Transcript Presentation - AHS - American Headache Society

Webcast Session II
An Introduction to Evaluation and Management (EM) Coding
Accurate Coding for Evaluation and Management (EM) Services
A webcast designed for headache and migraine specialists
Presenters
Stuart B. Black, MD
American Headache Society (AHS)
Sheila J. Madhani, MA, MPH, CCS-P
MARC Associates
October 16, 2007
Goals
• Introduction to CPT EM codes
• How to properly select the appropriate
level of Medical Decision Making (MDM)
for a specific EM encounter
• Application of CPT coding guidelines and
practices to clinical scenarios relevant to
headache specialists
What Will We Discuss?
• Importance of accurate coding
• Key components of EM codes
• How to properly select the appropriate level of Medical
Decision Making (MDM) for a specific EM encounter
• General principles of medical record documentation
• Clinical examples
• Coding resources
Importance of Accurate Coding
• Full and fair description of services
provided
• Avoid over-coding (fraud and abuse) and
under-coding (not reporting all the services
you have provided)
• Improve quality of patient care
Importance of Accurate Coding
• Physicians use EM codes to report
professional services
• Documentation in the medical record must
support the EM code and ICD-9 code(s)
submitted
• Submitting a code that is not supported by
documentation may be considered fraud
Key Components of EM Codes
• Three key components must be
considered and supported by
documentation in the medical record
before selecting a code
– History
– Examination
– Medical decision making (MDM)
Key Components
History
• Summary
Elements
HPI
History of
Present Illness
ROS
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive
Brief
(1-3
elements)
Brief
(1-3 elements)
Extended
(4 or more
elements)
Extended
(4 or more elements)
None
Problem Specific
Extended
Complete
None
None
Pertinent
Complete
Review of
Systems
PFSH
Past Medical,
Family and
Social History
Key Components
Physical Examination
• Summary – 1997 Guidelines, Single System Specialty Exam, Neurological
Level of Exam
1997 Single Organ System
Problem focused
1-5 elements
Expanded Problem Focused
At least 6 elements
Detailed
At least 12 elements
Comprehensive
Perform all elements
Document all elements in
•Constitutional
•Eyes
•Musculoskeletal
•Neurological
Document 1 element in
•Cardiovascular
How to properly select the
appropriate level of Medical
Decision Making (MDM) for a
specific EM encounter
Medical Decision Making (MDM)
• What is medical decision making (MDM)?
– MDM refers to the complexity of establishing
a diagnosis and/or selecting a management
option
• Of the three key components of EM, MDM is the
most challenging to meet and document
Medical Decision Making (MDM)
• MDM Factors
– Factor #1: Number of diagnoses or
management options
• Number of possible diagnoses
• Number of options that must be considered
– Levels
•
•
•
•
Minimal
Limited
Multiple
Extensive
Medical Decision Making (MDM)
• MDM Factors
– Factor #2: Amount and/or complexity of data
to be reviewed
• Amount and/or complexity of medical records,
diagnostic tests and/or other information that must
be obtained, reviewed and analyzed
– Levels
•
•
•
•
Minimal or none
Limited
Moderate
Extensive
Medical Decision Making (MDM)
• MDM Factors
– Factor #3: Risk of complications and/or morbidity or
mortality
• The risk of significant complications, morbidity and/or
mortality associated with the patient’s presenting problem
• The risk of comorbidities associated with the patient’s
presenting problem
• The risk of the diagnostic procedure(s) and/or the possible
management options
– Levels
•
•
•
•
Minimal
Low
Moderate
High
Medical Decision Making (MDM)
• What are the different levels of MDM?
– Straightforward
– Low complexity
– Moderate complexity
– High complexity
Medical Decision Making (MDM)
• How do I determine the level of MDM for a
specific EM encounter?
– The level of MDM is based on the level of complexity
of the 3 factors of MDM
• Number of diagnoses or management options
• Amount and/or complexity of data to be reviewed
• Risk of complications and/or morbidity or mortality
Medical Decision Making (MDM)
•
How do I determine the level of MDM for a specific EM encounter?
– The level of MDM is based on the level of complexity of the 3 factors of MDM
#1 - Number of
diagnoses or
management
options
#2 - Amount
and/or complexity
of data to be
reviewed
#3 - Risk of
complications
and/or morbidity
or mortality
Type of decision
making
(Level of MDM)
Minimal
Minimal or
None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Medical Decision Making (MDM)
• The next few slides provide the following
guidance
– Issues to consider when determining the level
of complexity of the 3 factors of MDM
– Recommendations for documenting MDM
– Based on 1997 EM Guidelines, Centers for
Medicare and Medicaid Services (CMS)
Medical Decision Making (MDM)
• Factor #1: Number of diagnoses or
management options
– Issues to consider
• MDM is easier for a diagnosed problem than for an identified
but undiagnosed problem
• Problems which are improving are less complex than
problems that are worsening or failing to change as expected
• The need to ask advice from an outside source is an
indication of complexity of diagnosis
Medical Decision Making (MDM)
• Factor #1: Number of diagnoses or
management options
– Documentation recommendations
• An assessment, clinical impression or diagnosis
should be documented
• Initiation of treatment or changes in treatment
should be documented
• Any referrals or consultations, advice sought
should be documented
Medical Decision Making (MDM)
• Factor #2: Amount and/or complexity of
data to be reviewed
– Issues to consider
• The type of diagnostic testing ordered or reviewed
• Decision to review old medical records and/or
obtain history from a source other than the patient
increases complexity
• Discussion of contradictory or unexpected results
with the physician who performed or interpreted
test increases complexity
Medical Decision Making (MDM)
• Factor #2: Amount and/or complexity of
data to be reviewed
– Documentation recommendations
• Any of the following tasks should be documented
– Any diagnostic services ordered, planned or scheduled
– The review of lab, radiology and/or other diagnostic tests
– Decision to obtain old records or obtain additional history
from other sources that the patient
– Relevant findings from the review of old records and/or
additional history
– Discussion of diagnostic tests with the physician who
performed them
– The direct visualization and independent interpretation of
an image, tracing or specimen
Medical Decision Making (MDM)
• Factor #3: Risk of significant
complications, morbidity, and/or mortality
– Issues to consider
• Risk associated with the presenting problem
• Risks associated with the diagnostic procedure(s)
• Risks associated with the possible management
problems
Medical Decision Making (MDM)
• Factor #3: Risk of significant
complications, morbidity, and/or mortality
– Documentation recommendations
• Any of the following risks should be documented
– Comorbidities/underlying diseases
– Surgical or invasive diagnostic procedures ordered,
planned or scheduled at the time of the EM
– Any invasive or surgical diagnostic procedure performed
at the time of the EM encounter
– The referral for or decision to perform a surgical or
invasive diagnostic procedure on an urgent basis
Medical Decision Making (MDM)
• Risk Table
– CMS has developed a risk table to help determine the level of
medical decision making for a specific EM encounter (minimal,
low, moderate, high)
– Table includes common clinical scenarios
– Table provides an assessment of risk in 3 categories
• Presenting problem(s)
• Diagnostic procedure(s) ordered
• Management options selected
– Highest level of risk in any 1 category determines the overall risk
Centers for Medicare and Medicaid Services (CMS), Documentation Guidelines for EM, 1997.
Key Components
Medical Decision Making (MDM)
• Table of Risk
– For headache specialists the most important
risk categories are:
• Number of treatment options
• The levels of risk complications and/or morbidity or
mortality
Medical Decision Making (MDM)
• Table of Risk Comparison – elements relevant to headache
specialists extracted from Table of Risk
Number of Treatment
Options
Risk of Complications
Minimum
Rest
One self limited or minor
problem
Low
Over the counter drugs
Stable chronic illness
Moderate
Prescription drug
management
One or more chronic
illnesses with mild
exacerbation
High
Drug therapy requiring
intensive monitoring for
toxicity
One or more chronic
illnesses with severe
exacerbation
Medical Decision Making (MDM)
• MDM scoring system
– Methodology to determine level of MDM developed by private
organizations
– There are several systems currently in use
• Based on a point system that takes qualitative information collected by the
provider and translates it into quantitative data
• More points; higher level of service
• Example that follows was developed by the American Health Information
Management Association (AHIMA)
• In general scoring systems are not part of any CMS guidelines or
recommendations
Medical Decision Making (MDM)
•
MDM scoring system example
–
Factor 1: Number of Diagnoses or Treatment Options (more than 1 may apply)
Number of Diagnoses or Treatment Options
Self limited or minor
Established problem; stable
Points
1
1
Established problem; worsening
New problem; no additional workup
New problem (to examiner); additional workup
2
3
4
Medical Decision Making (MDM)
•
MDM scoring system example
– Factor 2: Amount/Complexity of Data Reviewed (more than 1 may apply)
Data Reviewed
Order/review clinical lab tests
Order/review from radiology services
Order/review from medical services
Discussion of tests results with performing
provider
Decision to obtain old records/history/discuss
case with provider
Independent visualization of image, tracing or
report
Points
1
1
1
1
2
2
Medical Decision Making (MDM)
• MDM scoring system example
– Factor 3: Risk of significant complications
•
•
•
•
Minimal
Low
Moderate
High
Medical Decision Making (MDM)
• MDM scoring system example
Straightforward
Low
Moderate
Complexity Complexity
High
Complexity
Diagnosis/
Management Options
<=1
2
3
>=4
Amount/Complexity of
Data
<=1
2
3
>=4
Minimal
Low
Moderate
High
Risk
Medical Decision Making (MDM)
• Summary
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or morbidity
or mortality
Type of decision
making
(Level of MDM)
Minimal
Minimal or
None
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Choosing an appropriate level of
EM service
• Based on Key Components
– The three key components must be
considered and supported by documentation
in the medical record before selecting a code
• History
• Examination
• Medical decision making (MDM)
Choosing an appropriate level of
EM service
• New patient, office/outpatient and office
consultations
– You must meet or exceed ALL of the requirements to
qualify for a particular level of an EM service
• Established patient, office/outpatient
– You must meet or exceed 2 out of the 3 requirements
to qualify for a particular level of an EM service
Summary
• New Patient – Office/OP (3 out of 3)
Code
History
Exam
Medical Decision
Making
99201
Problem focused
Problem focused
Straightforward
99202
Extended problem
focused
Extended problem
focused
Straightforward
99203
Detailed
Detailed
Low complexity
99204
Comprehensive
Comprehensive
Moderate Complexity
99205
Comprehensive
Comprehensive
High Complexity
Summary
• Office or other Outpatient Consultation (3 out of 3)
Code
History
Exam
Medical Decision
Making
99241
Problem focused
Problem focused
Straightforward
99242
Extended problem
focused
Extended problem
focused
Straightforward
99243
Detailed
Detailed
Low complexity
99244
Comprehensive
Comprehensive
Moderate Complexity
99245
Comprehensive
Comprehensive
High Complexity
Summary
• Established Patient – Office/OP (2 out of 3)
Code
History
Exam
Medical Decision
Making
99211
Minimum services; Physician not required
99212
Problem focused
Problem focused
Straightforward
99213
Extended Problem
Focused
Extended Problem
Focused
Low complexity
99214
Detailed
Detailed
Moderate Complexity
99215
Comprehensive
Comprehensive
High Complexity
Time
• Time determines the level of E/M service
when counseling and/or coordination of care
dominate (> 50%) the encounter
– Counseling and coordination is separate from the
history, physical exam and medical decision making
– More common scenario for headache specialists
– The extent of counseling and/or coordination of care
must be documented in the medical record
independent of the three key components
Documentation
• General Principles of Medical Record Documentation¹
– Medical record should be complete and legible
– The documentation of each patient encounter should include:
• Reasons for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
• Assessment, clinical impression or diagnosis;
• Plan for care; and
• Date and legible identity of the provider
– If not documented, the rationale for ordering diagnostic and other
ancillary services should be easily inferred
¹ 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)
Documentation
• General Principles of Medical Record
Documentation¹
– Past and present diagnoses should be accessible
– Appropriate health risk factors should be identified
– Patients progress and response to changes in
treatment should be included
– CPT and ICD-9 codes submitted should be supported
by documentation in the medical record
¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)
Documentation
• Elements of a consultation
• There are three documented elements that comprise a consultation
– A written request, asking a question, for specific advice or specific
management direction in the care of a patient
– Documentation of the patient evaluation
– A specific written response i.e. the answer to the question, as simple as
“Yes, the patient didn’t have a PE and you may proceed with the
surgery”
• The unspoken fourth component- all of the above must materially
contribute to the evaluation and/or management of the patient or the
consult is not medically necessary
Clinical examples
Case #1 – History (HPI, ROS, PFSH)
70 yr old man with hx of DM. 6 months ago developed
herpes zoster; right V1 distribution. After Rx of acute
zoster developed constant, deep burning pain in V1 (R)
with tic like pain and pain to light touch. Also developed
severe (R) hemicranial headaches Under care of PCP;
pain refractive to Rx. Referred to H/A Specialist for
consult.
Case #1
Level of Care
99241?, 99242?, 99243?, 99244?, 99245?,
99201?, 99202?, 99203?, 99204?, 99205?
Physical Exam
Examination 23 bullets: BP 150/85; pulse 82 regular RR16. Carotids
full. Pt did appear to be in acute distress with pain in V1 distribution of
R trigeminal nerve. No skin lesions present.
M/S & Symbolic Function intact. CN; Normal except for extreme pain to
touch (R) V1 area of face. Motor, Coordination, Gait, Reflexes WNL.
Sensation otherwise intact
Diagnosis
1.History of Acute Herpes Zoster ; 2. Post Herpetic Neuralgia
3. Trigeminal Neuralgia; 4. New onset right hemicranial persistent
headache; 5. Diabetes Mellitus - currently well controlled on oral
medication
Complexity of
Data Reviewed
1.Reviewed all records from consulting PCP and prior Neurologist; 2.
Personal discussion with consulting Physician; 3. Reviewed all prior lab
values; 4. Reviewed prior Ct and MRI of Head; 5. Reviewed all prior
treatments
Risk
Risk of Presenting Problem:
Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?
High severity?
Risk of Management Options?; Risk of Diagnostic Procedures?
Case #1
Pre-service
– Reviewed all the patient’s referral records. Reviewed the medical history form completed by
the patient, vital signs, additional information obtained by PA. Personal communication with
referring physician
Intra-service
– Comprehensive H&P performed
– Reviewed relevant data, risks, and explained clinical features of Post Herpetic Neuralgia
– Discussed diagnostic and therapeutic options
– Discussed recommended treatment plan
Medical Decision Making
– Number of Diagnoses or Treatment Options > 4
– Amount / Complexity of Data Reviewed > 4
– Using the Table of Risk:
• “Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g..
multiple trauma, acute MI, pulmonary embolus, progressive severe rheumatoid
arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal
failure”
• “Drug therapy requiring intensive monitoring for toxicity”
.
Case #1
Post-service
–
Complete medical record documentation and send written report to
referring physician
– Post 1st visit communicate with referring doctor and treat any treatment
failures or AE’s if need
– Receive and respond to any interval testing results or correspondence
– Revise treatment plan if necessary and communicate with patient as
necessary
The level of care would meet CPT criteria for an Office
Consultation 99245. It includes a comprehensive H & P and
MDM of high complexity. There has been no transfer of
care.
Case #2 – History (HPI, ROS, PFSH)
27 year old woman, established pt, seen in follow up
B/O MOH. Post hospital visit following detoxification
week ago. Detailed review of post hospital instructions;
discussed all medications; discussed Dx and risks of
MOH; discussed situation with family and importance of
family support. Scheduled for support group.
Case #2
Level of Care
99212; 99213; 99214; 99215; 99212; 99213; 99214; 99215
Physical Exam
BP 115/70; Pulse 65
Entire 30 minute encounter spent in Counseling and Coordination of
Care. More than 50% of the time spent in face – to –face discussion
with patient and family.
Diagnosis
1. Migraine w/o aura; 2.Transformed migraine; 3. Medication Overuse
Headache
Complexity of
Data Reviewed
The encounter was a “counseling visit”. A detailed and concise
overview of the medical problem and current treatment plan was
discussed with the patient and her family. Current and future care
including the diagnoses, treatments, prognosis, risks, and management
options discussed.
Risk
The risks of noncompliance reviewed at length.
The risks of the overall presenting problem reviewed.
The risk of not monitoring medication therapy reviewed.
Reviewed risk of morbidity; prolonged functional impairment.
Case #2
Pre-service
Reviewed medical record and hospitalization in detail before encounter with
patient and her family.
Intra-service
Counseling and Coordination of care comprised more than 50% of the
encounter; in fact it comprised 100% of the encounter. This was “face - to –
face time with the patient and family. Although time is not taken into
account as a factor for determining the level of E/M care for most medical
encounters, time is often the key or controlling factor in selecting the level
of service in headache management.
When counseling and Coordination of care is the CPT determining factor,
there is no consideration of the extent of the history, the exam, the medical
decision making required, or the nature of the presenting problem.
Case #2
Intra-service (cont.)
The time spent in Counseling/Coordination of care is the sole determinant
of the E/M code.
Counseling is defined as a discussion with the patient and/or family or other
care giver concerning: diagnostic results, prognosis, risks and benefits of
treatment, instructions for management, compliance issues, risk factor
reduction, patient and family education.
Coordination is defined as discussions about the patient’s care with other
providers or agencies. Time is defined in the CPT codebook. For an
established patient: 99212 =10min; 99213= 15 min; 99214 = 25 min; 99215
= 40 min.
Case #2
Post-service
The Physician must document the total length of time of the visit /
encounter. In addition, the description of the counseling and / or activities
involved in coordinating care must be documented.
The physician also must document that more than 50% of the
encounter was involved in Consultation and / or Coordination of care.
The E/M code for this visit would be 99214. Consultation and
Coordination of care is a major factor in the management of headache
patients.
Coding resources
Coding resources
• American Headache Society (AHS)
– AHS’s Headache Coding Corner
• http://www.americanheadachesociety.org/professionalresources/AHSs
HeadacheCodingCorner.asp
• American Medical Association
– CPT-related resources
• http://www.ama-assn.org/ama/pub/category/3113.html
• Centers for Medicare and Medicaid Service (CMS)
– Evaluation and Management Services Guide
• http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pd
f
– 1997 Documentation Guidelines for Evaluation and Management
Services
• http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Thank You
The American Headache Society thanks
you for your participation.
Please contact American Headache
Society (AHS) headquarters for further
information: [email protected] or 856423-0043.