Transcript Consultants - Gary Cavett & Co., CPAs, LTD

Developing an E&M Chart
Review Process
Presented by:
Gary Cavett, CPA
President
Find out more at www.gmcavett.com
Audit vs.
Review
Audit



Provides a reasonable basis for expressing an
opinion
Detailed, independent testing procedures
Verification and substantiation procedures

May include direct correspondence with creditors or
debtors to verify details of amounts owed, physical
inspection of inventories or investment securities,
inspection of minutes and contracts

Give auditor knowledge and understanding of the entities
system of internal control
Review




Does not provide a basis for the expression of an opinion
 Does not contemplate obtaining an understanding of
the internal control structure or assess control risk
Requires inquiry and analytical procedures
 Focus on information your company provides that
doesn’t validate if the underlying transactions
represented by your organization’s financial
statements are correct
 No source document testing is performed
Less in scope than an audit
Does not require an opinion as to the records like an
audit does
E&M Utilization
Inter-category Utilization (2007)
Category Descriptions
FP
IM
Ortho
New Office Visits to All E/M Codes
Established Office Visits to All E/M codes
Initial Hospital Visits to All E/M Codes
Established Hospital Visits to All E/M Codes
Outpatient Consults to All E/M Codes
Inpatient Consults to All E/M Codes
Follow-up Consults to All E/M Codes
Confirmatory Consults to All E/M Codes
Emergency Department Services to All E/M Codes
Comprehensive Nursing Home Visits to All E/M Codes
Subsequent Nursing Home Visits to All E/M Codes
2.71%
66.99%
2.74%
12.51%
0.55%
0.35%
0.00%
0.00%
2.17%
0.87%
6.41%
1.56%
49.39%
4.28%
27.24%
1.01%
1.53%
0.00%
0.00%
0.93%
0.86%
6.26%
12.14%
69.06%
1.02%
2.54%
10.88%
3.68%
0.00%
0.00%
0.27%
0.04%
0.14%
All
All
All
All
69.70%
15.25%
0.90%
7.28%
44.50%
44.50%
50.96%
31.51%
2.55%
7.12%
52.70%
52.70%
81.20%
3.56%
14.55%
0.18%
32.00%
32.00%
Office Visits to All E/M Codes
Hospital Visits to All E/M Codes
Consults to All E/M Codes
Nursing Home Visits to All E/M Codes
All E/M Visits to All Procedures
ESTABLISHED PATIENT UTILIZATION
99211
Family Practice
Internal Medicine
Ortho. Surg
1994
1997
2000
2008
4.37%
4.31%
4.17%
3.94%
4.35%
2.39%
3.65%
4.34%
1.86%
1.10%
5.34%
4.21%
Family Practice
Internal Medicine
Ortho. Surg
22.78%
12.15%
36.39%
19.17%
10.40%
31.58%
17.90%
10.66%
33.10%
24.18%
5.15%
7.42%
Family Practice
Internal Medicine
Ortho. Surg
56.88%
57.65%
42.54%
58.48%
57.15%
46.07%
60.02%
58.27%
49.53%
56.65%
51.92%
57.46%
Family Practice
Internal Medicine
Ortho. Surg
12.98%
20.33%
13.95%
15.29%
22.43%
16.39%
15.81%
22.09%
13.39%
16.30%
33.07%
28.21%
Family Practice
Internal Medicine
Ortho. Surg
2.99%
5.55%
2.95%
3.11%
5.67%
3.57%
2.64%
4.65%
2.12%
1.77%
4.53%
2.71%
99212
99213
99214
99215
E&M Relative Value Units
Code
99201
99202
99203
99204
99205
New Office Visit
RVUs
0.99
1.73
2.56
3.92
4.93
Established Office Visit
Code
RVUs
99211
0.55
99212
1.02
99213
1.66
99214
2.52
99215
3.42
Code
99241
99242
99243
99244
99245
Outpatient Consult
RVUs
1.34
2.49
3.42
5.04
6.26
Code
99251
99252
99253
99254
99255
Inpatient Consult
RVUs
1.31
2.09
3.1
4.46
5.55
Consult
vs.
Referral
Definition of a Consultation
“A consultation is a type of service provided by a physician
whose opinion or advice regarding evaluation and/or
management of a specific problem is requested by a
physician or other appropriate source.” [CPT, 2004]
“Specifically, a consultation is distinguished from a visit
because it is provided by a physician whose opinion or
advice regarding evaluation and/or management of a
specific problem is requested by another physician or
other appropriate source [Medicare Carriers Manual,
§15506 (A)(1)]
Facts about Consultation Services




If the diagnosis is known, it can still be considered a
consultation.
If diagnostic or therapeutic treatment is started by the
consulting physician during the initial evaluation it is
deemed a consultation.
Primary care physicians, nurse practitioners, PAs,
clinical nurse specialists and certified nurse midwives
can also bill for consultation services.
Requesting and consulting physicians do not have to be
of different specialties.
Facts about Consultation Services
continued…



Even though you’ve seen a patient with a condition and previously
charged for a consult, you can bill for a consult again on the same
condition when a new request is made for your advice or opinion by
the attending provider.
Even if a patient has previously been charged for a consultation
relative to a condition, that same patient can be charged a consultation
again for the same condition if a request for another consultation is
made by the attending physician.
Inpatient consults need to be billed for evaluation and management
services provided in a hospital or similar setting, even when the
physician takes over managing an aspect of the patient’s care.
Referral for medical management from a surgeon to another physician
is not a consultation.
MEDICARE INSTRUCTION ON BILLING FOR
CONSULTATIONS AUGUST, 1999
Codes 99241-99255
Consultation - An E&M service provided by a physician whose
opinion or advice of a specific problem is requested by another
physician or other appropriate source.
1. Consult vs. Visit: The consultant prepares a report of his/her findings, provided to the
referring physician, for the referring physician’s use in treating the patient. A consultant may
initiate diagnostic and/or therapeutic services. However, when the referring physician transfers
the responsibility for treatment to the receiving physician at the time of the referral in writing or
verbally, the receiving physician may not bill a consult. (If the referring physician tells you to
take over and manage the care of the patient, you cannot bill a consult).
2. A request for a consultation from an appropriate source and the need for consultation must
be documented in the patient’s medical record. This can be either verbal or written. But, either
way, it should be documented in the patient's medical record by the requesting and the
consulting physician.
3. After the consultation is provided, the consultant prepares a written report of their findings,
which is provided to the referring physician. This report cannot be verbal. Copies of progress
notes also cannot be used as the sole written report.
Continued….
4.
5.
6.
7.
8.
9.
Consult Followed by Treatment: If the referring physician does not transfer the responsibility of patient care to the
receiving physician until after the consult service is completed, the receiving physician can bill a consult. After
the consulting physician assumes responsibility for the patient care, subsequent visits should be reported as
established patient visits or subsequent hospital care, depending on the setting. (This means that a physician can
treat and consult on the same day, as long as they get back to the initial doctor before the treatment begins.)
Consult Requested by Member of Same Group Practice: Consultations may be requested within the same physician
group practice. This may be done as long as all the requirements are met for use of the CPT consultation codes.
Documentation for Consult: The request for a consult from the attending and the need for a consult must be
documented in the patient medical record. The consulting physician must provide a written report to the
requesting physician for his/her use in treatment. In an inpatient setting, the request may be documented as part
of a plan written in the requesting physician’s progress note, an order in a hospital record, or a specific written
request for the consult. In an office setting, the requirement can be met by a specific reference to the request.
Consult for Preoperative Clearance: You can bill a consult for preoperative clearance for a new or established
patient when the consult is done at the request of a surgeon.
Post-Op Care by Physician who did Preoperative Clearance Consult: After a physician completes a pre-op consult
in the office or hospital, the physician should not bill another consult if he/she then assumes responsibility for
the management portion or all of the patient’s condition(s) during the post-op period. In an in-patient setting,
the physician who performed a pre-op consult and assumes responsibility of the management of a portion or all
of the patient’s condition(s) during the post-op period should use the appropriate subsequent hospital care codes
to bill for the concurrent care he or she provides. In the office setting, physicians should use the appropriate
established patient visit code during the post-op period. A primary care physician or specialist who performs a
post-op evaluation of a new or established patient at the request of the surgeon may bill a consult for E&M
services furnished during the post-op period following surgery as long as the physician did not already perform a
pre-op consult. (This clarification, in June of 1996, states point-blank that a non-specialist can bill consults for
pre-op care.)
Surgeon Requests Another Physician Participate in Post-Op Care: If the surgeon asks a physician who has not seen
the patient for a pre-operative consult to take responsibility for the management of an aspect of the patient's
condition during the post-op period, the physician may not bill a consult because the surgeon is not asking that
physician's opinion or advice for the surgeon’s use in treating the patient. The physician’s service would
constitute concurrent care and should be billed using the appropriate visit code.
What is the principal issue?
The actual issue that has to be answered is whether
there is a transfer of care. If the complete
care of the patient’s problem has been turned
over to the specialist and that specialist agrees to
accept accountability for the patient’s care prior
to an initial evaluation being performed then a
consultation code cannot be billed.
When does Transfer of Care occur?

“…A transfer of care occurs when the referring
physician transfers the responsibility for the patient’s
complete care to the receiving physician at the time of
the referral, and the receiving physician documents
approval of care in advance…” [Medicare Carrier’s Manual, §
15506 (B)]
Examples of Transfer of Care


Patient is seen by her family practice physician with
complaints of wrist and hand pain, finger numbness
and is suspected to have carpal tunnel syndrome. It is
recommended to the patient to seek a hand surgeon’s
care and treatment of possible carpel tunnel syndrome.
Patient with a knee injury is treated by an Emergency
Department physician. The patient is told to follow up
with an orthopedic physician the next day.
Consult vs. Referral
Continued…

An easy way to think about consults is the “3 R’s”---a
Request, Rendering an opinion, and Reporting back to the
attending physician.
Request: Can be written or verbal and also must be
documented in the patient’s medical record. [MCM § 15506
(A)(2) and (D) and CPT Assistant November 1999]
• Don’t assume the request is acknowledged in the requesting
physician’s medical record.
• “Who may we thank for referring you?” on the patient
demographics sheet should not be used as proof that a
consultation was requested. Ask the patient if another physician
has recommended the evaluation.
• Just because the patient has a managed care
referral/authorization form does not mean it is a
consultation request.
Consult vs. Referral
Continued…
Rendering: The need for the consult, and also the
history, exam and medical decision making
components of the evaluation has to be
documented in the patients medical record.
Report: The requesting physician must be
furnished with a written report. [MCM § 15506
(D). “…communicate findings and/or
recommendations by written report to the
requesting physician or other appropriate
source.” [CPT Assistant, August 2001]
*Documentation must be textbook perfect*
Consult vs. Referral
Continued…

Wording on the requesting physician’s documentation
ought to include “requested consult from” or “sought
advice from” instead of the usual “referred to” or “sent
to”.

If the referring physician tells the consulting physician
to take over and manage the care of the patient, you
CANNOT bill a consult.

This “hand-off ” point is often where physicians run
into a problem billing consults. Physicians will say
“Take care of this patient” and refer the patient to
another physician. This is a visit…not a consult!
Consultation Request vs.
Recommendation
If the patient only wants a recommendation for
someone their doctor trusts for services that this
patient will be needing on their own in the future then
the doctor providing this information is not asking
for advice or opinion and this service is not
considered a consultation.
Examples of non-consultation
services
Examples:

The patient’s family practice physician was asked by the general surgeon to
provide pre-operative clearance for the FP’s diabetic patient with CAD. After
surgery, the surgeon asks the FP to assess the patient’s diabetic control for the
remainder of the hospital stay. The initial hospital service by the FP cannot
be a consultation because he provided the pre-op clearance consultation
services. [MCM, § 15506 (G)]
*Note: The above is a requirement for Medicare only. CPT has not specified
any rules regarding post-op consultations
when pre-op clearance was performed
by the same physician/group.

There is a standing order in the hospital that when a patient experiences XYZ
symptoms during the night, the Emergency Department physician (or
internist or hospitalist) is called to assess the patient and provide treatment as
necessary. Standing orders do not satisfy the criteria for a valid consultation
request. [MCM § 15506 (J)]
Types of Consultation Services
Office or Outpatient (99241-99245)
Physician office
 Hospital observation services
 Home services
 Domiciliary, rest home and custodial care
 Emergency department
Examples:
 Office consultation for 30 year-old female tennis player with
sprain or contusion of the forearm.
 Initial office consultation for a 60 year-old male with vascular
necrosis of the left femoral head with increasing pain.
 Office consultation for independent medical evaluation of a
patient with a history of complicated low back and neck
problems with previous multiple failed back surgeries.

Types of Consultation Services
Inpatient (99251-99255)
 Hospital inpatients
 Nursing facilities
 Partial hospital setting
Examples:
 Hospital consultation for a 50 year-old female with
incapacitating knee pain due to generalized rheumatoid
arthritis.
 Hospital consultation for a 70 year-old diabetic female with
gangrene of the foot.
 Hospital consultation for a 35 year-old multiple-trauma male
patient with complex pelvic fractures to evaluate and
formulate management of plan.
Who Can Request a Consultation?


A physician or other appropriate source may request a
consultation.
*Medicare Carrier’s Manual, §15506 (A)(1)
What is an “other appropriate source?”
“CPT guidelines do not set restrictions regarding
individuals who may be considered an ‘appropriate
source’…..Some common examples include a physician
assistant, nurse practitioner, doctor of chiropractic,
physical therapist, occupational therapist, speechlanguage therapist, psychologist, social worker, lawyer
or insurance company…” [CPT Assistant, September 2002]
Who Can Provide and Bill For
Consultation Services?
“Any procedure or service in any section of this book (CPT
2004) may be used to designate the services rendered by any
qualified physician or other qualified healthcare professional.”
[Introduction, CPT 2004 Professional Edition, page xiii]



Primary care physicians
Specialists
Nurse practitioners and physician assistants as
long as the service is within the scope of practice
in your state.
Who Can Provide and Bill For
Consultation Services?
Primary Care Physicians:
 A pre-operative clearance evaluation is the
most common consultation service provided
by a PCP.
-PCP needs to evaluate the patient before surgery. The
surgeon’s request to have this evaluation done is documented
in the patient’s medical record.
-A medically necessary evaluation is provided by the PCP.
-A written report from the PCP showing the results of the
evaluation and recommendation for surgery is given to the
surgeon.
Who Can Provide and Bill for
Consultation Services?

Does not have to be a physician.
“Non-physician practitioners, e.g., nurse practitioners, certified nurse
mid-wives or physician assistants, may….also perform other medically
necessary services, e.g., consultations when the performance is within
the scope of practice for that type of non-physician practitioner in
the State in which they practice. Applicable collaboration and general
supervision rules apply as well as billing rules.” [MCM §15506 (C)]
[CPT Assistant, January 2002, “Beyond the Ordinary: Coding
‘Challenging’ E/M Circumstances,” Case #2 – “The fact that this is
an established patient of the family practitioner is irrelevant.”]
Medicare agrees [MCM § 15506 (E) and (F)].
Unusual Consultation Requests



Pre-surgical clearance from the PCP or specialist
treating the condition.
Intra-specialty consultation requests (e.g., a
gastroenterologist requests a consultation from a GI
motility specialist).
[CPT Assistant, June 1999 and April 2000]
Intra-specialty, intra-practice consultation requests (e.g.,
orthopedic surgeon requests consult from his/her spine
specialist partner. Or a pediatrician requests a consult
from his nurse practitioner who has special training in
diagnosis and treatment of children with ADHD).
[CPT Assistant, April 2000]
Use of Modifiers with Consultation
Services
-25 “Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Same Day of
the Procedure or other service.
* If there are diagnostic or therapeutic services that were
performed on the same day as the consultation evaluation.
 -32 “Mandated Service”
*Should be used when the evaluation is required by a third party
payer.
-57 “Decision for Surgery”
* Most often used for emergency room and inpatient
consultations.
* Use if the decision to immediately perform surgery was a result
of the consultation evaluation.

Do’s and Don’ts of Consultation Billing
DO





Do check your state Medicaid and contracted managed care
program definitions for consultation services, they may be
different than CPT or Medicare’s definitions.
Do document the request for advice or opinion in your medical
record and be as specific as possible.
Do promptly return a written report to the requesting physician
with a copy of the report in your records.
Do charge for a consultation service when a surgeon asks you
for surgical clearance.
Do charge for consultation services when a medically necessary
opinion is sought from a physician of the same specialty as the
requesting physician.
Do’s and Don’ts of Consultation Billing
DON’T





Don’t charge for a consultation when the patient comes to you
for ER follow-up care.
Don’t charge for a consultation when the patient has self
referred to your practice.
Don’t charge for a consultation when the patient received your
name as just a recommendation from another physician.
Don’t charge for a consultation every time a new managed care
referral form is received.
Don’t forget to make sure that the documentation supports all
three “R’s.” If any one of the three are missing, according to
both CPT and Medicare, the service must be charged as a regular
office or hospital visit, regardless of the intent of the requesting
physician.
Consultation Checklist




Is this encounter a request for my advice or opinion?
Is the request for consultation documented in my copy
of the medical record?
Is the medical necessity for this service demonstrated
and have I provided the key elements of E/M
documentation to support the service that was billed?
Did the requesting physician or other appropriate
source receive a written report and is there a copy of
this report in my medical record?
HISTORY QUESTIONNAIRE
Date:
Name:
Patient ID number
(office use only)
Last
First
Birth Date
Middle
Male
Female
Chief Complaint (Reason for visit)
Date of Injury:
History of the Present Illness**
Location (Identify specific location of the pain or problem)
______________________________________________________________
Quality (Has the pain increased or decreased since the injury or symptom happened)
______________________________________________________________
Severity (Identify on a scale of 1 to 10 the degree of pain)
None - 1 2 3 4 5 6 7 8 9 10 - Severe
Duration (Identify the length of time of the injury or symptom)
______________________________________________________________
Timing (Is there a time or condition that increases or decreases the pain)
______________________________________________________________
Context (How did the injury happen or when did the symptoms start)
__________________________________________________________________
Modifying Factors (Do certain conditions increase or decrease the pain or problem)
______________________________________________________________________________________
Associated Signs & Symptoms (Has this injury or symptom created problems with other areas of the body)
______________________________________________________________________________________
Review of Systems**
PRIMARY SYSTEMS
Do you now or have you ever had any problems related to the following systems?
Please circle Y (Yes) or N (No) (Please explain any Yes answers in space provided or on attached sheet.)
Musculoskeletal
Head and Neck
Spine, Ribs, Pelvis
Right Upper Extremity Arm
Left Upper Extremity Arm
Right Lower Extremity Leg
Left Lower Extremity Leg
Comments______________________
Constitutional Symptoms
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Y
Y
N
N
Y
Y
N
N
Y
N
Integumentary
Skin rash
Skin Inflammation
Other_________________________
Neurological
Tremors
Dizzy Spells
Numbness/Tingling
Other__________________________
Fever/Temperature
Weight gain/loss
Headache
Other _________________________
Hematologic/Lymphatic
Swollen Glands
Blood Clotting problem
Other____________________
Cardiovascular
Chest Pain
Varicose Veins
Y
Y
N
N
High Blood Pressure
Y
N
Other______________________
Psychological
Has this injury/condition affected your
attitude?
SECONDARY SYSTEMS
Allergic/Immunologic
Ear/Nose/Throat/Mouth
Hay Fever
Drug Allergies
Food Allergies
Other__________________________
Y
Y
Y
N
N
N
Ear Infections
Sore Throats
Sinus Problems
Other_________________________
Gastrointestinal
Y
Y
Y
Y
N
N
N
N
Eyes
Y
Y
Y
N
N
N
Abdominal
Nausea/Vomiting
Indigestion/Heartburn
Other__________________________
Blurred Vision
Double Vision
Pain
Other_________________________
Respiratory
Wheezing
Frequent Cough
Shortness of Breath
Other__________________________
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Endocrine
Excessive Thirst
Too Hot/Cold
Tired/Sluggish
Other_____________________
Genitourinary
Urine Retention
Painful Urination
Other__________________________
Y
Y
N
N
Past, Family & Social History**
Occupation: _________________________
Were you referred by another Doctor? Y
N
Is this injury job related?
Y
N
If yes, who__________________________
List any personal past illnesses and/or surgeries and when they occurred.
Illness or surgery
Date
Are you on any medications?
(Please identify)
Y
N
____________________________________
__________________________________________
List all related injuries or conditions in your immediate family.
Description
Family Member
___________________________________
___________________________________
Identify activities that have affected your injury or condition.
Do you exercise regularly?
Does your job require physical exercise?
Please explain.
Y
Y
N
N
First Visit:
Physician:____________________
Date:__________
Subsequent Visits:
Physician:____________________
Physician:____________________
Date:__________
Date:__________
Do you participate in sports?
Are there other circumstances that
affect this condition? Please
explain.
Comments:
Y
Y
N
N
HISTORY QUESTIONNAIRE
DATE
Date of Birth
Employer
NAME:
Last
First
M S W D
Marital Status
Age
Male
Occupation
Middle
Female
Family MD
Referring MD
Chief Complaint (Reason for visit, When did your symptoms start?)
If this is an injury, is it related to your employment?
History of the Present Illness**
Latex Allergies: Yes No
Medication/Dose/Frequency
Allergies:
1.
2.
3.
4.
5.
6.
7.
8.
PLEASE USE ATTACHED SHEET IF EXTRA SPACE IS NECESSARY
Location (Identify specific location of the pain or problem)
______________________________________________________________
Quality (Has the pain increased or decreased since the injury or symptom happened)
______________________________________________________________
Severity (Identify on a scale of 1 to 10 the degree of pain)
None - 1 2 3 4 5 6 7 8 9 10 - Severe
Duration (Identify the length of time of the injury or symptom)
______________________________________________________________
Timing (Is there a time or condition that increases or decreases the pain)
______________________________________________________________
Context (How did the injury happen or when did the symptoms start)
__________________________________________________________________
Modifying Factors (Do certain conditions increase or decrease the pain or problem)
___________________________________________________________________________________
Associated Signs & Symptoms (Has this injury or symptom created problems with other areas of the body)
Review of Systems**
Do you now or have you ever had any problems related to the following systems?
Please circle Y (Yes) or N (No) (Please explain any Yes answers in space provided or on attached sheet.)
Constitutional Symptoms
Fever / Temperature
Weight gain/loss
Headache
Other
Musculoskeletal
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Neurological
Tremors
Dizzy Spells
Numbness/Tingling
Other
N
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
N
N
Integumentary
Skin Rash
Inflammation
Other
Psychological
Has this injury/condition affected your
attitude?
Y
Head and Neck
Spine, Ribs, Pelvis
Right Upper Extremity (arm)
Left Upper Extremity (arm)
Right Lower Extremity (leg)
Left Lower Extremity (leg)
Comments
Cardiovascular
Chest Pain
Varicose Veins
High Blood Pressure
Other
Hematologic/Lymphatic
Y
Y
Y
N
N
N
Swollen Glands
Blood Clotting Problem
Other
Y
Y
N
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Y
Y
Y
N
N
N
Ear/Nose/Throat/Mouth
Allergic/Immunologic
Hay Fever
Drug Allergies
Other
Ear Infections
Sore Throats
Sinus Problems
Other
Y
Y
N
N
Y
Y
Y
N
N
N
Blurred Vision
Double Vision
Pain
Other
Y
Y
Y
N
N
N
Endocrine
Y
Y
N
N
Gastrointestinal
Abdominal Problems
Nausea/Vomiting
Indigestion/Heartburn
Eyes
Respiratory
Wheezing
Frequent Cough
Shortness of Breath
Other
Excessive Thirst
Too Hot/Cold
Tired/Sluggish
Other
Genitourinary
Urine Retention
Painful Urination
Other
Past, Family & Social History**
CIRCLE ANY OF THE FOLLOWING ILLNESSES YOU HAVE HAD: Circle Yes (Y) or No (N)
Y N High Blood Pressure
Y N HIV (AIDS)
Y N Heart Trouble
Y N Rheumatic Fever
Y N Scarlet Fever
Y N Ulcer
Y N Emphysema
Y N Tuberculosis
Y N Asthma
Y N Thyroid Trouble
Y N Kidney Infection
Y N Seizures
Y N Pneumonia
Y N Transfusion with blood
Y N Unconsciousness
Y N Diabetes
byproduct
Y N Head Injury
Y N Yellow Jaundice
Y N Fractures
Year of your last physical ______ Where? __________________________________________________
When did you have your last chest x-ray?________ Electrocardiogram? _________ Pap Smear? _______
Do you smoke? Y N Cigarettes per day_________ How many years have you Smoked?___________
When did you quit?__________________
Do you drink alcohol? Y N
How many drinks do you consume per day? ______________________
Menstrual History: Last Period___________ Onset Age __________ Regular Periods? Y N
Are you Pregnant? Y N No. of pregnancies?____ Age of first Pregnancy _________ No. of Children
Other Medical Problems/Hospitalizations:
Previous Surgeries:
Alive
Deceased
Cause of
Death
Mother
Brothers
Father
Sisters
Spouse
Grandparents
ILLNESSES THAT OCCUR IN YOUR FAMILY:
Cancer of the Bowel
Y N
Cancer of the Ovary/Uterus
Y
Cancer of the Breast
Y N
Other Cancers:__________________
Cancer of the Lung
Y N
Severe or early age heart problems
Y
Any problems after anesthesia
Y
Alive
N
N
N
Deceased
Cause of
Death
Bleeding
Diabetes
High Blood Pressure
Y
Y
Y
N
N
N
**(If additional space is needed in order to complete this questionnaire, please use the attached sheet.)
Date:_____________ TEMP:_____ B/P:___________________ HT:_____________ WT:______________
Completed By:________________________ Physician Signature:___________________ Date___________
Time as the Main Component
•Documentation of an encounter dominated by
counseling or coordination of care.
• In the case where counseling and/or coordination of
care dominates (more than 50%) of the
physician/patient and/or family encounter (face-toface in the office or other outpatient setting, floor/unit
time in the hospital or nursing facility), time is
considered the key or controlling factor to qualify for a
particular level of E/M service.
• If the physician elects to report the level of service
based on counseling and/or coordination of care, the
total length of time of the encounter (face-to-face time,
as appropriate) should be documented and the record
should describe the counseling and/or activities to
coordinate care.
TIME COMPONENT
New
Patient
Established
Patient
Time
Outpatient
Consult
Code
Time
Code
Code
Time
99201
10 min
99211
5 min 99241
15 min
99202
20 min
99212
10 min 99242
30 min
99203
30 min
99213
15 min 99243
40 min
99204
45 min
99214
25 min 99244
60 min
99205
60 min
99215
40 min 99245
80 min
Contact Information
Gary Cavett, CPA
President
51 Broadway
Suite 601
P.O. Box 2927
Fargo, ND 58108
Tel:
(701) 235-1124
Fax:
(701) 235-1854
Email: [email protected]
Web site: www.gmcavett.com