Webcast Session IIAn Introduction to Evaluation and Management (EM) Coding

Accurate Coding for Evaluation and Management (EM) Services A webcast designed for headache and migraine specialists

PresentersStuart 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 Problem Focused

Expanded Problem Focused

Detailed Comprehensive

HPIHistory of Present Illness

Brief

(1-3 elements)

Brief

(1-3 elements)

Extended

(4 or more elements)

Extended

(4 or more elements)

ROSReview of Systems

None Problem Specific Extended Complete

PFSHPast Medical, Family and Social History

None None Pertinent Complete

Key ComponentsPhysical 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 Points

Self limited or minor 1

Established problem; stable 1

Established problem; worsening 2

New problem; no additional workup 3

New problem (to examiner); additional workup 4

Medical Decision Making (MDM)

• MDM scoring system example– Factor 2: Amount/Complexity of Data Reviewed (more than 1 may apply)

Data Reviewed Points

Order/review clinical lab tests 1

Order/review from radiology services 1

Order/review from medical services 1

Discussion of tests results with performing provider

1

Decision to obtain old records/history/discuss case with provider

2

Independent visualization of image, tracing or report

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 exampleStraightforward Low

ComplexityModerate

ComplexityHigh

Complexity

Diagnosis/

Management Options<=1 2 3 >=4

Amount/Complexity of Data

<=1 2 3 >=4

Risk Minimal Low Moderate High

Medical Decision Making (MDM)

• SummaryNumber 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 #1Level 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 #1Pre-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 #2Level 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 #2Pre-serviceReviewed medical record and hospitalization in detail before encounter with patient and her family.

Intra-serviceCounseling 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-serviceThe 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/AHSsHead

acheCodingCorner.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.pdf

– 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: ahshq@talley.com or 856-423-0043.