today’s training plan evaluation and ... - kmc university guideline… · kmc university...
TRANSCRIPT
1www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Evaluation and Management (E/M) Documentation Guidelines Made
Simple – Part 1
Presented by:
Kathy Mills Chang, MCS-P, CCPC, CCCA
KMC University
Today’s Training Plan
• Recognize and apply E/M documentation requirements for history and consultation
• Properly execute the four sub-components of history to be documented for new and established patient documentation
• Properly execute the appropriate documentation for chiropractic examination components necessary to meet E/M
documentation requirements
• Reproduce quality documentation components within history and examination for new and established patients
•Distinguish necessary elements of E/M documentation guidelines necessary for various levels of coding
Method to the MadnessThe Difference? Documentation and Intent
Another Difference? NP vs. EP
NP= If the patient has never been to your office, has only seen a different provider specialty in your office, or it’s been at least 3 years since they have seen you or another provider of your specialty
Evaluation + Management (E/M)
1 2
3 4
5 6
2www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Breaking News-09/2018 Interesting Proposal
Can We Imagine A World Where…. If only Carriers Will Follow This…
But That May Be the Future….
7 8
9 10
11 12
3www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
1995 vs. 1997 Guidelines
• History and Medical Decision Making are virtually identical
• 1995’s guidelines are more vague and general and 1997’s are structured based on specialty
• Majority of difference is in examination element
What is Documentation and Why is it Important?
Key Components1-2-3
Three Key Components-#1 History
• The first and most important element
• Determines the level of service necessary for all the rest
• Can’t rely on only what the patient fills out
• The art of consultation is critical
Biggest Errors We See
1. Using the patient’s written history alone
2. Forgetting to include the patient’s history with notes records sent
3. Lack of expansion by the provider on important points
4. No history on re-exams
Big Error! Consultations 99241-99245
•A consultation is not history
•A reason that FREE consultations are an issue
•Key components are the same as NP/EP EM coding
•Consulting provider CAN assume treatment
•Required elements slightly different
•A documented referral to the consulting provider and a written report of findings from the consulting provider back to the referring provider
13 14
15 16
17 18
4www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
HistoryKey Components
Chief Complaint (CC)
• A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter
• Usually stated in the patient’s own words
• The medical record should clearly reflect the CC.
Chief ComplaintComponents of HPI
19 20
21 22
23 24
5www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
HPI Section
25 26
27 28
29 30
6www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Review of Systems
31 32
33 34
35 36
7www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Past, Family and Social History (PFSH)
37 38
39 40
41 42
8www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
History = Detailed
The Weakest Link
43 44
45 46
47 48
9www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
1995 Examination Guidelines
•Focus is on body areas and organ systems vs. bullets in 1997• Levels listed
for coding purposes are the same
1995 Examination Guidelines
1995= Rules Rules Rules
Cardiovascular Exam
Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)
49 50
51 52
53 54
10www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
For Example… Circle this Bullet if Performed
Lymphatic Exam
•Palpation of lymph nodes in neck, axillae, groin, and/or other location
•Notation of any abnormalities or notation of within normal limits
For Example…
Circle this Bullet if Performed Extremity Exam
•Extremities are covered as a part of the musculoskeletal examination
•Extremities are not required, but may apply on a patient by patient basis.
55 56
57 58
59 60
11www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Skin Exam
• Inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas:•1) head and neck, 2) trunk,
3) right upper extremity, 4) left upper extremity,•5) right lower extremity,
and 6) left lower extremity
For example…
Skin Has Multiple Options
Head and Neck = 1 Trunk = 1 R&L UE = 2
Four Bullets Earned for Three Lower
Exam Levels!
Neurological Exam•Test coordination (e.g.,
finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)•Examination of deep
tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)
Neurological Exam
•Examination of sensation (e.g., by touch, pin, vibration, proprioception)
•Orientation to time, place and person
•Mood and affect (e.g., depression, anxiety, agitation)
Mood, Affect, Appearance
•Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed? •Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span? •Speech: Is it normal in tone, volume and quantity? •Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?
61 62
63 64
65 66
12www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Mood, Affect, Appearance•Awareness of environment, also referred to as
orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year? •Mood: How do they feel? You may ask this directly
(e.g. "Are you happy, sad, depressed, angry?"). Is it appropriate for their current situation? •Affect: How do they appear to you? This interpretation
is based on your observation of their interactions during the interview. Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, appropriate.
Circle All that Have Been Performed
Constitutional Exam• 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)
For Example
Count These Elements if Performed Musculoskeletal Exam
•This is the primary and most significant portion of the exam you will most typically perform
•Although you may always do these things, they must be documented in a particular manner
67 68
69 70
71 72
13www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Musculoskeletal Exam•Examination of gait and
station• Identify gross
abnormalities in the gait• Observe the patient
walking into the room; how they get up and down from the exam table•Heel/Toe Walking and/or
Romberg’s Test• Is the Gait slow, or
limited by pain?
For example…
Count this Element if Performed General Musculoskeletal
Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four 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; and 6) left lower extremity
General Musculoskeletal
• Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions•Assessment of range of motion with notation of any
pain (e.g., straight leg raising), crepitation 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
For Example…
73 74
75 76
77 78
14www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Multiple Bullets AvailableMultiple Bullets Available
Multiple Bullets Available Multiple Bullets Available
Multiple Bullets AvailableWhat About Comprehensive?
79 80
81 82
83 84
15www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Score The Examination
Examination = Detailed Established Patient- Detailed
E/M Knowledge Pays Off in Better Documentation
85 86
87 88
89 90
16www.kmcuniversity.com 1-(855)-TEAMKMC X105
www.footlevelers.com
Need Help? [email protected]
91 92