Evaluation And

Management Coding For

PsychiatryKEY COMPONENTS OF DOCUMENTATION

PRESENTER: DEBBIE FLEMINGS, CPC

1

Why Is Documentation So Important?

Accurate documentation of medical records provides for program

integrity, ensures patient safety, and protects our providers.

Providers’ claims must be accurate and billable with the correct code, not

just the code that offers the greatest reimbursement.

This ensures that payer programs such as Medicare and Medicaid pay the

correct amount – not too much, not too little, and ensures that the

programs pay the right people.

Healthcare delivery is becoming increasingly more complex and the

medical data describing the services performed is growing. Increased

medical complexity requires increased documentation complexity.

2

Why Is Medical Coding So Important?

Medical coding helps prove the medical necessity of treatment.

The narrative text is matched to a code that has a corresponding charge.

This coding of services is the main source for accurate reimbursement of

services.

Insurance companies often perform random reviews to ensure charges

are valid. Accurate coding and detailed documentation help insurance

companies to understand why specific charges were submitted.

3

What Is The Purpose Of Auditing?

Quality healthcare is based on accurate and complete clinical

documentation in the medical record. The best way to improve our

clinical documentation and the livelihood of our organization is through

medical record auditing.

Goals: Improve the financial health of our practice.

Audits specifically target and evaluate procedural and diagnosis code

selection as determined by physician documentation.

4

“

”

If It Isn’t Documented, It Hasn’t Been

Done

AN ADAGE THAT IS FREQUENTLY HEARD IN THE HEALTH CARE SETTING

Bringing It All Together:

Accurate and complete documentation can serve purposes that are outside of their existing purposes such as, legal interests of the affected individuals. The medical professionals are then, protected by maintaining records which serve as valuable references. They can also explain potential health risks for the family of which the individual belongs.

These specific tasks will help maintain a highly systematic and organized record keeping.

5

Introducing E/M Coding

General Principles

Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results

Assessment, clinical impression or diagnosis

Plan for care

Date and legible identity of the observer

Rationale for ordering ancillary services should be easily inferred

Appropriate health risk factors should be identified

Document the patient’s response to, changes in treatment, and revision of diagnosis

Past and present diagnoses should be accessible

The CPT and ICD-10-CM codes reported should be supported

6

E/M Key

Component

Overview

7

History

Examination

Medical Decision Making

Counseling

Coordination of Care

Time

Nature of presenting problem

History Detail

HistoryChief Complaint

History of Present Illness

Past, Family, and Social History

Review of Systems

Chief ComplaintCC states the reason for the encounter

May be from the provider perspective

May be from the patient perspective

All Levels of History Require a CC

HPIDescription of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

Elements:

Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Signs/Symptoms

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History Detail

HPI ExampleThe patient reports intermittent, emotional problems of moderatesadness starting with a romantic breakup six months ago, now more so when alone and associated with poor sleep and

appetite.

Using 1997 Guidelines-Single Organ System Exam

Brief- 1-3 elements

Extended- 4 or more elements

PFSHPast History-

Illnesses, Operations, Injuries, Treatments

Family History-

Medical events in patient’s family

Social History-

Past and current activities

Pertinent-Item from 1 area

Complete- 2 areas (established)

3 areas (new)

Review of SystemsConstitutional Psychiatric

Eyes Endocrine

ENT Hematologic/Lymph

Cardiovascular Allergic/Immunologic

Musculoskeletal Gastrointestinal

Respiratory Genitourinary

Integumentary Neurological

Problem Pertinent- 1 System

Extended- 2-9 Systems

Complete- 10 or more Systems

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History Type

HPI PFSH ROS Type

Brief N/A N/A Problem Focused

Brief N/A Problem Pertinent Expanded

Problem Focused

Extended Pertinent*Not required with subsequent hospital

2 elements for established patients

Extended Detailed

Extended Complete Complete Comprehensive

*Lowest level selectedIn any section is the history

type.

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Psychiatric Examination Detail

Constitutional

Three Vital Signs:

Sitting or standing blood

pressure,

supine blood pressure, pulse

rate and regularity

respiration, temperature,

height, weight

*Shaded

Musculoskeletal

Assessment of muscle strength and

tone, with notation of any atrophy or

abnormal movements

Examination of gait and station

*Unshaded

Mental Status ExamSpeech

Thought process

Associations

Abnormal or psychotic thoughts

Judgment and insight

Orientation

Recent and remote memory

Attention span and concentration

Language

Fund of knowledge

Mood and affect *Shaded

11

Examination Type

12

Performed and Documented Level of Exam

One to five bullets Problem Focused

Six to eight bullets Expanded Problem Focused

At least nine bullets Detailed

At least one bullet in the unshaded

box AND every bullet in the shaded

boxes

Comprehensive

Medical Decision

Making Process

13

Number of diagnoses or

management options

Amount and/or complexity of

data to be reviewed

Risk of complications and/or

morbidity or mortality

*2/3 elements must be met or exceeded for scoring

level of MDM

Number of Diagnoses or Management Options

14Category of Problems/Major New Symptoms Points

Per

Problem

Self-limiting or minor (stable, improved or worsening) (max-2) 1

Established problem (to examining physician);stable, improved 1

Established problem (to examining physician); worsening 2

New problem (to examining physician); no additional workup

or diagnostic procedures ordered (max-1)

3

New problem (to examining physician); additional workup

planned* Additional workup does not include referring patient

to another physician for future care

4

Number of Diagnoses or Management Options

15Number or types of problems addressed

during the encounter

Complexity of establishing a diagnosis

The management decisions that were

made

Other Indicators:

Problem undiagnosed

Number or types of tests ordered

Need for consultation

Problem worsening

Level Total Problem

Points

Minimal 0-1

Limited 2

Multiple 3

Extensive 4

Amount and/or Complexity of Data

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Categories of Data to be Reviewed (max=1 for each) Points

Review and/or order of clinical lab tests 1

Review and/or order of tests in the radiology section of CPT 1

Review and/or order tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from

someone other than patient

1

Review and summarization of old records and/or obtaining

history from someone other than patient and/or discussion of

case with another health care provider

2

Independent visualization of image, tracing, or specimen itself

(not simply review report)

2

Amount and/or Complexity of Data

17Types of diagnostic tests

ordered

Review of old medical records

-Document the relevant

findings

History from other sources

-Document the relevant

findings

Discussion of test results with

physician who interpreted the

test

Level Total Data Points

Minimal or none 0-1

Limited 2

Moderate 3

Extensive 4

Risk of Significant

Complications,

Morbidity, and/or

Mortality

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Based on risks associated

with the presenting

problem, diagnostic

procedure, and the

possible management

options

The highest level of risk in

any one of these

categories determines

the overall risk.

Table of Risk Examples

Low Complexity

Presenting Problem:

Acute Uncomplicated Illness

(exacerbation of anxiety disorder)

Diagnostic Procedure Ordered:

Psychological Testing

Management Options Selected:

Psychotherapy

Environmental intervention

(agency, school)

Referral for consultation

(physician, social worker)

Moderate Complexity

Presenting Problem:

Undiagnosed new problem with uncertain prognosis (psychosis)

Diagnostic Procedure Ordered:

Neuropsychological Testing

Electroencephalogram

Management Options Selected:

Prescription drug management

ECT

No comorbid medical conditions

High ComplexityPresenting Problem:

Acute illness with threat to life

(suicidal or homicidal ideation)

Diagnostic Procedure Ordered:

Suicide risk assessment

Management Options Selected:

Drug therapy requiring intensive monitoring (tapering diazepam for patient withdrawal)

Suicide observation

ECT; patient has comorbid medical condition (cardiovascular disease)

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Medical Decision Making

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Number of diagnoses

or management

options

Amount and/or

complexity of

data

Risk Complexity of

decision

making

Minimal Minimal or

none

Minimal Straightforward

Limited Limited Low Low

Multiple Moderate Moderate Moderate

Extensive Extensive High High

*2/3 elements must

be met or exceeded

Selecting The

Appropriate Level

of E/M Service

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For New Patients:

The three key components (History,

Exam, and MDM) must meet or

exceed in complexity with the stated

requirements for office visits and

initial hospital care.

Example:

Detailed History, Detailed Exam, and

Low MDM would qualify for 99203.

For Established Patients:

Two of the three key components

must meet or exceed in complexity

with the stated requirements of

office visits and subsequent hospital

care.

Example:

A Comprehensive History,

Comprehensive Exam, and

Moderate MDM still qualifies for

99215 because two out of the three

components meet.

22Case Study 99213

CC 9 year old male seen for follow up visit for ADHD. Visit attended by patient and mother; history obtained from both.

HPI Grades are good (associated signs and symptoms) but patient appears distracted(quality) in class (context). Lunch appetite poor but eating well at other meals.HPI Scoring: 3 elements= Brief

PFSH N/A

ROS Psychiatric: denies depression, anxiety, sleep problemsROS Scoring: 1 system=Problem-Pertinent

Exam Const. Appearance: appropriate dress, comes to office easily

MS N/A

Psych Speech: normal rate and tone; Thought content: no SI/HI or psychotic

symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic

and full and appropriateExamination Scoring: 6 elements= Expanded problem-focused

MDM Problem 1: ADHD Comment: Relatively stable; mild symptoms

Plan: Renew stimulant script and increase dose; Return visit in 2 monthsMDM: Low Complexity

Problem Scoring: 1 established problem, stable; total of 1= Minimal

Data: Obtain history from someone other than patient; total of 2= Limited

Risk: Chronic illness with mild exacerbation, progression, or side effects, and

prescription drug management=Moderate

23HPI PFSH ROS Type

Brief N/A Problem

Pertinent

Expanded Problem

Focused

Performed

and

Document

ed

Level of Exam

Six to eight

bullets

Expanded Problem Focused

History Level

Exam Level

MDM Level

Minimal/Limited Moderate Low

Diagnoses/

Amount of data

Risk Complexity of

decision

making

99213

Level of Service

PF EPF D C

PF EPF D C

SF L M H

99212 99213 99214 99215

24Medicare Rates for Evaluation and Management Codes

New Patient Office Initial Hospital Care

99202 $69.69 99221 $100.58

99203 $75.96 99222 $135.00

99204 $128.09 99223 $102.35

99205 $166.62

Established Patient Office Subsequent Hospital Care

99212 $25.10 99231 $35.32

99213 $49.64 99232 $70.98

99214 $76.83 99233 $102.35

99215 $109.33

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Any Questions?