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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
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2
CMS Guidelines
• Presentation based on CMS guidelines
• Your MAC provider guidelines may vary
• Basics only
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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
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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
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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
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History - HPI
• History of Present Illness - HPI Location
Severity
Timing
Modifying Factors
Quality
Duration
Context
Associated Signs and Symptoms
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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.
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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.
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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.
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History - ROS• Review of Systems –ROS
– Constitutional – ENT – Eyes – Cardiovascular – GI – GU – Respiratory – Musculoskeletal – Psychiatric – Integumentary – Endocrine – Hem/Lymph – Allergy/Immunology – Neurologic
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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
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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• 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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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