1

Basics of AuditingMelody S. Irvine

CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS

Materials Needed

• SOAP note Abdominal Pain

• 4 audit sheets

– History

– 97 General Multisystem Examination

– 95 Examination

– Medical Decision Making

2

2

CMS Guidelines

• Presentation based on CMS guidelines

• Your MAC provider guidelines may vary

• Basics only

3

4

3

Components

• E/M services are scored based on the documentation of necessary components

– History - 1st component

– Examination - 2nd component

– Medical Decision Making (MDM) – 3rd component

• Contributing factors

– Counseling, coordination of care, nature of presenting problem, and time

5

History

• History of the medical record documentation

should include four areas:

– Chief Complaint

– History of Present Illness

– Review of Systems

– Past, Family and Social History

6

4

Chief Complaint

• Per CMS Guidelines “the medical record

should clearly reflect the chief complaint”

• Concise statement that describes the

problem/condition for the patient encounter

• Identifies the medical necessity of the

service

7

History - HPI

• History of Present Illness - HPI Location

Severity

Timing

Modifying Factors

Quality

Duration

Context

Associated Signs and Symptoms

8

5

History - HPI

• Brief History – 1 -3 Elements

• Extended History – 4 or more elements for 95/97 guidelines

– 3 or more chronic/inactive for 97 guidelines

□ Location □ Severity □ Timing

□ Modifying Factors □ Quality □ Context

□ Duration □ Associated Signs & Symptom

Brief

1-3

Elements

Extended

4 > elements or

status of

3> chronic or inactive

cond.

9

SOAP Abdominal Pain

• Patient is a 52 yr-old established female patient who comes in complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends.

10

6

History - HPI• We have 6 elements of the HPI

– Timing - intermittent

– Location – right lower quadrant pain

– Associated signs and symptoms – diarrhea

– Duration – x one week

– Modifying Factors – tried Imodium

– Context or Severity– wakes her at night

• Extended HPI■ Location □ Severity ■ Timing

■ Modifying Factors □ Quality

■ Context ■ Duration

■Associated Signs & Symptom

Brief

1-3

Elements

Extended

4> elements or status of

3> chronic or inactive

cond.

11

History - ROS• Review of Systems –ROS

– Constitutional – ENT – Eyes – Cardiovascular – GI – GU – Respiratory – Musculoskeletal – Psychiatric – Integumentary – Endocrine – Hem/Lymph – Allergy/Immunology – Neurologic

12

7

History - ROS

• Unremarkable and/or non-contributory are not acceptable forms of review of systems documentation

• Specifics of positive findings need to be documented, not necessary for negative findings

• Systems reviewed must meet medical necessity

• All others negative "remainder of the 10 review of systems were reviewed and are all negative".

• No double dipping

13

History - ROS

• None

• Pertinent to 1 system

• Extended 2-9 systems

• Complete 10 systems or “all others negative”

□ Constitutional □ ENT □ Eyes □ Cardiovascular □ Respiratory □ GI □ GU □ Neurology □ Musculoskeletal □ Psychiatric □ Integumentary □ Endocrine □ Hem/Lymph □ Allergy/Immunology □ All Others Negative

None Pertinent

to

1 system

Extended

2-9

Systems

Complete

10 systems

or all neg

14

8

SOAP Abdominal Pain• Patient is a 52 yr-old established female patient comes in

complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends.

15

History - ROS• We have 5 Review of Systems

– Constitutional – positive fatigue, neg -chills, sweats

– GI – positive vomiting, neg - blood in stool

– Respiratory – neg shortness of breath

– Cardiovascular – neg chest pain

– GU – neg urinary problems

• Extended ROS

■ Constitutional □ ENT □ Eyes ■ Cardiovascular ■ Respiratory ■ GI ■ GU □ Neurology □ Musculoskeletal □ Psychiatric □ Integumentary□ Endocrine □ Hem/Lymph □ Allergy/Immunology □ All Others Negative

None Pertinent

to

1 system

Extended

2-9

Systems

Complete

10 systems

or all neg

16

9

History - PFSH

• Past Medical, Family, Social History – PFSH• Past History

– Current medications, past surgeries, past illnesses • Family History

– Family; i.e., parents, siblings, children, aunts, uncles, grandparents

• Social History– Smoking, alcohol intake, marital status, sexual

history, employment status, educational information

17

History - PFSH

• Established or New Patient

• How many histories are documented

□ Past Medical History □ Family History □ Social History

Established Patient None None

1History

Area

2 or 3

History

Area

□ Past Medical History □ Family History □ Social History

New Patient

None None 1 or 2 History Area

3

History

Areas

18

10

SOAP Abdominal Pain

• Patient is a 52 yr-old established female patient who comes in complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends.

19

History - PFSH

• Established patient

• We have two histories

– Past Medical History - history of diverticulitis

– Social History – alcohol and non-smoker■ Past Medical History □ Family History ■ Social History

Established Patient None None

1History

Area

2 or 3

History

Area

□ Past Medical History □ Family History □ Social History

New Patient

None None 1 or 2 History Area

3

History

Areas

20

11

Unobtainable History• Sometimes it is impossible to obtain a history due to the

status of the patient.

• Document why the history was unobtainable

• How to score

– Omit the history as scorable component

– Allow a complete history

• Recommendation:

– Let doctors decide and document in your compliance manual

21

HPI - HISTORY OF PRESENT ILLNESS

□ 1 Chronic Conditions □ 2 Chronic cond □ 3 Chronic Cond

□ Location □ Severity □ Timing □ Modifying Factors

□ Quality □ Duration □ Context □ Associated Signs & Symp

Brief

1 – 3

Elements

Extended

4 elements or

3 chronic/inactive

cond.

ROS - REVIEW OF SYSTEMS □ Constitutional □ ENT □ Eyes □ Cardiovascular □ GI

□ GU □ Respiratory □ Neurology □ Musculoskeletal

□ Psychiatric □ Integumentary □ Endocrine □ Hem/Lymph

□ Allergy/Immunology □ All Others Negative

None Pert

to 1

system

Extended

2-9

Systems

Complete

10 systems

or all neg

PFSH - PAST, FAMILY, SOCIAL HISTORY EST PT. □ Past Medical History □ Family History □ Social History None None 1 History 2- 3

History

NEW PT □ Past Medical History □ Family History □ Social History None None 1-2History 3 History

Level of history is determined by the column that is

marked farthest to the left

Prob

Focus

Exp Prob

Focused Detailed Comp

Let’s Put History Together

22

12

Second Component/Examination

• An examination based on either the 1995 or 1997 documentation guidelines.

• 1995 examinations are based on the organ systems and body areas.

• 1997 examinations are based on bullets outlined through specific system examinations.

23

Examination

• Examination is the hands on examination

performed by the provider

• Negative or normal meet documentation

guidelines

• If abnormal – reason it is abnormal must be

documented

24

13

97 Examination General Multisystem

• Measurement of any three of the following seven vital signs: 1) sitting

or standing blood pressure, 2) supine blood pressure, 3) pulse rate

and regularity, 4) respiration, 5) temperature, 6) height, 7) weight

(may be measured and recorded by ancillary staff)

• General appearance of patient e.g. development, nutrition, body,

habitus, deformities, attention to grooming

• Inspection of conjunctvae and lids

• Examination of pupils and irises e.g. reaction to light and

accommodation, size, symmetry

• Ophthalmoscopic examination of optic discs e.g. size, C/D ratio,

appearance and posterior segments e.g. vessel changes,

exudates,hemorrhages

Constitutional

Eyes

25

97 Examination General Multisystem

•External inspection of ears and nose

•Otoscopic examination of external auditory canals and tympanic

membranes

• Assessment of hearing e.g. whispered voice, finger rub, tuning fork

• Inspection of nasal mucosa, septum and turbinates

• Inspection of lips, teeth and gums

• Examination of oropharynx: oral mucosa, salivary glands, hard and soft

palates, tongue, tonsils and posterior pharynx

Ears, Nose,

Mouth, &

Throat

• Examination of neck e.g. masses, overall appearance, symmetry,

tracheal position, crepitus

• Examination of thyroid e.g. enlargement, tenderness, mass

Neck

26

14

Respiratory • Assessment of respiratory effect e.g. intercostal retractions, use of accessory

muscles, diaphragmatic movement

• Percussion of chest e.g. dullness, flatness,hyperresonance

• Palpation of chest e.g. tactile fremitus

• Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs

Palpation of heart e.g. location, size, thrills

• Auscultation of heart with notation of abnormal sounds and murmurs

Examination of:

• Carotid arteries e.g. pulse, amplitude, bruits

• Abdominal aorta e.g. size bruits

• Femoral arteries e.g. pulse, amplitude, bruits

• Pedal pulses e.g. pulse amplitude

• Extremities for edema and/or varieosities

97 Examination General Multisystem

Cardiovascular

27

97 Examination General Multisystem

Chest (breasts) • Inspection of breasts e.g. symmetry, nipple

discharge

• Palpation of breasts and axillae e.g. masses or

lumps, tenderness

• Examination of abdomen with notation of (abdomen presence of

masses or tenderness)

• Examination of liver and spleen

• Examination for presence or absence of hernia

• Examination when indicated of anus, perineum and rectum,

including sphincter tone, presence of hemorrhoids, rectal masses

• Obtain stool sample for occult blood test when indicated

Gastrointestinal

28

15

Genitourinary • Examination of the scrotal Contents

e.g. hydrocele,spermatocele,tenderness of cord, testicular, mass

• Examination of the penis

• Digital rectal examination of prostate gland e.g. size

symmetry, nodularity, tenderness

Pelvic examination (with or without specimen collection for smears and cultures)

including:

• Examination of external genitalia e.g. general appearance, hair distribution, lesions and

vagina e.g. general appearance, estrogen effect, discharge lesions, pelvic support,

cystocele, rectocele

• Examination of the urethra e.g. masses, tenderness, scarring

• Examination of the bladder e.g. fullness, masses tenderness

• Cervix e.g.general appearance, lesions, discharge

• Uterus e.g. size, contour, position, mobility, tenderness, consistency, descent or support

• Adnexa/parametria e.g. masses, tenderness, organomegaly, nodularity

97 Examination General Multisystem

Genitourinary

29

Lymphatics Palpation of lymph nodes in two or more areas:

• Neck • Axillae • Groin • Other

97 Examination General Multisystem

•Examination of gait and station

• Inspection and/or palpations of digits and nails e.g. clubbing, cyanosis, inflammatory

conditions, petechiae, ischemia, infections, nodes

Examination of joints, bones and muscles of one or more of the following six areas: 1)

head and neck, 2) spine, ribs and pelvis, 3) right upper extremity 4) left upper extremity, 5) right

lower extremity 6) left lower extremity. The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any misalignment, asymmetry,

crepitation, defects, tenderness, masses, effusions

• Assessment of range of motion with notation of any pain, creptitation or contracture

• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity

• Assessment of muscle strength and tone e.g. flaccid cog wheel, spastic with notation of any

atrophy or abnormal movements

Musculoskeletal

30

16

• Inspection of skin and subcutaneous tissue e.g. rash, lesions, ulcers

• Palpation of skin and subcutaneous tissue e.g. induration, subcutaneous

nodules, tightening

• Test cranial nerves with notation of any deficits

• Examination of deep tendon reflexes with notation of pathological

reflexes e.g. Babinski

• Examination of sensation e.g. tough, pin, vibration, proprioception

• Description of patient's judgement and insight

Brief assessment of mental status including:

•Orientation to time, place, and person

• Recent and remote memory

• Mood and affect e.g. depression, anxiety, agitation

97 Examination General Multisystem

Neurologic

Skin

Psychiatric

31

SOAP Abdominal Pain – 97 Exam

• Vital signs 120/85, WT 134, Temp 99.3. The patient is

comfortable appearing and in no apparent distress.

Neck: Supple. Thyroid: Normal. Heart: regular rate

and rhythm. No edema. Lungs: clear to auscultation.

Abdomen is soft and non-tender with normal bowel

sounds and no masses. No guarding or rebound.

Skin clear, no rashes or ulcers. Urine dip is negative

aside from trace of glucose.

32

17

97 Examination

Problem Focused One to five elements identified by a bullet

Exp Prob Focused At least six elements identified by a bullet

Detailed At least two elements identified by a bullet from each six areas/systems OR at least

twelve elements identified by a bullet in two or more areas/systems

Comprehensive Performed all elements identified by a bullet and document at least two elements by a

bullet from each of nine area/system

• We have 9 bullets identified

• Constitutional – Vitals, General Appearance

• Neck

• Thyroid

• Heart – auscultation, edema

• Respiratory - auscultation

• GI – abdomen

• Skin – skin clear

33

95 Examination

BA Head, including the face

BA Neck: neck (masses, symmetry, etc), thyroid

BA Chest (Breasts): inspection breast, palpation breast/axillae

BA Abdomen

BA Genitalia, groin, buttocks

BA Back, including spine

BA Left upper extremity

BA Right upper extremity

BA Left lower extremity

BA Right lower extremity

Body Areas = BA

34

18

95 Examination

OS Constitutional 3 of the following: sit/stand BP, sup BP, temp, pulse rate, respiratory, height, weight or general appearance

OS Eyes conjunctivae/lids, pupils/irises, optic discs

OS Ears, Nose, Mouth/Throat External exam ears/ nose, external auditory canal/tympanic membrane, hearing assessment, nasal mucosa/septum/turbinates, lips/teeth/gums, oropharynx

OS Respiratory: Respiratory effort, chest percussion, chest palpation, auscultation of lungs

OS Cardiovascular Palpation heart, auscultation, exam of: carotid, femoral arteries, abdominal aorta, pedal pulses, extremities

OS Gastrointestinal Abdominal, lever/spleen, hernia, stool sample taken, anus, perineum, rectum

OS Genitourinary Male: scrotum, penis, DRE/prostate Female: pelvic, ext genitalia, urethra, bladder, cervix, uterus, adnexa/parametria

OS Musculoskeletal Gait/station, digits/nails, examination of jointst, bone, muscles, inspect & palpate, stability, ROM, strength & tone

OS Skin Inspection skin/ subcutaneous tissue, palpation skin/ subcutaneous tissue

OS Neurologic Crainal nerves, deep tendon reflexes, sensation

OS Psychiatric Judgment/ insight, MSE: orientation, remote & recent memory, mood & affect

OS Hematological/ lymphatic Neck, axillae, groin, other/immunologic

Organ Systems=OS

35

SOAP Abdominal Pain – 95 Exam

• Vital signs 120/85, WT 134, Temp 99.3. The patient is

comfortable appearing and in no apparent distress.

Neck: Supple. Thyroid: Normal. Heart: regular rate

and rhythm. No edema. Lungs: clear to auscultation.

Abdomen is soft and non-tender with normal bowel

sounds and no masses. No guarding or rebound.

Skin clear, no rashes or ulcers. Urine dip is negative

aside from trace of glucose.

36

19

95 Examination

Problem Focused 1 organ system or 1 body area

Exp Problem Focused 2 - 7 organ systems or body areas, no detail of system required

Detailed 2 - 7 organ systems or body areas, with affected system in detail

Comprehensive 8 or more organ system

Problem Focused 1 organ system or 1 body area

Exp Problem Focused 2 - 4 organ systems or body areas

Detailed 5 - 7 organ systems or body areas

Comprehensive 8 or more organ system

OR

• We have 5 organ systems and 1 body area

•Organ Systems – Constitutional, Cardiovascular, Respiratory, GI, Skin

•Body Area – Neck, Thyroid

37

Third Component

Medical Decision Making - MDM

• The medical decision making portion of the documentation

includes information that tells the diagnosis of the patient and

how the diagnosis or diagnoses will be treated.

• Three areas of documentation:

– Diagnosis

– Complexity

– Risk

38

20

MDM - Diagnosis

• Cannot get credit for mentioning a diagnosis that

may not be applicable to the day’s visit

• Minimum of one diagnosis treated with a developed

plan of care.

• Diagnosis should have relevance to the treatment.

• Mentioning diagnosis may be a secondary issue

39

MDM - Diagnosis• Self Limited/Minor?

• Improved?

• Worsening?

• New Problem, no work-up?

• New Problem, additional work-up?

Self Limited or minor (stable, improved, or worsening) (Max 2) 1 x

Established problem, stable, improved 1/dx x

Established problem, worsening 2/dx x

New problem; no additional work-up planned (Max 1) 3 x

New problem; additional work-up planned ie; referred, testing 4 x

Total

40

21

SOAP Abdominal Pain

Right lower quadrant pain, etiology unclear

We will schedule her today for a abdominal ultrasound

and CBC. Depending on ultra sound results, we may

proceed with the colonoscopy. I will also let the

patient know of the CBC results. Patient was

informed to go directly to the emergency room if pain

worsens.

41

Diagnosis -MDM

Self Limited or minor (stable, improved, or worsening) (Max 2) 1 x

Established problem, stable, improved 1 x

Established problem, worsening 2 x

New problem; no additional work-up planned (Max 1) 3 x

New problem; additional work-up planned ie; referred, testing 4 x 4

Total 4

New or Established Problem?

New problem with additional work-up of ultra sound

4 points

42

22

Review and/or order clinical lab tests 1

Review and/or tests in radiology section 1

Review and/or tests in medicine section 1

Decision to obtain old records and/or obtain history from someone other than patient 1

Review and summarization of old records and/or discussion of case with another health

provider

2

Independent visualization of image, tracing or specimen itself (not simple review of report) 2

TOTAL

MDM – Complexity of Data

43

SOAP Abdominal Pain

Right lower quadrant pain, etiology unclear

We will schedule her today for a abdominal ultra sound and CBC. Depending on ultra sound results, we may proceed with the colonoscopy. I will also let the patient know of the CBC results. Patient was informed to go directly to the emergency room if pain worsens.

44

23

Review and/or order clinical lab tests 1 1

Review and/or tests in radiology section 1 1

Review and/or tests in medicine section 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 provider

2

Independent visualization of image, tracing or specimen itself (not simple review of report) 2 ?

TOTAL 2

2 Points: 1 point – Order CBC

1 points – Order Ultra Sound

Urine Dip ?????

MDM – Complexity of Data

45

Risk- MDM

• There are three components to the table of risks:

– Presenting problem

– Diagnostic procedures

– Management options

46

24

Level of Risk -MDMPresenting Problem Diagnostic Procedure Management Options

M

I

One self-limited, minor problem

e.g. cold, insect bite

Lab testing requiring venipuncture, chest x-ray

or US, EKG/EEG, KOH prep or UA

Rest, gargles, dressing, band aid

L

O

W

2 or more self limited or minor

problems, 1 stable chronic, acute

illness or injury uncomplicated

Physiological test not under stress, PFT, non

cardiovascular image study with contrast,

superficial needle biopsy, clinical lab requiring

arterial puncture, skin biopsy

OTC drugs, PT or OT, IV fluids w/o

additive. Minor surgery no identified risk

factors

M

O

D

One or more chronic illness with

mild exacerbation, 2 or more

chronic illness, acute illness with

uncertain prognosis, acute

complicated injury

Physiological test under stress, diagnostic

endoscopy with no identified risk factors, deep

needle or incision biopsy, cardio imaging

study with contrast no identified risk factors,

obtain fluid from body cavity

Minor surgery with identified risk factors,

elective major surgery with no identifiable

risk factors, prescription drug

management, therapeutic nuclear

medicine, IV with additives, closed

treatment of fracture or dislocation w/o

manipulation

H

I

G

H

1 or more chronic illness with

severe exacerbation, progression

or side effect of treatment, acute or

chronic illness or injury that may

pose a threat to life or body

function, abrupt change in

neurological status

Cardiovascular imaging studies with contrast

with identified rsk factors, cardiac

electrophysiological test, diagnostic

endoscopy with identified risk factors,

discography

Elective major surgery with identifiable

risk factors, emergency major surgery, IV

controlled substances, drug therapy

requiring intensive monitoring for toxicity,

decision not to resuscitate or de-escalate

because of poor prognosis

47

SOAP Abdominal Pain

Right lower quadrant pain, etiology unclear

We will schedule her today for a abdominal ultra sound

and CBC. Depending on ultra sound results, we may

proceed with the colonoscopy. I will also let the

patient know of the CBC results. Patient was

informed to go directly to the emergency room if pain

worsens.

48

25

Level of Risk -MDMPresenting Problem Diagnostic Procedure Management Options

M

I

One self-limited, minor problem

e.g. cold, insect bite

Lab testing requiring venipuncture, chest x-

ray or US, EKG/EEG, KOH prep or UA

Rest, gargles, dressing, band aid

L

O

W

2 or more self limited or minor

problems, 1 stable chronic, acute

illness or injury uncomplicated

Physiological test not under stress, PFT, non

cardiovascular image study with contrast,

superficial needle biopsy, clinical lab requiring

arterial puncture, skin biopsy

OTC drugs, PT or OT, IV fluids w/o

additive. Minor surgery no identified risk

factors

M

O

D

One or more chronic illness with

mild exacerbation, 2 or more

chronic illness, acute illness with

uncertain prognosis, acute

complicated injury

Physiological test under stress, diagnostic

endoscopy with no identified risk factors,

deep needle or incision biopsy, cardio

imaging study with contrast no identified risk

factors, obtain fluid from body cavity

Minor surgery with identified risk factors,

elective major surgery with no identifiable

risk factors, prescription drug

management, therapeutic nuclear

medicine, IV with additives, closed

treatment of fracture or dislocation w/o

manipulation

H

I

G

H

1 or more chronic illness with

severe exacerbation, progression

or side effect of treatment, acute

or chronic illness or injury that

may pose a threat to life or body

function, abrupt change in

neurological status

Cardiovascular imaging studies with contrast

with identified rsk factors, cardiac

electrophysiological test, diagnostic

endoscopy with identified risk factors,

discography

Elective major surgery with identifiable

risk factors, emergency major surgery, IV

controlled substances, drug therapy

requiring intensive monitoring for toxicity,

decision not to resuscitate or de-escalate

because of poor prognosis

49

Diagnosis 1 or less 2 3 4 or more

Complexity 1 or less 2 3 4 or more

Risk Minimal Low Moderate High

Level Straight

Forward Low Moderate High

•Moderate MDM

•Diagnosis – 4 points

•Complexity – 2 points

•Risk – Moderate

•Level with 2 components or one in the middle

Scoring the MDM

50

26

Level of Service

• Three of Three Components

• The lowest component of all three

• Two of Three Components

• Middle or level with 2 components

51

Level of Service

• Place of Service?

– Office

• New or Established?– Established

• Codes? – 99212- 99215

• Require 2 out of 3 or 3 out of 3 components?– 2 out of 3 components

52

27

Level of Service • Detailed History

• Expanded Problem Focused Exam – 97

• Moderate MDM

– Level? 99214

• Detailed History

• Detailed Exam – 95

• Moderate MDM

– Level? 99214

53

Medical Necessity• Per CMS Guidelines

– “Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service”

• High level of service billed when simple/minor problems are treated?

• Medical necessity is the driving component

• Medical necessity key to avoiding fraud/abuse

54

28

MAC Contractor Regulations

• MAC Contractor Regulations can vary

• Areas to investigate:– History

• HPI – 3 chronic 97?

• ROS – all others negative

• Unremarkable or Noncontributory

• Double dipping

55

MAC Contractor Regulations

• Examination

– Define 95 examination between Expanded Problem Focused and Detailed

• MDM

– Some MAC have their own MDM audit sheet

– Can you count the procedure in complexity if billed by the provider

56

29

Auditing Compliance Plan

• Recommend a auditing compliance plan within your compliance plan

• Consistency within auditors

• Address the grey areas and your MAC Contractor guidelines

• Puts it in writing

57

EMR/EHR System

• Automatically select level

– Decipher medical necessity?

• Cloning

– Copy/paste

• How are grey areas interpreted

58

30

Thank You

Chief Complaint: Abdominal Pain

S: Patient is a 52 yr old established female patient who comes in

complaining of intermittent episodes of right lower quadrant pain and

diarrhea x one week. She has had a couple of episode of vomiting. She

has tried Imodium, but has found no relief. The pain does wake her

occasionally at night and complains of fatigue. She denies blood in the

stool, chills, or sweats. She has no shortness of breath, chest pain or

urinary problems. She has a history of diverticulosis and is due for a

colonoscopy. The patient is a non-smoker and consumes approximately 2

beers on the week-ends.

O: Vital signs 120/85, WT 134, Temp 99.3. The patient is comfortable

appearing and in no apparent distress. Neck: Supple. Thyroid: Normal.

Heart: regular rate and rhythm. No edema. Lungs: clear to auscultation.

Abdomen is soft and non-tender with normal bowel sounds and no

masses. No guarding or rebound. Skin clear, no rashes or ulcers. Urine

dip is negative aside from trace of glucose.

A: 1. Right lower quadrant pain, etiology unclear

P: We will schedule her today for a abdominal ultra sound and CBC.

Depending on ultra sound results, we may proceed with the colonoscopy.

I will also let her know of the CBC results. Patient was informed to go

directly to the emergency room if pain worsens.

Electronically Signed: Hannah May, MD

MEDICAL DECISION MAKING DIAGNOSIS

COMPLEXITY OF DATA REVIEWED OR ORDERED

Review and/or order clinical lab tests (80000) 1

Review and/or order tests in radiology section (70000) 1

Review and/or order tests in medicine section (90000) 1

Decision to obtain old records and/or obtaining history from someone other than patient 1

Review and summarization of old records or discussion of case with another health provider 2

Independent visualization of image, tracing or specimen itself (not simple review of report) 2

Total

RISK OF COMPLICATIONS

Presenting Problems Diagnostic Procedure Management Options M I N

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

Lab Test requiring Venipuncture Chest x-ray or US, EKG/EEG, KOH prep or UA

Rest, Gargles, Elastic Bandage, Dressing

L O W

2 or more self limited or minor Problems, 1 stable chronic, Acute illness or injury uncomplicated

Physiologic test not under stress eg PFT Non cardiovascular image study with contrast Superficial needle biopsy Clinical lab requiring arterial puncture Skin biopsies

OTC drugs, PT or OT, IV Fluids w/o additive Minor surgery no identified risk factors

M O D

One or more chronic illness with mild exacerbation, 2 or more chronic illness, Acute illness with uncertain prognosis, Acute complicated injury

Physiologic test under stress, Diagnostic endoscopy with no identified risk factors, Deep needle or incision biopsy, Cardio/Vasc imaging study with contrast no identified risk factors, Obtain fluid from body cavity

Minor surgery with identified risk factors, Elective major surgery with no identifiable risk factors, Prescription drug management, Therapeutic Nuclear Medicine, IV’s with additives, Closed treatment of fracture or dislocation w/o manipulation

H I G H

1 or more chronic illness with severe exacerbation, progression or side effects of treatment, Acute or chronic illnesses or injury that may pose a threat to life or body function, Abrupt change in neurological status

Cardiovascular imaging studies with contrast with identified risk factors, Cardiac electrophysiological tests Diagnostic endoscopy with identified risk factors, Discography

Elective major surgery with identifiable risk factors, Emergency major surgery, IV controlled substances, Drug therapy requiring intensive monitoring for toxicity, Decision not to resuscitate or de-escalate because of poor prognosis

LEVEL OF MEDICAL DECISION MAKING Level determined with 2-3 or center level

Diagnosis 1 or less 2 3 4 or more

Complexity 1 or less 2 3 4 or more

Risk Minimal Low Moderate High

LEVEL Straight Forward Low Moderate High

Self-limited or minor (stable, improved, or worsening) (MAX 2) 1 X Est. problem; stable, improved 1/dx X Est. problem; worsening 2/dx X New problem; no additional work-up planned (MAX 1) 3 X

New problem; additional work-up planned ie; referred, testing 4 X

Total

HISTORY

HPI - HISTORY OF PRESENT ILLNESS

□ 3 Chronic Conditions

□ Location □ Severity □ Timing □ Modifying Factors

□ Quality □ Duration □ Context □ Associated Signs & Symp

Brief

1 – 3 Elements

Extended

> 4 elements or (95)

> 3 chronic/inactive (97)

ROS - REVIEW OF SYSTEMS

□ Constitutional □ ENT □ Eyes □ Cardiovascular □ GI □ GU

□ Respiratory □ Neurology □ Musculoskeletal □ Psychiatric

□ Integumentary □ Endocrine □ Hem/Lymph □ Allergy/Immunology □ All other systems reviewed and are negative

None

Pertinent

to

1 system

Extended

2-9

Systems

Complete

10 systems

or all neg

PFSH - PAST, FAMILY, SOCIAL HISTORY

EST PT. □ Past Medical History □ Family History □ Social History None None 1 History

2- 3 History

NEW PT □ Past Medical History □ Family History □ Social History None None 1-2 History

3 History

Level of history is determined by the column that is

marked farthest to the left Problem

Focused

Exp Prob

Focused

Detailed

Comp

HPI Location - Where on the body the symptom is occurring or problem experienced ________________________________ Quality - Character of the symptom – burning, gnawing, stabbing, fullness, throbbing, sharp, dull, crushing, cramping, piercing, popping, metallic taste,, low it looks or feels _____________________________________ Severity – Ranking of the symptom – Severe, slightly, worst, chronic, can’t describe, moderate distress, takes breath away, size of lump or mass, scale 1-10, improved, high blood sugars, so bad the patient can’t sleep ___________________________________ Duration – How long the symptom has been present, when first symptoms occurred, time of onset of signs & symptoms. Began in childhood, since 1995. _________________________________________ Timing - When the symptom happens – night, after meals, after medications, frequency, lasts 5 minutes, comes and goes, etc. Intermittent, constant, occasional, on and off, mornings_____________________________________ Context – Situation associated with the symptom – dairy products, big meals, on exertion, how did the injury occur, what were they doing when it happened or symptoms occurred. While sleeping, MVA, slipped and fell, eating certain foods. ____________________________ Modifying Factors - Things that are done to make the symptom worse or better, has anyone besides the patient attempted to relieve the problem or symptom, hurts when I move, no relief with medical care or medications. Calms down when mother feeds, worse standing,______________________________________ Associated Signs and Symptoms – Other things that are happening – runny nose, sore throat, is also experiencing, along with, in addition too, etc. Secondary complaints_____________________________________________________

ROS (should be medically necessary) CONSTITUTIONAL – Weight Changes, fever, weakness, fatigue, exercise tolerance, impairs ability EYES – Glasses, contacts, last eye exam, glaucoma, cataracts, eyestrain, redness, diplopia, discharges, obstruction, post nasal drip, sinus pain EAR, NOSE, MOUTH, THROAT – EARS – hearing, discharge, tinnitus, dizziness, pain NOSE – Head cold, epistaxis, hoarseness, difficulty in swallowing MOUTH/THROAT – Teeth/gums, last dental exam, soreness, redness, CARDIOVASCULAR – Chest pain, rheumatic fever, tachycardia, palpitations, high BP, varicose veins, thrombophlebitis, faintness, vertigo, color changes in fingers or toes, edema, leg pain when walking RESPIRATORY – Chest pain, wheezing, cough, dyspnea, sputum (color/quantity), hempotysis, asthma, bronchitis, emplysema, pneumonia, tuberculosis, pleurisy, last chest xray GASTROINTESTINAL - Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowel habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhoids, jaundice, heartburn, abdominal swelling, digestive aids or laxatives GENITOURINARY – Urinary: frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infection. Gastroreproductive; male-venereal diseases, sores, discharge from penis, hernias, testicular pain or masses female: age of menarche and menstruation, (frequnecy, type, duration, dysmenorrheal, menorrhagia, symptoms of menopause, contraception, pregnancy, deliveries, abortions, last pap MUSCULOSKELETAL – Joint pain or stiffness, arthritis, gout, backache, muscle pain, cramps, swelling, redness, limitation in motor activity INTEGUMENTARY (SKIN/BREAST) – Rashes, eruptions, dryness, cyanosis, jaundice, changes in skin, hair/nails, hot, cold, lesions, scars, moles, bruising, breast pain, tenderness, swelling, lumps, nipple discharge NEUROLOGICAL – Faintness, blackouts, seizures, paralysis, tingling, tremors, memory loss, convulsions, attention difficulties, hallucinations, disorientations, speech & language dysfunction, balance, coordination PSYCHIATRIC – Personality type, nervousness, mood, insomnia headache, nightmares, depression, suicidal, sadness, anxiety, energy loss, restlessness, irritability, mood swings ENDOCRINE – Thyroid trouble, heat or cold intolerance, excessive sweating, BS readings, increased appetite/thirst or urination, changes in height/weights HEMATOLOGIC/LYMPHATIC – Anemia, easy bruising or bleeding, past transfusions, swollen glands, night sweats, itching with no rash ALLERGIC/IMMUNOLOGIC- Allergies to medicine, food, dye, hepatitis, HIV

Constitutional • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3} pulse rate and regularity,

4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff)

• General appearance of patient e.g. development, nutrition, body habitus, deformities, attention to grooming

Eyes • Inspection of conjunct!vae and lids • Examination of pupils and irises e.g. reaction to light and

accommodation, size, symmetry • Ophthalmoscopic examination of optic discs e.g. size, C/D ratio, appearance and posterior segments e.g. vessel changes, exudates, hemorrhages

Ears, nose, •External inspection of ears and nose mouth & throat e.g. overall appearance, scars, lesions, masses

• Otoscopic examination of external auditory canals and tympanic membranes

• Assessment of hearing e.g. whispered voice, finger rub, tuning fork • Inspection of nasal mucosa, septum and turbinates • Inspection of lips, teeth and gums

• Examination of oropharynx: oral mucosa, salivary glands, hard/soft palates, tongue, tonsils/posterio phary

Cardiovascular Palpation of heart e.g. location, size, thrills • Auscultation of heart with notation of abnormal sounds and murmurs

Examination of: • Carotid arteries e.g. pulse, amplitude, bruits • Abdominal aorta e.g. size bruits • Femoral arteries e.g. pulse, amplitude, bruits • Pedal pulses e.g. pulse amplitude • Extremities for edema and/or varieosities

Chest (breasts) • Inspection of breasts e.g. symmetry, nipple discharge

• Palpation of breasts and axillae e.g. masses, lumps,

tenderness

Gastrointestinal • Examination of abdomen with notation of (abdomen) presence of masses or tenderness

• Examination of liver and spleen • Examination for presence or absence of hernia

• Examination when indicated of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses • Obtain stool sample for occult blood test when indicated

Genitourinary • Examination of the scrota! contents e.g. hydrocele, spermatocele, tenderness of cord, testicular mass • Examination of the penis • Digital rectal examination of prostate gland e.g. size symmetry, nodularity, tenderness

Genitourinary Pelvic examination (with or without specimen _ collection for smears and cultures) including:

• Examination of external genitalia e.g. general appearance, hair distribution, lesions and Vagina e.g. general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, rectocele • Examination of the urethra e.g. masses, tenderness, scarring

__ • Examination of the bladder e.g. fullness, masses tenderness • Cervix e.g.general appearance, lesions, discharge • Uterus e.g. size, contour, position, mobility, tenderness, consistency, descent or support • Adnexa/parametria e.g. masses, tenderness, organomegaly, nodularity

Lymphatic Palpation of lymph nodes in two or more areas: • Neck • Axillae • Groin • Other

Musculoskeletal •Examination of gait and station • Inspection and/or palpations of digits and nails e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck, 2) spine, ribs and pelvis, 3) right upper extremity 4) left upper extremity, 5) right lower extremity, 6) left lower extremity. The examination of a given area includes: • Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions • Assessment of range of motion with notation of any pain, creptitation or

contracture • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity • Assessment of muscle strength and tone e.g flaccid cog wheel, spastic with notation of any atrophy or abnormal movements

Skin • Inspection of skin and subcutaneous tissue e.g. rash, lesions, ulcers • Palpation of skin and subcutaneous tissue e.g. induration, subcutaneous nodules, tightening

Neurologic • Test cranial nerves with notation of any deficits • Examination of deep tendon reflexes with notation of pathological reflexes e.g. Babinski • Examination of sensation e.g. tough, pin, vibration, proprioception

Psychiatric • Description of patient's judgement and insight Brief assessment of mental status including: • Orientation to time, place, and person

• Recent and remote memory • Mood and affect e.g. depression, anxiety,

agitation

1997

Neck • Examination of neck e.g. masses, overall appearance, symmetry, tracheal position, crepitus • Examination of thyroid e.g. enlargement, tenderness, mass

Respiratory • Assessment of respiratory effect e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement

• Percussion of chest e.g. dullness, flatness, hyperresonance • Palpation of chest e.g. tactile fremitus • Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs

Problem Focused ----------- One to five elements identified by a bullet

Exp. Prob. Focused -------- At least six elements identified by a bullet

Detailed --------------------- At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet

in two or more areas/systems

Comprehensive ------------- Performed all elements identified by a bullet and document at least two elements by a bullet from each of nine areas/systems

1995 General Multi-System Examination

Body Areas=BA

Organ Systems=OS

OS Constitutional 3 of the following: sit/stand BP, sup BP, temp, pulse rate, respiratory, height, weight or general appearance

OS Eyes conjunctivae/lids, pupils/irises, optic discs

OS Ears, Nose, Mouth/Throat

External exam ears/ nose, external auditory canal/tympanic membrane, hearing assessment, nasal mucosa/septum/turbinates, lips/teeth/gums, oropharynx

OS Respiratory: Respiratory effort, chest percussion, chest palpation, auscultation of lungs

OS Cardiovascular Palpation heart, auscultation, exam of: carotid, femoral arteries, abdominal aorta, pedal pulses, extremities

OS Gastrointestinal Abdominal, lever/spleen, hernia, stool sample taken, anus, perineum, rectum

OS Genitourinary Male: scrotum, penis, DRE/prostate Female: pelvic, ext genitalia, urethra, bladder, cervix, uterus, adnexa/parametria

OS Musculoskeletal Gait/station, digits/nails, examination of jointst, bone, muscles, inspect & palpate, stability, ROM, strength & tone

OS Skin Inspection skin/ subcutaneous tissue, palpation skin/ subcutaneous tissue

OS Neurologic Crainal nerves, deep tendon reflexes, sensation

OS Psychiatric Judgment/ insight, MSE: orientation, remote & recent memory, mood & affect

OS Hematological/lymphatic Neck, axillae, groin, other/immunologic

LEVEL OF SERVICE

Level can be scored using either one below

Problem Focused – 1 organ system or 1 body area

Expanded Problem Focused – 2 - 4 organ systems and/or body areas

Detailed – 5 - 7 organ systems and/or body areas in detail

Comprehensive – 8 + organ systems

OR

Problem Focused – 1 organ system or 1 body area

Expanded Problem Focused – 2-7 organ systems or body areas, no detail of system required

Detailed - 2 - 7 organ systems or body areas, with affected system in detail

Comprehensive – 8 or more organ systems

BA Head, including the face

BA Neck: neck (masses, symmetry, etc), thyroid

BA Chest (Breasts): inspection breast, palpation breast/axillae

BA Abdomen

BA Genitalia, groin, buttocks

BA Back, including spine

BA Left upper extremity

BA Right upper extremity

BA Left lower extremity

BA Right lower extremity