13 - icd10 specialtytips evaluation and management ... · icd$10!specialtytips’...

ICD-‐10 SPECIALTY TIPS

EVALUATION AND MANAGEMENT | 1 of 8

SPECIALTY TIP #13 Evaluation and Management (E&M) This topic is being addressed in our Specialty Tips series as most providers rate Evaluation and Management as one of the more challenging areas for documentation. All providers have, at some time or another, had to produce an E/M note for the medical record so the following may help you to better understand what is needed. There are no easy “fixes” as consistent use of the same mid or high level code raises red flags with carriers; not all of your patients would logically warrant the identical level of care all the time. EVERY note is subject to documentation guidelines dependent on the setting and type of patient. The Basics For every initial encounter with a patient, your note sets up the course for the continuing care and/or treatment and is usually driven by the acuity of the patient’s condition. It is rarely necessary to document a level 5 outpatient visit for an earache unless there are other far more serious comorbid conditions concurrently under treatment. The nature of the patient’s presenting problem and the related conditions for which the physician performed E/M work drive the medical necessity determination. Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

CMS Manual System, 100-04 Medicare Claims Processing, Rev. 178, 05-14-04 Contrary to most popular thought, Medical Decision Making and Medical Necessity are not synonymous. The AMA’s definition of medical necessity follows: Services or procedures that a prudent physician would provide to a patient in order to prevent, diagnose, or treat an illness, injury or disease or the associated symptoms in a manner that is:

• In accordance with the generally accepted standard of medical practice. • Clinically appropriate in terms of frequency, type, extent, site and duration. • Not intended for the economic benefit of the health plan or purchaser, or the convenience of the patient, physician or other

health care provider. In other words, an overly zealous amount of documentation does not necessarily support a higher level of service.

Documentation • Documentation in the medical record must illustrate the service as it was provided to the patient:

– Chief Complaint-‐ reason for the encounter should be included in EVERY note – Relevant history (this may be an interval history for subsequent or established patients) – Physical examination findings and prior diagnostic test results – Assessment, clinical impressions or diagnosis – Plan for care

• Document your presence and participation in the E&M services in patient specific terms especially with NPP split/shared notes or with resident involvement (Teaching Physician linking statement is only applicable to resident documentation)

– Use personal pronouns and phrases (“my exam”, “I reviewed the ROS and confirmed with patient”, “patient seen and examined with ....”)

• This leaves no doubt as to your involvement in the care of the patient • Each note should reflect a “snapshot” of the encounter to the highest degree of certainty at its conclusion. • Each note should be unique to the patient and their condition, avoid a “cookie cutter” note. • A “New patient” means a patient who has not received any professional services, i.e., Evaluation and Management (E/M) service

or other face-‐to-‐face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

– Applicable to Office/Outpatient clinic setting • An “Established patient” is one who has received professional services from the physician or another physician of the same

specialty who belongs to the same group practice, within the last 3 years. – Applicable to Office/Outpatient clinic setting.



NOTE: Dependent on the region and carrier, there may be slight variations in the following note requirements.

History- Composed of 3 components of HPI (History of Present Illness), ROS (Review of Systems, and PFShx (Past Medical, Family, and Social History)

History (Requires all 3 components met or exceeded) PROBLEM FOCUSED

EXPANDED PROBLEM FOCUSED

DETAILED

COMPREHENSIVE HPI (History of Present Illness): Characterize HPI by considering either the status of

chronic conditions (under treatment) or the number of elements recorded 1 Condition 2 Conditions

OR 3 Conditions

Status of 1-‐2 Chronic Conditions

Status of 3 Chronic Conditions

Location Severity

Timing Modifying factors

Quality Duration

Context Associated signs & symptoms

Brief (1-‐3)

Extended (4 or more)

ROS (Review of Systems): NOTE: Be sure to address the system currently under treatment None

Pertinent to Problem (1 system)

Extended

Pertinent and others

(2-‐9 systems)

Complete

Pertinent and all others

(10 or more systems)

Constitutional Eyes Ears, nose,

mouth, throat

Card/vascular GI GU Musculoskeletal

Respiratory Integumentary

(skin, breast) Neurological

Psychiatric Endocrine Hem/lymph Allergy/immunology

All other systems negative (See NOTE below) PFShx (Past medical, Family, Social History) areas:

Past History (the patient’s past experiences with illness, operations, injuries and treatments) Family History (a review of medical events in the pts family, including diseases which may be

hereditary or place the patient at risk) (See NOTE below) Social History (an age appropriate review of past and current activities)

None

None

Pertinent (1 history area)

Complete

*(2 or 3 history areas dependent on setting and type, see below)

*For Complete PFSH requirements see setting 2 PFS history areas:

a) Established patients. Office (OP) care; domiciliary care; home care b) Subsequent hospital care c) Subsequent observation care d) Emergency Department; e) Subsequent nursing facility care

3 PFS history areas: a) New patients. Office (OP) care; domiciliary care; home care; b) Consultations c) Initial hospital care; d) Initial observation care; e) Comprehensive nursing facility assessments

NOTE: In ROS, for “All other systems negative” most carriers will allow the use of this phrase AFTER the pertinent systems have been reviewed and some carriers require each system to be addressed as either positive or pertinent negative responses in order to be counted. NOTE: In Family History, do not use “Non-‐contributory” – this is interpreted as “did not ask” and, therefore, not counted. • CAUTION in using “see HPI” especially in review of systems. In leveling the visit, each piece of information can only be used as an item

once, it may already have been used in another element (as an HPI item, in PFS history, as a condition for MDM, etc.). • A lower level could result by not addressing all of the Past Medical, Family, and Social history for Consults, Initial and New patients. • If the history is unobtainable, document reason (GCS 3, intubated & sedated, AMS, etc.) and this element could still be credited.

o Every effort should be made to get the information from other sources (i.e., translator, family, parents, spouse, “no other source available for history”, “no translator available”, etc.), note source if information obtained from other than patient.

• History is the one area that may change regarding requirements. o For New patients, Admitted patients – Initial Visit, Initial Observation, Consultations, and Emergency Visits = All three

elements of history, exam, and medical decision making are required to determine the Level of Care. o For Established patients, subsequent hospital visits, subsequent observation patients, an interval history may be used (the

level of service for these types of visits is determined by only two out of three elements of history, examination, and/or medical decision making).

In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history. (Please document date and location of earlier review in current record).

CMS Manual System, 100-04 Medicare Claims Processing, Rev. 178, 05-14-04



Examination

NOTE: A notation of “abnormal” without elaboration is not sufficient. For normal findings, a brief statement or notation indicating “negative” or “normal” is sufficient for unaffected areas or asymptomatic organ systems.

Ø Either 1995 or 1997 documentation guidelines may be used (but not a combination of both) • 1995 exam guidelines are most often used as they are easier and are usually more beneficial to the physician.

o I usually do not encourage use of body areas over systems as each body area includes multiple systems. • 1997 exam guidelines may be beneficial for specialty groups; however, not all specialty systems are covered and some

specialty groups have exams that may overlap.

Medical Decision Making (MDM) Ø The complexity of your Medical Decision Making reflects the risk and the resulting care you are extending to the patient

• MDM (Medical Decision Making) is composed of three elements. We will discuss each of the three elements below.

Box Type of Decision Making Straight-‐ Forward Low Complexity Moderate Complexity

High Complexity

A Number of diagnoses or management options ≤ 1 Minimal

2 Limited

3 Multiple

≥ 4 Extensive

B Amount of complexity of data to be reviewed ≤ 1 Minimal or Low

2 Limited

3 Moderate

≥ 4 Extensive

C Risk of complications &/or morbidity or mortality Minimal

Low

Moderate

High

Box A: Number of Diagnosis or Management Options (the formula to determine the total points is N x P = R) Problems to Exam Physician Number Points Result

Self-‐limited or minor (stable, improved or worsening) Max = 2 Problems x 1 =

Est. problem (to examiner); stable, improved x 1 =

Est. problem (to examiner); worsening or not responding as expected x 2 =

New problem (to examiner); no additional work-‐up planned Max = 1 Problem x 3 =

New problem (to examiner); additional work-‐up planned (Admitted, follow-‐up after immediate stress test, etc.)

x 4 =

Bring total to line “A” in Final Result box for MDM (Maximum of 4 total points) TOTAL

• Here is where your handling of multiple conditions and complications will count • Be sure to document the severity of each condition when applicable. As you can see, this helps your coder determine the number

of points per condition

Examination Dependent on the number of systems / body area(s) examined Body Areas: Head, (Including. Face) Neck

Chest, (Including breast & axillae) Abdomen

Genitalia, groin, buttocks Back (Including Spine)

Each extremity

Organ Systems: Constitutional (e.g., vital, gen app) Eyes Ears, nose, throat, mouth

Cardiovascular Respiratory Gastrointestinal

Genitourinary Musculoskeletal Integumentary

Neurological Psych Hem/lymph/immunological

Exam Level Description '95 Guideline Requirements ‘97 Guideline Requirements Type of Exam

Limited to affected body area or organ system

One body area or organ system 1-‐5 bulleted elements = PROBLEM-‐FOCUSED EXAM

Affected body area or organ system and other symptomatic or related organ systems

2-‐7 body areas and/or organ systems

6-‐11 bulleted elements = EXPANDED PROBLEM-‐ FOCUSED EXAM

Extended exam of affected body area or organ system and other symptomatic or related organ systems

2-‐7 body areas and/or organ systems with one in detail

12-‐17 bulleted elements for 2 or more systems

= DETAILED EXAM System____________________

General multi-‐system 8 or more body areas and/or organ systems

18 or more bulleted elements for 9 or more systems

= COMPREHENSIVE EXAM Complete single organ system exam Not defined

See requirements for individual single system exams



• Example: Patient, in addition to CAD (stable), has diabetes (not under control), COPD (stable, on oxygen), spiking a fever with labs ordered (new problem with additional work-‐up planned)

• 2 established problems (stable) = 1 point per condition x 2 conditions = 2 points (CAD & COPD) • 1 established problem not responding as expected = 2 points (DM) • 1 new problem with additional work-‐up planned = 4 points (elevated fever with cultures ordered)

• Total of 8 points (notice that >4 points is the highest you can achieve in this category).

• Everything you do carries value into the determination of an Evaluation & Management visit o Did you order labs, how about an EKG (medicine section), or x-‐rays. Did you read those tests (remember, for an EKG or

radiology, you MUST detail your findings)? Did you discuss results with the radiologist (what did you discuss)?

Ø Risk is probably the most important factor in the determination of your visit! Obviously the following list is not all inclusive, but I have underlined some of the key words in each category to illustrate the increasing severity of each level and the need to add the severity of each of the conditions under treatment.

Box C: Risk (Choose risk factor(s) and bring result of highest determined risk to line “C” in above box) • Choosing your risk first helps you to determine how extensive the rest of your documentation should be. • Many auditors first review the medical necessity/risk portions to determine the appropriate level of service the rest of the

note should reflect. Risk Level Presenting Problem(s) Diagnostic Procedure(s)

Ordered Management Options

Selected M I N I M A L

•One self-‐limited or minor problem; e.g., cold, insect bite, tinea corporis

•Laboratory tests requiring venipuncture •Chest x-‐rays •EKG/EEG •Urinalysis •Ultrasound; e.g., echo •KOH prep

•Rest •Gargles •Elastic bandages •Superficial dressings

L O W

•Two or more self-‐limited or minor problems •One stable chronic illness; e.g., well controlled hypertension or non-‐insulin dependent diabetes, cataract, BPH •Acute uncomplicated illness or injury; e.g., cystitis, allergic rhinitis, simple sprain

•Physiological tests not under stress; e.g., pulmonary function tests •Non-‐cardiovascular imaging studies with contrast; e.g., barium enema •Superficial needle biopsies •Clinical laboratory tests requiring arterial puncture •Skin biopsies

•Over-‐the-‐counter drugs •Minor surgery with no identified risk factors •Physical therapy •Occupational therapy •IV fluids without additives

M O D E R A T E

•One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment •Two or more stable chronic illnesses •Undiagnosed new problem with uncertain prognosis; e.g., lump in breast •Acute illness with systemic symptoms; e.g., pyelonephritis, pneumonitis, colitis •Acute complicated injury; e.g., head injury with brief loss of consciousness

•Physiologic tests under stress; e.g., cardiac stress test, fetal contraction stress test •Diagnostic endoscopies with no identified risk factors •Deep needle or incisional biopsy •Cardiovascular imaging studies w/ contrast and no identified risk factors; e.g., arteriogram, cardiac catheterization •Obtain fluid from body cavity; e.g., lumbar puncture, thoracentesis, culdocentesis

•Minor surgery w/ identified risk factors •Elective major surgery (Open, percutaneous or endoscopic) w/ no identified risk factors •Prescription drug management •Therapeutic nuclear medicine •IV fluids with additives •Closed treatment of fracture or dislocation w/o manipulation

H I G H

•One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment •Acute or chronic illnesses or injuries that pose a threat to life or bodily function; e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, ARF •An abrupt change in neurologic status; e.g., seizure, TIA, weakness or sensory loss

•Cardiovascular imaging studies with contrast with identified risk factors •Cardiac electrophysiological tests •Diagnostic endoscopies w/identified risk factors •Discography

•Elective major surgery (open, percutaneous or endoscopic) w/ identified risk factors •Emergency major surgery (open, percutaneous or endoscopic) •Parenteral controlled substances •Drug therapy requiring intensive monitoring for toxicity •Decision not to resuscitate or to de-‐escalate care because of poor prognosis

Box B: Amount and/or Complexity of Data to be Reviewed Points Review and/or order of clinical lab tests = 1

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

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

Discussion of test results with performing physician = 1

Decision to obtain old records and/or obtaining history from someone other than patient Record type and source must be noted. Review of old records must be reasonable and necessary based on the nature of the patient’s condition. Practice-‐ or facility protocol-‐driven record ordering does not require physician work thus should not be considered when coding E/M services. Perfunctory notation of old record ordering/review solely for coding purposes is inappropriate and counting such is not permitted

= 1

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

= 2

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

Bring total to line “B” in Final Result box for MDM (Maximum of 4 total points) TOTAL



An Example for Determination of Medical Decision Making MDM is composed of three elements (You must meet or exceed two of the three elements) • For example:

o This is a new problem, patient admitted, and you are planning additional work-‐up (Box A), (4 points) o You only ordered labs in data review (Box B) with a resulting straight-‐forward complexity (1 point), o Your risk (Box C) is Moderate because you are treating a patient with pyelonephritis.

• You met (and exceeded in Box A) two of the three elements at the Moderate Complexity Level (i.e., where two of the elements meet in the chart).

• If you think of the arrow as a slide going back and forth, where does the arrow cover two darker blue points in the chart? o In this example, even though you would also meet at Low complexity, since both are the same, you would choose the

higher Moderate level. Best two out of three.

Box Type of Decision Making Straight-‐ Forward

Low Complexity Moderate Complexity

High Complexity For MDM, only 2 out of the 3 elements must be met or

exceeded

A Number of diagnoses or management options

≤ 1 Minimal

2 Limited

3 Multiple

≥ 4 Extensive

This element meets another element at

the Moderate Complexity level in the

chart

B Amount of complexity of data to be reviewed

≤ 1 Minimal or Low

2 Limited

3 Moderate

≥ 4 Extensive

This can be ignored because it is the lowest of the 3 categories

C Risk of complications &/or morbidity or mortality

Minimal

Low

Moderate

High

This will drive the visit as Moderate

Complexity is the highest common

denominator for 2 of the 3 elements

How Does It All Come Together? Steps to Determine the Level of Service

1. Find the appropriate setting (Inpatient, Outpatient, Emergency, etc.) and type (Initial, new, established, etc.)

2. What was the extent of your history? • (Circle the F [problem focused], E [expanded problem

focused], D [detailed], or C [comprehensive]) 3. What was the extent of your examination?

• (Circle the F [problem focused], E [expanded problem

focused], D [detailed], or C [comprehensive]) 4. What was the extent of your Medical Decision Making?

• (Circle the S [straight-‐forward], L [low], M [moderate], or H [high] in the MDM column of that setting)

5. Finally, how many elements are required? Ø Consults, New Outpatient, Initial Inpatient Visits, Initial

Observation, Emergency § Require all three elements of history, exam, and

medical decision making met or exceeded Ø Established Outpatient, Subsequent Inpatient, Subsequent

Observation § Require two out of three elements of history, exam,

and/or medical decision making met or exceeded

*When all three elements are required, the lowest element determined could affect the result of the entire visit.

Legend:

History and Exam: Medical Decision Making:

F = Problem focused S = Straightforward

E = Expanded problem focused L = Low Complexity

D = Detailed M = Moderate Complexity

C = Comprehensive H = High Complexity

EXAMPLE: (Step #1 Determine setting and type ) Office/Outpatient Initial Visit

Code Step #2 History

Step #3 Exam

Step #4 Medical Decision Making

99201 F F S

99202 E E S

99203 D D L

99204 C C M

99205 C C H

Step #5 = All 3 Elements of History, Examination, and Medical Decision Making are required for Initial Visits

*As all 3 elements are required, the extent of the history, exam, and MDM only meet at the 99203 level because of the history



Documentation Requirements per Setting

Outpatient Consult Codes* Inpatient Consult Codes* Emergency Department Codes

Code History Exam Medical

Decision Making Code History Exam

Medical Decision Making

Code History Exam Medical

Decision Making

99241 F F S 99251 F F S 99281 F F S

99242 E E S 99252 E E S 99282 E E L

99243 D D L 99253 D D L 99283 E E M

99244 C C M 99254 C C M 99284 D D M

99245 C C H 99255 C C H C C H

Consult codes require documentation of the request for an opinion as well as documentation of the communication back to the requesting provider in the medical record

*99285 is the only code that may override the documentation requirements due to the urgency of the patient’s clinical

condition and/or mental status All 3 Elements of History, Examination, and Medical Decision Making are required for Consult Codes and Emergency Department Codes

Office/Outpatient Initial Visit Office/Outpatient Established Visit

Code History Exam Medical Decision

Making Code History Exam

Medical Decision Making

99201 F F S 99211 Not applicable for physicians

99202 E E S 99212 F F S

99203 D D L 99213 E E L

99204 C C M 99214 D D M

99205 C C H 99215 C C H All 3 Elements of History, Examination, and Medical Decision Making are required for

Admits Two out of three elements are required for Subsequent Visits

Inpatient Initial Hospital Codes Inpatient Subsequent Hospital Codes

Code History Exam Medical Decision Making Code History Exam Medical Decision

Making

99221 D/C D/C S or L 99231 F F S or L

99222 C C M 99232 E E M

99223 C C H 99233 D D H

All 3 Elements of History, Examination, and Medical Decision Making are required for Admits

Two out of three elements are required for Subsequent Visits

Observation Initial Visit Observation Subsequent Visit Observation or Inpatient Hospital Care

Admit and Discharge Same Day

Code History Exam Medical Decision Making



99218 D/C D/C S or L 99224 F F S or L 99234 D/C D/C S or L

99219 C C M 99225 E E M 99235 C C M

99220 C C H 99226 D D H 99236 C C H All 3 Elements of History, Examination, and Medical

Decision Making are required for Initial Visits Two out of three elements are required for Subsequent

Visits All 3 Elements of History, Examination, and Medical Decision

Making are required for Same Day Admit / D/C

• For Consults, you cannot self-‐refer. There must always be a request for your services in the medical record in order to qualify for a consult as well as documentation of your communication back to the requesting provider.

o If you assume all or a portion of care for the patient, it is no longer considered a consult but a visit. o See Specialty Tip #8, Consults vs. Visits for more detailed information on consults

• YOUR documentation should easily clarify the INTENT of the visit. Keep in mind that Charge Tickets are not a part of a legal medical record.



Time as the Controlling Factor When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M service. In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-‐to-‐face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-‐to-‐face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

The duration of counseling or coordination of care that is provided face-‐to-‐face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling. CMS Manual System, 100-04 Medicare Claims Processing, Rev. 178, 05-14-04 Documentation requirements:

• Physician must complete at least 2 out of 3 criteria of history, exam, and/or MDM • Total time of visit • Time spent on Counseling and/or Coordination of Care • Summary of the discussion

EXAMPLE: “Today, I spent a total of 45 minutes with the patient; after my limited interval history of __, my expanded exam of__, 30 minutes of that time was spent counseling Mr Smith on the test results, prognosis, and treatment options for his new diagnosis of insulin dependent diabetes.”

Modifiers for E/M Modifiers 24, 25 and 57 may only be used on E/M services. • -‐24 Unrelated evaluation and management service by the same physician during a postoperative period. • -‐25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the

procedure or other service. • -‐57 An evaluation and management service that resulted in the initial decision to perform a major surgery.

o Major surgery = 90-‐day global.

Diagnosis Diagnoses are the mechanism that supports the medical necessity for treatment and your documentation illustrates that medical necessity. It directs the type of codes used whether it is a consult, an interval note for established patients, or an emergency note for a trauma patient. ICD-‐10 opens up a wider range of coding opportunities. • If applicable, always state laterality. • Detail anatomical locations. • For musculoskeletal conditions and injuries, state whether the patient is:

o In the treatment phase (surgery, Emergency Department, evaluation and treatment by new physician, etc.), o In the healing phase (cast change or removal, medication adjustment, aftercare following treatment), o Or is this a late effect/sequela of an injury?

• Rather than a current condition, are you treating a late effect or should this be termed a “history of”? • When treating a sequela for an injury you need to gather information on the mechanism of the injury:

o Details of the original injury (“closed spiral fracture of the right radius”) o When did the original injury occur? (Date) o What happened? (“driver in an MVA”, “slip and fall in home”, “bitten by a neighbor’s dog”, etc.)

• Coding rules dictate that when coding for multiple conditions, the more severe or acute code is sequenced first with chronic conditions as secondary. o Be sure to qualify the severity of each condition under treatment (i.e. severe OA, stable HTN, COPD exacerbation, mild

Asthma, etc.). Diagnostic sequencing depends on severity (acute over chronic, etc.) o In addition, for E&M coding, those descriptive words help in the medical decision making portion of the visit

• State acute or chronic, old injury, any descriptive wording that help to illustrate the condition o Example: “Glaucoma, early stage”, “Insulin dependent diabetes”, “torn meniscus, recurrent injury”

• State any “due to” or precipitating conditions o Example: “Pathological fracture of hip due to metastatic carcinoma of bone”

• Include comorbid and relevant conditions that impact decision making or complicate surgery o Appropriate health risk factors should be identified.

§ Example: “Morbidly obese patient-‐BMI 40”, “smokes 2 packs of cigarettes per day x 20 years”, “patient is fragile, 87 year old who lives alone with limited access to medical care”



• If ordering tests for a suspected condition, include differential diagnosis (even though they cannot be coded as definitive diagnosis) and/or sign and symptoms to support your decision making and medical necessity for the tests.

• Update your diagnosis for the current service being provided especially in bringing forward visits in an EMR: o While prior conditions may have originally prompted the visit, would they still be relevant? o Unless a condition is under treatment or has an impact on the condition under treatment, it is not considered relevant. o For Inpatients, day-‐to-‐day conditions may change, update each day. This could be beneficial if a new condition requires

additional work-‐up. (Example: “Fever spiked overnight, cultures sent to lab, antibiotics prescribed”) • For chronic patients, new conditions are relevant and can impact the medical decision making IF they are addressed (i.e. during the

examination, within the plan, etc.) • If a patient is pregnant, always include trimester and number of weeks regardless of the setting.

o The only time pregnancy is considered incidental is when it is documented as such. Otherwise it is coded as “Pregnancy complicated by...” to support the increased medical decision making required.

• Be sure that you are listing as your diagnosis the condition YOU are treating (i.e. COPD under treatment by a Pulmonologist, atrial fibrillation treated by a Cardiologist, etc.)

• Certain conditions (neoplasms, respiratory, etc.) ask for additional information regarding alcohol and tobacco use, abuse, exposure to, or history of which influence the condition.

For additional information, the following CMS site offers an 84 page informational guide, which includes both the 1995 and 1997 Guidelines: https://www.cms.gov/Outreach-‐and-‐Education/Medicare-‐Learning-‐Network-‐MLN/MLNProducts/downloads/eval_mgmt_serv_guide-‐ICN006764.pdf The following CMS site offers additional guidelines for Teaching Physicians: https://www.cms.gov/Outreach-‐and-‐Education/Medicare-‐Learning-‐Network-‐MLN/MLNProducts/Downloads/Teaching-‐Physicians-‐Fact-‐Sheet-‐ICN006437.pdf

abeo has a variety of Evaluation and Management Pocketcards available for fast, easy reference.

The information provided is only intended to be a general summary and not intended to take place of either written law or regulations.

13 - icd10 specialtytips evaluation and management ... · icd$10!specialtytips’...

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