and mild effusion. She has no significant laxity on provocative tests of the ACL, PCL, MCL or LCL. McMurray’s is negative. She has mild tenderness over the posterior aspect of the lateral meniscus.

62

Case #1• HEART: Regular rate and rhythm

• LUNGS: Clear to auscultation

32

63

Case #1• HEART: Regular rate and rhythm

• LUNGS: Clear to auscultation

64

Score It Up Baby!

Expanded Problem

Focused Exam (EPF)

Comprehensive Exam (C) 8 or more body

systems

Not Applicable for 1997

Guidelines

Comprehensive Exam (C)

Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.

Circle the type of examination within the appropriate grid in section 5.

Detailed Exam (D)

2-7 Body Systems- No

Detail of any system

required

2-7 body systems

w/affected system

in detail

Not Applicable to 1995

Guidelines

Exam Equals

One body area or

organ system1-5 bulleted elements

Problem Focused

Exam (PF)

6-11 bulleted elements

2. Examination

12-17 bulleted elements

for

2 or more systems

18 or more bulleted

elements for 9 or more

systems.

See requirements for

individual single system

exams

Not Applicable to 1995

Guidelines

CPT Type of Exam 95 Guidelines 97 Guidelines

X

33

65

1997 Guidelines

X

66

1997 Guidelines

X

X

34

67

1997 Guidelines

X

68

1997 Guidelines

X

X

35

69

1997 Guidelines

X

70

1997 Guidelines

X

X

36

71

1997 Guidelines

X

X

X

72

1997 Guidelines

X

X

X

X

37

73

Score It Up Baby!

Expanded Problem

Focused Exam (EPF)

Comprehensive Exam (C) 8 or more body

systems

Not Applicable for 1997

Guidelines

Comprehensive Exam (C)

Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.

Circle the type of examination within the appropriate grid in section 5.

Detailed Exam (D)

2-7 Body Systems- No

Detail of any system

required

2-7 body systems

w/affected system

in detail

Not Applicable to 1995

Guidelines

Exam Equals

One body area or

organ system1-5 bulleted elements

Problem Focused

Exam (PF)

6-11 bulleted elements

2. Examination

12-17 bulleted elements

for

2 or more systems

18 or more bulleted

elements for 9 or more

systems.

See requirements for

individual single system

exams

Not Applicable to 1995

Guidelines

CPT Type of Exam 95 Guidelines 97 Guidelines

X

74

Case #1

• No tests to report at this time.

• IMPRESSION:

1. Initial visit

2. Left knee sprain/strain

PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks.

• SIGNED: Patrick Wise, MD

38

75

Case #1

• No tests to report at this time.

• IMPRESSION:

1. Initial visit

2. Left knee sprain/strain New Problem no added workup

PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks.

• SIGNED: Patrick Wise, MD

76

Case #1

• No tests to report at this time.

• IMPRESSION:

1. Initial visit

2. Left knee sprain/strain New Problem no added workup

PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks.

• SIGNED: Patrick Wise, MD

39

77

Score It Up Baby!

B x C= D

Number Points Result

Max=2 1

1

2

Max=1 3

4

Est. problem (to

examiner); stable,

improved

A

Problem(s) Status

Self-Limited or minor

(stable, improved, or

w orsening)

Est. problem (to

examiner); w orseningNew problem (to

examiner); no add'l

w orkup planned

New problem (to

examiner);

add'l w orkup planned

Number of Diagnosis or Treatment Options

Total:

X 3

3

78

Score It Up Baby!

Points

1

1

1

1

1

2

Review and/or order of tests in the

medicine section of CPT

Reviewed Data

Review and/or order of clinical lab tests

Review and/or order tests in the radiology

section of CPT

Decision to obtain old records and/or

obtain history from someone other than

patientReview and summarization of old records

and/or obtaining history fro someone other

than patient and or discussion of case w ith

another health care provider

Amount and/or Complexity of Data Reviewed

Discussion of test results w ith performing

physician

Total:

Independent visualization of image, tracing

or specimen itself (not simply review of 2

0

40

79

Level of Risk

Minimal

Low

Moderate

High

O One or more chronic illnesses

with mild exacerbation ,

progression, or side effects of

treatment

O Two or more stable chronic

illnesses

O Undiagnosed new problem with

uncertain prognosis , e.g., lump in

breast

O Acute illness with systematic

symptoms ,

O Major surgery (open,

percutaneousor endoscopic w ith

identif ied risk factors).

O Emergency major surgery

(open, percutaneous or

endoscopic)

O Parenteral controlled

substances

O Drug therapy requiring

intensive monitoring for toxicity

O Decision not

O One self-limited or minor

problem , e.g. cold, insect bite, Tinea

Corporis

O Laboratory tests requiring

venipuncture

O Chest x-rays

O EKG/EEG

O Urinalysis

O Ultrasound, e.g., echo

O Rest

O Gargles

O Elastic bandages

O Superficial dressings

O Physiologic tests not under stress,

e.g., pulmonary function tests.

O Non-cardiovascular imaging studies

w ith contrast, e.g., barium enema

O Superficial needle biopsies

O Clinical laboratory tests requiring

arterial puncture

O Skin biopsies

O Over-the-counter drugs

O Minor surgery w ith no identif ied

risk factors

O Physical therapy

O Occupational therapy

O IV f luids

Risk of Complications and/or Morbidity or Mortality

Diagnostic Procedure(s) Ordered

O One or more chronic illnesses

with severe exacerbation ,

progression, or side effects of

treatment

O Acute or chronic illnesses or

injuries that may pose a threat to

life or bodily function , e.g. multiple

trauma, acute MI, pulmonary

embolus, severe r

O Cardiovascular imaging studies w ith

contrast w ith identif ied risk factors

O Cardiac electrophysiological tests

O Diagnostic endoscopies w ith

identif ied risk factors

O Discography

Presenting Problem(s) Management Options

O Physiologic tests not under stress,

e.g. cardiac stress test, fetal

contraction stress test

O Diagnostic endoscopies w ith no

identif ied factors

O Deep needle or incisional biopsy

O Cardiovascular imaging studies w ith

contrast and no identif ied risk

O Minor surgery w ith identif ied

risk factors

O Major surgery (open,

percutaneous or endoscopic) w ith

no identif ied risk factors

O Prescription drug management

O Therapeutic nuclear medicine

O IV f luids w ith additives

O Closed treatment of fracture o

O Two or more self-limited or minor

problems

O One stable chronic illness , e.g.

w ell controlled hypertension or non-

insulin dependent diabetes, cataract,

BPH

O Acute uncomplicated illness or

injury , e.g. cystitis, allergic rhinitis,

x

80

Score It Up Baby!

History PF EPF PF EPF D C

Examination PF EPF PF EPF D C

Complexity

of Medical

decision SF

SF

ER: L SF L M H

Average time

(minutes)

(Confirmatory

consults & ER

have no

average

time)

99201-10

NEW

99241-15

OUTPT CONS

99251-20

IP CONS

ER 99281

99202-20

NEW

99242-30

OUTPT

CONS

99252-40

IP CONS

ER 99282

99212

10MIN.

99213

15MIN.

99214

25MIN.

99215

40MIN.

LEVEL I II II III IV V

5. Level of Service

OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER

*Established Office

requires 2 components within

New Office/ Consults/ ER

requires 3 components within shaded area

99203-30

NEW

99243-40

OUTPT

CONS

99253-55

IP CONS

ER 99283

III

C

C

H

99205-60

NEW

99245-80

OUTPT

CONS

99255-110

IP CONS

ER 99285

C

ER:D

D

ER:EPF

D

ER:EPF

L

ER:M

C

ER:D

V

99204-40

NEW

99244-60

OUTPT

CONS

99254-80

IP CONS

ER 99284

M

IV

X

41

81

Score It Up Baby!

History PF EPF PF EPF D C

Examination PF EPF PF EPF D C

Complexity

of Medical

decision SF

SF

ER: L SF L M H

Average time

(minutes)

(Confirmatory

consults & ER

have no

average

time)

99201-10

NEW

99241-15

OUTPT CONS

99251-20

IP CONS

ER 99281

99202-20

NEW

99242-30

OUTPT

CONS

99252-40

IP CONS

ER 99282

99212

10MIN.

99213

15MIN.

99214

25MIN.

99215

40MIN.

LEVEL I II II III IV V

5. Level of Service

OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER

*Established Office

requires 2 components within

New Office/ Consults/ ER

requires 3 components within shaded area

99203-30

NEW

99243-40

OUTPT

CONS

99253-55

IP CONS

ER 99283

III

C

C

H

99205-60

NEW

99245-80

OUTPT

CONS

99255-110

IP CONS

ER 99285

C

ER:D

D

ER:EPF

D

ER:EPF

L

ER:M

C

ER:D

V

99204-40

NEW

99244-60

OUTPT

CONS

99254-80

IP CONS

ER 99284

M

IV

X

X

82

Score It Up Baby!

History PF EPF PF EPF D C

Examination PF EPF PF EPF D C

Complexity

of Medical

decision SF

SF

ER: L SF L M H

Average time

(minutes)

(Confirmatory

consults & ER

have no

average

time)

99201-10

NEW

99241-15

OUTPT CONS

99251-20

IP CONS

ER 99281

99202-20

NEW

99242-30

OUTPT

CONS

99252-40

IP CONS

ER 99282

99212

10MIN.

99213

15MIN.

99214

25MIN.

99215

40MIN.

LEVEL I II II III IV V

5. Level of Service

OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER

*Established Office

requires 2 components within

New Office/ Consults/ ER

requires 3 components within shaded area

99203-30

NEW

99243-40

OUTPT

CONS

99253-55

IP CONS

ER 99283

III

C

C

H

99205-60

NEW

99245-80

OUTPT

CONS

99255-110

IP CONS

ER 99285

C

ER:D

D

ER:EPF

D

ER:EPF

L

ER:M

C

ER:D

V

99204-40

NEW

99244-60

OUTPT

CONS

99254-80

IP CONS

ER 99284

M

IV

X

X

X

42

83

Score It Up Baby!

History PF EPF PF EPF D C

Examination PF EPF PF EPF D C

Complexity

of Medical

decision SF

SF

ER: L SF L M H

Average time

(minutes)

(Confirmatory

consults & ER

have no

average

time)

99201-10

NEW

99241-15

OUTPT CONS

99251-20

IP CONS

ER 99281

99202-20

NEW

99242-30

OUTPT

CONS

99252-40

IP CONS

ER 99282

99212

10MIN.

99213

15MIN.

99214

25MIN.

99215

40MIN.

LEVEL I II II III IV V

5. Level of Service

OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER

*Established Office

requires 2 components within

New Office/ Consults/ ER

requires 3 components within shaded area

99203-30

NEW

99243-40

OUTPT

CONS

99253-55

IP CONS

ER 99283

III

C

C

H

99205-60

NEW

99245-80

OUTPT

CONS

99255-110

IP CONS

ER 99285

C

ER:D

D

ER:EPF

D

ER:EPF

L

ER:M

C

ER:D

V

99204-40

NEW

99244-60

OUTPT

CONS

99254-80

IP CONS

ER 99284

M

IV

X

X

X

X

84

Wait just a minute!

Medical Necessity!

43

85

Levels of

ServiceLevel of Risk

99201

99241

99202

99212

99242

Minimal

99203

99213

99243

Low

99204

99214

99244Moderate

99205

99215

99245

High

Presenting Problem(s)

Risk of Complications and/or Morbidity or Mortality

O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

O Two or more stable chronic illnesses

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

O Acute illness with systematic symptoms,

O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus,

severe r

O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis

O Two or more self-limited or minor problems

O One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH

O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain

86

Levels of

ServiceLevel of Risk

99201

99241

99202

99212

99242

Minimal

99203

99213

99243

Low

99204

99214

99244Moderate

99205

99215

99245

High

Presenting Problem(s)

Risk of Complications and/or Morbidity or Mortality

O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment

O Two or more stable chronic illnesses

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

O Acute illness with systematic symptoms,

O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus,

severe r

O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis

O Two or more self-limited or minor problems

O One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH

O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprainX

44

87

Overall• Documentation supports 99203

• Medical Necessity supports 99203

• 99203 billable level of service

88

Questions?

45

89

CPT® CopyrightCPT® copyright 2009 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT ®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT ® is a registered trademark of the American Medical Association.