Hello everyone. Welcome to an introduction to Evaluation and Management coding session. Before we begin, I
want to let you know that Evaluation and
Management coding can be pretty complex. There are lots of
areas of uncertainty, areas that have not been clarified via the
official guidelines, there are differences in how evaluation and management
guidelines are interpreted. Today's session is
not meant to cover every aspect of evaluation
and management for every region or locality
in the United States. I want to let you know that I am based in the Chicagoland area, so some of the rules
that I present today may vary from your
part of the country. Also, today's session is not
meant to be a consultation. Please refer to
your specific payer for guidelines regarding Evaluation
and Management coding. Today we're going to
focus on the basics. To begin, you'll want to
have your 2019 or 2018, that's fine, CPT coding
manual with you. You'll want to ensure
that you are at the very beginning of the evaluation and
management section where the guidelines are. You'll know that you are in the correct place
in your CPT manual because it will say Evaluation and Management
Services guidelines. I highly recommend
that you review those guidelines as they
will prove to be very helpful in developing
a basic understanding of evaluation and
management services. Additionally, in our industry today to
accompany and support the guidelines that are housed in the CPT manual we also have the 1995 and 1997 Evaluation
and Management guide from CMS. Of note, in day-to-day practice
a provider can utilize the 1995 or 1997 guidelines based on their specific
practice policy. If your practice does not have an Evaluation and Management
Services guidelines policy, for consistency in code selection and application of
coding practices, I highly recommend
that you create one. Let's begin. Whenever we talk about evaluation and
management services, you're going to hear the term
components, key components. Well, according to
the CPT manual, there are actually
seven components to a potential CPT code. Three of the seven components
are known as history, exam, and medical
decision making. Those three key components will actually be the focus
of our session today. However, when it applies, a provider can also use the other four components which
are known as contributing factors when they contribute to the evaluation and
management service that is being performed on today. Now, some of our evaluation
and management codes are not based on key
components rather, they are based on
other characteristics, such as discharge services which have a primary
division of time. Another example could be
your critical care services, which are not only based on time, but have other characteristics
that must be considered. Our preventive medicine
services codes, which are based upon whether the patient is new or the
patient is established, and whether or not the patient falls into a
particular age category. Remember I mentioned
having the CPT manual and reviewing the guidelines that appear at the beginning
of the manual. You will also want to make
sure that you review the subsection notes
that appear in front of a particular family of codes. What's the bottom line?
The bottom line is that you need to ensure
that you review the guidelines in front of the Evaluation and
Management Services, and then all of the guidelines subsection notes that appear throughout the Evaluation and
Management Service. Whenever I introduce Evaluation and Management
Services coding, I always like to refer to my process as having five steps. Step number 1 requires me
to determine what range of codes I am going to be using for the encounter that I'm going
to assign a code for today. I need to consider
the type of service. Is this the consultation? Is it an office visit? Is it a hospital visit? Is it an emergency
department visit? So, place of service. I also need to consider
the patient's status. Are they a new patient? Are they an established patient? In your CPT manual, there is some instruction, some guidance on what's considered a new patient
versus an established patient. The one rule that you'll
need to remember is, has the patient receives any professional services from the physician or qualified
health care professional or another qualified health care professional or physician in the same group of specialty
within the past three years? If the answer is yes, then the next question that
you have to ask yourself. Is it the exact same specialty? There's a flowchart in
your CPT manual that I highly recommend
that you become friends with because
it most certainly will help you with your
decision-making process. When I say determine the range
of codes, this is saying, I need to know am I coding an
emergency room visit today? Which falls in the range
of 9-9-2-8-1 to 9-9-2-8-5. Am I coding an initial
hospital care visit 9-9-2-2-1 to 9-9-2-2-3. In your CPT manual, in the back of the manual, you will find an index. Using your index, you can
use the type of service, the place of service or
patient status to locate the range of codes for the encounter that you
are going to code today. Additionally, in the
professional edition of the CPT manual, you can also go to the
table of contents for the Evaluation and
Management Services area to locate the range of codes for the service that you
are coding on today. That's step number 1. Step number 2 is to determine the extent of the history that was obtained by
your provider one today. From a CPT coding perspective, our histories can be
divided into four levels, problem focused, expanded problem focused, detailed,
or comprehensive. Now, in the real world, the provider is not going
to state that they did a problem focused history or an expanded problem
focused history. The provider is going to document what are known as the four
elements of the history, which are the chief complaint, history of present illness, review of systems, and past
family social history. Keep in mind that the chief complaint
has to be documented, but these other areas may not be documented for each
and every encounter. Every service that is
documented must be medically necessary for the reason for the patient's
encounter on today. Let's spend some time looking
at the four elements of the history and
then explore how we turn them into a history level. What's our history levels again? Problem-focused, expanded
problem-focused, detailed, and comprehensive. The chief complaint is the reason why the patient is seeing
the provider today. Generally, the chief
complaint is expressed in the patient's own words. It is the patient
saying why they are visiting our facility
or the provider today. Every encounter must have a
chief complaint documented. Of note, it is not
acceptable to use the word "follow-up" for
your chief complaint. The chief complaint
can be something like follow-up for diabetes, follow-up from hospital visit, follow-up from the ED visit. Patient is new to the practice
today to establish care. Patient is here to follow up from their last visit where
they had labs done. In some offices, it is the medical assistant that is actually documenting
the chief complaint. One of the things
that I recommend is training our
medical assistants to capture a clear and
concise statement from the patient about
why they are there today. Now, it is the provider's
ultimate responsibility to ensure that that chief complaint is stated or can be
easily inferred. Next up, we're going to go to the history of the
present illness. Per the AMA CPT Manual, the history of present illness is a chronologic code description
of the development of the patient's illness from the first sign and/or
symptom to present. In your CPT manual, we are given a total of seven
history of present illness. Those are: location, quality, severity, timing, contexts,
modifying factors, associated signs and symptoms. It is the CMS evaluation
and management services guidelines that gives us the
eighth element of duration. I encourage you to
become familiar with the different characteristics
of these eight elements. Now, we want to look at how we quantify the HPI when we're reading provider's
documentation. From a quantification
perspective, from a coding perspective, the history of present illness is documented as either
brief or extended. Brief means that the provider has described 1-3 HPI elements. Remember, there are
a total of eight, so the provider describes
1-3 elements of the HPI. In an extended HPI, the provider describes four
or more elements of the HPI. Now, for my new coders out there, I want to be very
clear in making sure that you understand that, the provider doesn't have to say words like location, abdomen. The duration of the
problem is two days. He or she can simply
state the patient presents with a four-day
history of abdominal pain. You, as the coding specialist, need to be able to identify
that the location is the abdomen and the duration is three or four days or whatever the
provider has stated. Now, this model here is
generally referring to a patient that's
coming in for what is known as a
problem-oriented visit. They're coming in because they're sick and they have a problem that needs to be resolved or cared for or
further investigated. Here is an example. The patient complains
of sharp pain in the right upper quadrant
with nausea since Monday. We have the duration
of the problem, we have the quality of the
problem because the providers said that the pain was sharp. We know the location, the right upper quadrant. We know associated
signs and symptoms, which are the nausea
and the vomiting, and we know that
the patient has had this problem since Monday. Let's check your understanding. How many elements of
the HPI do I have? I have duration, quality, location, and associated
signs and symptoms. This means that my HPI has been documented as extended
because I have four or more. Now. In the 1997 guidelines, we have been instructed
that the HPI can also be quantified for situations where the patient is not
necessarily sick, and they're coming in to follow up on their chronic condition. In the guidelines they refer to an extended HPI under this model, as a situation where
the provider documents the status of the three or
more chronic conditions, when the patient comes in
for their visit today. For visual purposes, I
have identified for you, that if it's less than
three chronic conditions, one or two, that is
quantified as a brief HPI. Let's check your understanding
of this concept. Diabetes controlled
by oral medication; extrinsic asthma without
acute exacerbation in the past six months; and hypertension
stable with pressures ranging from 130-140 over 80-90. Here, the provider has stated the status of three chronic
conditions: your diabetes, your asthma, and
your hypertension. You have if you are using
this model, so again, the 1997 guidelines were
the first place that this model was established and some of our
payers are saying, this is also okay to
be used for 1995. If you are able to use this approach whenever you're
looking at an encounter, you must ask yourself; is this a sick visit or is this a patient that's coming
in for chronic condition? Now, let me give you
a disclaimer about the use of the status
of chronic conditions. Based on my experience, this model can only be used when you have an
established patient, where the provider is able to document the status of
the chronic condition, the status from the last time that he or she saw the patient. Next up, we're going to go on to our next area of the history, which is the review of systems. CPT defines the
review of systems, as an inventory of body system obtained through
a series of question, seeking to identify signs
and/or symptoms that the patient may be experiencing
or has experienced. For purposes of the CPT code set, there are about 14 systems
that can be reviewed. The review of systems actually helps the provider
define the problem, clarify any
differential diagnosis, identify any needed testing that the provider has to request, it can also serve as baseline
data on other system that may be affected by any
possible management options. One thing I want my new
coders to know is that the provider may not use the word review of
systems verbatim. The question that you
may be asking is, how do I know that he or she is actually reviewing the system? Well, let's say
the provider says, "Patient denies
nausea and vomiting." How does the provider know that the patient denies
nausea and vomiting? He or she ask the question. So he or she has just completed a gastrointestinal
review of system. The provider can say, "Patient denies
shortness of breath." In that situation, the
provider is performing a respiratory review of systems. With the electronic
health record today, you will see where there are nicely formatted areas that say, review of system but oftentimes, providers perform the review of systems simultaneously
with the HPI, and so you may notice that they're intertwined in the HPI. One rule I want you to
alert, be informed of, the review of systems and HPI must be counted individually, but you can't count
something as HPI, and then turn around and count
it as review of systems. This is known as double dipping. Let's look at an example
of A, review of system. No fevers/chills
or blurred vision, no chest pain, no
shortness of breath, or belly pain, so how many systems has
our provider reviewed? No fever/chills,
that's constitutional. Blurred vision; eyes, chest
pain; cardiovascular, shortness of breath; respiratory, belly pain; gastrointestinal. To pull this all together, how do we quantify this
from a coding perspective, if the provider documents one
system that was reviewed, that's known as a problem
pertinent review of systems. If the provider
reviews 2-9 systems, that's known as an extended
review of systems. So in that example that I
just gave you, let's go back. We had constitutional,
eyes, cardio, respiratory, gastro, that's five, so that would be an
extended review of systems. Then the third type that we have is known as a complete
review of systems. A complete review of
systems has two options. Option number 1, the provider can individually document
10 or more systems, or he or she can document. They're positive and
pertinent negative. It should be clearly stated that they've performed the complete review of systems. They could say something like, all other systems were
reviewed and were negative. But notice the statement of all other systems were review. What this means is
I have reviewed XYZ systems which are clearly documented in terms of
positive and negative, and then all of the other systems are reviewed were negative. In absence of that statement, the provider must
individually document pin systems in order to have
a complete review of system. Let's look at an example. No fever, chills
or blurred vision, no chest pain,
shortness of breath, or belly pain, all other systems reviewed
and are negative. All right. The last part of the history is past,
social, family history. As experienced coders, we
refer to this as the PFSH, past family and social history. The PFSH has history, information about
the past history pertinent to today's encounter. Social history, such
as drinking, smoking, marital status,
educational background, and family history. Now, the one thing about
these three areas is when the provider is seeing the patient for the first time, you're going to expect to see one or more of
these three items, documented because they don't know the patient and they want to establish a baseline
about their patient. But when they come back
for unestablished visit, you don't expect to see a full discussion of
all of these items. But only those items, past family social history
that are pertinent and medically necessary
for today's encounter. From a coding perspective, quantifying this and don't worry, we're going to pull
it all together. From a coding perspective, there are two type of PFSH. They are pertinent, where the provider documents at least one item from the
three history areas. The three history areas are what? Past history, family
history, and social history. So one of those three. Complete, however, has the little funky rule that you need to
be familiar with. In some setting a complete
past, family social history requires that the
provider document two of the three past
family social items. But in other settings, the provider has to document
three of the three areas. Now, you might be wondering, well, how do I know? Well, remember those evaluation
and management guidelines that we spoke of
earlier from CMS, the 1995 and 1997. In those guidelines, they have identified in which settings two of the three meet the
requirements for a complete PFSH as opposed to other settings
where we need all three. Now, remember I said
that there are lots of rules regarding evaluation
and management services. This is one of the main
reasons why one must have a policy regarding evaluation
and management services. All right. Let's check
our understanding here. We have a scenario where we
have past history, list this, but then they jump right
into social history and talk about the mother and the father and they live with
their children, live with three other children. How? No medications
since Pepto Bismol, no allergies, immunizations
are up-to-date. Essentially, you have
the past history documented and you have the
social history documented. Whether this would be considered
complete or a pertinent, would depend on what setting our patient
is being seen in. Remember this. Some settings two of the three history areas
qualify for complete PFSH. Then these other areas, you need all three if you want to quantify a complete past
family social history. All right. Pulling all of this together to essentially take us back to the very beginning, which was trying to
make a decision as to whether or not my
patient's history level was problem focused, expanded problem focused,
detailed or comprehensive. Now, at this point, I want you to pause the
recording and I want you to very carefully examine what must be documented
for each level. All right. The first thing that you should notice is
that a patient that has a problem focused history does not have a review
of systems documented. The next thing you
should notice is that the only difference
between problem focused and expanded
problem focused is that we now have a problem
pertinent review of system. In terms of quantifying your documentation to come
up with a history level, for the two lower levels, the review of system
is the only difference because they both have brief HPI. Now, let's transition to detail. Let us see what is changed. First, you must have four
or more review systems. You must have 2-9
review of systems. Four or more HPI, 2-9 review of systems
and then one PFSH. You may be wondering, well what happens if my
provider has one PFSH? They have 2-9 review of systems, but only three HPI. In that case, you
have to drop down to expanded problem focused
because you have not met the requirements
for that level, you must have everything in that level in order
to use that level. It's okay if you have
more but at a minimum, in order to have a
detailed history, you must have at least four HPI. You must have two
to nine review of systems, and one PFSH. Finally, we are now
looking at comprehensive. Comprehensive, which
is the highest of the history level,
requires four HPI. Let's pause. What do you notice? Detailed and comprehensive, the two higher levels both
require four or more HPI. Review of system
under comprehensive. How it compares to detail is
that you need 10 or more. Then lastly, complete past
family social history, you need two or three. I know you remember it's two or three of those
elements of PFSH based on what setting you're
seeing the patient in. All right. Step number 3. Step number 3 is
determining the exam level. Just like the history, exam level has four types, problem focused, expanded problem focused, detailed,
or comprehensive. Now, let me give a disclaimer
regarding the exam. The exam is going to differ based upon
whether you are using the 1995 guidelines or
the 1997 guidelines. With the exam, in
your CPT manual, the CPT manual described the exam as either a body
area which could be head, including the face, neck, chest, including the
breath and axilla, abdomen, genitalia,
groin, buttocks, back, and each extremity. But then they also identify the exam as examination
of organ system. CPT recognizes eyes, as one, ear, nose, mouth, and
throat as another, followed by cardiovascular, respiratory, gastrointestinal,
genital urinary, musculoskeletal, skin,
neurologic, psychiatric, hematologic, lymphatic,
and immuno logic. In the CPT manual, they give us some ways to recognize these
four types of exams. They say that a problem
focused exam is a limited exam of the affected
body area or organ system. Expanded problem-focused, they recognize as a
limited examination of the affected body
area or organ system and other symptomatic or
related organ systems. Detailed as an extended
examination of the affected body area and other symptomatic or
related organ systems. Then comprehensive as a complete examination of a single organ system or a general multi-system
examination. I mentioned to you before
that there's lots of gray areas for evaluation
and management coding, and this happens
to be one of them. In some parts of the country, and I mentioned earlier that I'm in the Chicago land area, we have established
a numerical value [LAUGHTER] to the CPT definition. We define a problem focused exam as one body area or organ system. This matches the CPT
manual which says, a limited exam of the affected body area or
organ system. That's easy. Expanded problem-focused
and detailed is where it gets tricky. In your CPT manual, one distinct characteristic in those definitions is
the word limited, which is found in
expanded problem focused versus extended which
is found in detail. Every organization has
to have a policy in place as to how they handle this. Some schools although say, we going to do a very clean
quantification process. 2-4 body areas or organ systems is expanded
problem-focused, 5-7 body areas or organ
systems is detailed. Now, some organizations say, both expanded problem
focused and detailed, involve 2-7 body areas
or organ systems. But in expanded problem focused, it's 2-7 and it's very limited
detail 2-7 but extended. Now do you see why you
need a coding policy? Absolutely. Then comprehensive is very simple like problem focused, in that there are eight
or more organ systems. For a comprehensive exam, notice the word organ systems. For a comprehensive exam, must be eight or more
organ systems or a complete single
organ system exam. I know, confusing, right? You have to decide which model you're going
to use and stick with it. I mentioned about the 1997 evaluation
management guidelines. One of the things that I
encourage you to do is to explore the evaluation and management guideline
packet from CMS to develop an understanding regarding the differences between the two sets of guidelines. The most prevalent
difference really lies in the portion that
addresses the examination. In the 1997 guidelines, there is a greater specificity and variety in the
types of exams. Because the 1997
guidelines were really developed as an enhancement
to the 1995 guidelines. Now, I know many of
you may be thinking, "Why do we have '95 and
why do we have '97, and why is it 2019? These are still what we have. Because this is
what we have today. There are some plans in the
works to perhaps revise this, but this is what we have today. In your 1997 exam guidelines, you actually have
specialty exam options. Those specialty exam options can be for a cardiology practice, dermatology, ears,
nose, and throat. Your ophthalmologist, genital urinary female,
genital urinary male. For a hematologist, lymphatic, infectious
disease provider. There's musculoskeletal, there's neurology there's
psychiatry there's respiratory. If you are coding
for a specialist, this exam format may be more advantageous
to your provider. Now, 1997 also has what's known as a general multi-system exam, which to some extent reminds
me of the '95 guidelines. That's one big major enhancement. Then the other enhancement was something that I
spoke about earlier, which was related to the status of the chronic
conditions and the HPI. Let me just remind you again, you want to check with your
payer to see if that rule can be used in 1995 world
in addition to 1997. In those different
specialty examination templates that CMS
provided us with, they divided the exam into
these different bullets. I'm going to share that
approach with you shortly. But let's look at numerically
[LAUGHTER] how it applies. Problem-focused exam is when
the provider has documented an exam that is represented by these bullets that are
in those exam templates. I know you're wondering, "What the heck is she
talking about, bullets?" You must go and grab the evaluation and management services
guidelines and specifically look at
the exam templates because that's where you'll
see what I mean by bullets. It was my goal for this to
just be a one-hour session. Right now I'm probably
had about 45 minutes. I want to equip you with the tools that
you need to consider, but also recognizing that
you're going to have to do some additional research. The different exam templates
have these bullets. For example, under
general multi-system, there's an area called
constitutional. Sidebar, in your CPT manual, under organ systems
that are recognized, the CPT manual does not identify a constitutional
organ system. However, the 1995 guidelines specifically says from
an exam perspective, constitutional exams
are the vital signs. Or the provider can get
credit for those vital signs that were actually
performed on today. Okay. You got to look at those guidelines
for those bullets. 1-5 bullets problem-focused
example, constitutional. General appearance is one bullet. Vital signs if there are three of the seven
vital signs measured, it must be three, then
you have another bullet. Then when you get to
expanded problem-focused, then you transition
into 6-11 bullets. Now, detailed and comprehensive is where it gets more complex. I'm going to, in the
interest of time, refer you to going
back or going to those guideline
templates so that you can see very clearly about
detail versus comprehensive. What I'll tell you
just in parting from this section that
detail says that you are looking at bullets from six or more organ systems or 12 bullets from two
or more organ systems, but then with some exam
templates, eye and psych, you need nine-plus bullets, all others, you need
12-plus for detail. You see why I said
you got to go to the exam templates and actually lay eyes on them because
it can be pretty complex. With that said, I'm
going to move on. Here's an exam. if we looked at this
from a 1995 perspective, general, no acute distress, vital signs, one organ system
which is constitutional. Now, neck, head, ears, eyes, nose, and throat. I will tell you as a
documentation specialist, when I am looking at an
abbreviation that says H-E-E-N-T, I don't quantify that exam until I see something
documented about the head. In this particular
case, normocephalic. Eyes, here, they say
anti sclera again. Head, that's a body area. Eyes, organ system. Now, the next part of that abbreviation is
ears, nose, and throat. I don't see that
that was documented, and so for me, as a documentation specialist, I personally would not give
a provider credit for ears, nose, mouth, and throat because I don't see
that documented. Then I would go to neck, which is a body area. Then I have lungs. Then I have heart. Then I have abdomen. Let's talk a little
bit about abdomen. With the implementation of
electronic health records, a lot of times I see
abdomen, the word abdomen, but then when I read
directly behind abdomen, I see words like soft, non-tender, and no masses. Now, if you look at your
CPT manual for body area, you see abdomen, and for organ system, you see
gastrointestinal. As a documentation specialist, when I'm looking at
the word abdomen, I am trying to determine, am I only going to be able to count abdomen and/or
gastrointestinal. For soft and non-tender, I'm going to give
credit for abdomen, but for no masses, I'm going to give credit
for gastrointestinal. This is another great
area that I recommend in your own organizational
policy that you clarify. After that, we have extremities, neuro, breast, and
the lymph nodes. From a quantification
perspective, you have to go through here
and count them all up. This is where it gets somewhat tricky if you don't
have a policy that drives how you are applying the guidelines,
'97 versus '95. Also, when we have
electronic health record, sometimes we think that
the system is counting it based on '95 when in actuality it's calculating
it based on '97. So this is why it's
important for you to really truly identify. We have constitutional, so
that's one organ system. We have eyes, that's two. I'm going to skip
around a little bit. We have lungs, that's
three, that's respiratory. We have heart, that's four,
that's cardiovascular. I said I was going to count
masses as GI so that's five. We have neuro, which is six. We also have lymph nodes, so that can be counted
under lymphatic, so now that's seven. The million-dollar question is, do I have eight organ systems to then arrive at a
comprehensive exam? You see where it says breast. Some coders, auditors, documentation specialists
would say, okay, I'm going to count that
as chest because chest says including breast and axilla. As I'm looking at
this documentation, they're definitely
talking about the breast, then there is no
significant bruising, etc. But they also say
no skin changes, and so as a documentation
specialist, I would also give the provider
credit for integumentary, which is an organ
system called skin, which then gives me a
comprehensive exam. Again, evaluation
and management has a lot of great areas and
can be pretty subjective. Here, another version of a
physical exam documented. Here, you don't have
a lot of template of the information so to speak, so you have head
is normocephalic, that's a body area. Pupils are equal, round, they react to light
accommodation. That's eyes. As you can see, your goal is to read through the documentation and then
quantify the exam level. Step number 4 probably is the
most complex of them all, which is medical decision making. According to the CPT manual, medical decision making refers to the complexity of
establishing a diagnosis, and/or selecting a
management option and is measured by three areas. Number 1, the number of
diagnoses or treatment options. Two, the amount and/or complexity of the data that
the provider has to review. Then three, the risk of
complication and/or morbidity, which is disease or death, which is mortality, which is essentially how sick
the patient is. Let's tackle one at a time, starting with number of
diagnoses and treatment options. CPT manual uses the word number of diagnoses and
management options. Management options, treatment
options is the same. Potato, potato, right? Here's another area where different regions
have quantified, [LAUGHTER] have tried to classify this process because it
can be pretty complex. This table represents diagnoses
into three categories. Self-limited, minor
problem, such as a cold. Established problem that is
stable versus worsening. New problem, no
additional workup plan, new problem, additional
workup plan. As it relates to this table, our goal is to really just get to a numerical value
of four points. So after you get to four points, you could essentially
stop counting. In your CPT manual, in the evaluation and
management guidelines, there is a table 1 that's called the complexity of
medical decision-making. Under the column that says number of diagnoses or
management option, you see something
that says minimal, limited, multiple,
and then extensive. In my personal CPT manual, I've put some numerical
values to those areas. So first column, number of diagnoses or
management options, I say minimal, that's
one diagnosis, limited, that's two, multiple, that's three,
extensive, that's four. Let me pause and ensure that
you understand what I mean. I'm not referring
to one, two, three, or four diagnoses,
I'm referring to one, two, three, or four points. Why? Because this table here, I just told you, that once you get to four points, you can stop counting, and that has a direct correlation to table 1 in your CPT manual, where I've just identify
that minimal, one point, limited, two point, multiple, three points,
extensive, four points. Let's look at a
real life scenario to just of get our
heads around this. Here you have a patient that
has acute exacerbations, chronic diastolic
congestive heart failure, severe
pulmonary hypertension. Severe pulmonary hypertension,
documented again. Severe mitral regurgitation, questionable nursing
home, acquired pneumonia, acute or chronic
renal insufficiency, coronary artery disease,
history of atrial, history of seizure disorder. Now, don't overthink this. You've got at least
five or six diagnoses. No matter how you swing
this, it's four points. Why? You've got four diagnoses. If you say new problems, additional workup plan, yeah, you could say four problem, four points, 4 times 4 is 16. You don't need to do that.
Why? Four points total, done. What if you only had two
problems, same concepts. Are they new problems? Are they established problems? Assign the points based upon established problems stable, established problem worsening. Established problems
stable, one point. Established problem
worsening, two point. New problem, no
additional workup. We can only have one
new problem from a quantification perspective with a maximum of three points. So one new problem,
no additional workup. Three points times one problem
gives you three points. New problem, additional
workup plan. In this model, they don't
say that you can't have more than one new problem
with additional workup plan, but one new problem with additional workup plan
equals four points. You only need to
get to four points, so you can, yes, you've guessed it, stop. The next portion of this area is the amount and/or complexity of data that is to be reviewed. Let me just say again, this is another area where, in some parts of the country, this portion is
quantified differently. You must know how you are to quantify based upon the region
that you are working in. So how this works is you review your medical
record documentation, and if your provider
is reviewing and/or ordering a radiology
section tests, one point. Review and/or order pathology
section tests, one point. Review and/or order medicine
section tests, one points. If they discussed the
test results with a performing
physician, one point. Oh, tip here, four
points is the maximum. Let's pause for a second. Tie this back to table
1 in your CPT manual, complexity of medical
decision-making. Notice it says minimal or none, so that's zero to one point, limited, two, multiple,
three, extensive, four. Now, I want you to
know that all of these data points that
I'm mentioning here, these are not going to be documented in every
patient encounter. It's all about what's medically necessary
for that encounter. So I don't want you as a new
coder to say, "Well, wait, I can't give them a one point for the pathology
section because they didn't review or order that
particular test today." It's okay because
you are only going to focus on what was
actually documenting. You're quantifying this
information based on what's documented and based
on medical necessity. You can pause the recording, look at these other areas, see how we get one point for decision to
obtain the records. Again, take it step-by-step, this is a very complex process. Check your understanding. So provider says they
had a long discussion with the patients on DNR
status are confirmed. They're going to add blood, so we get one point for blood. Now, you notice it says we
will add to blood and lab, a Dilantin level,
cardiac enzymes, troponin, magnesium,
and a D-dimmer. So you may be wondering, "Oh, review and/or order of
radiology section test, pathology section test,
medicine section test, since I just saw
for pathology test, do I get one point?" No. Do I get one point
for each blood test? No, I'm sorry. If they order or review 10
pathology section test, you still only get one point. They can have a CT scan, an MRI, that's still one point from the
radiology section. Let's go back to our example. Let's see what else they got. They're going to change the diet, they're going to recheck the lab. They're going to check
their eyes and nose. The patient doesn't want a Foley. They want the patient
weight daily. They're giving them
Lasix, IV push, Cardizem, they are
going to hold for blood pressure, on and on and on. They're going to get a
chest X-ray in the morning. Here, you got blood test, one point, chest
X-ray, one point. Again, the maximum points
you can get is four. You have to read through
your documentation and make a decision as to how many
points you actually have. Something I should mention
to you guys with all of this whole
quantification process, don't over think it, but also, I have to tell you that it's important
for you to know that evaluation and management
is not learned overnight. It is definitely something that you have to
see more than once. In a day-to-day practice setting, you must have a policy. If you are looking for some assistance with
creating your policy, I'm available on a
contract basis to assist with the development
of your policy, because having a policy
in place is golden. Next, we're going to talk about probably the most complex, the most confusing part, which is the third measurement for determining the complexity of medical decision-making, which is the risk of
complications and/or morbidity, or mortality, which is
this table of risk. As it relates to
the table of risk, I want you to note that
there are three columns. Well, there are
actually four columns, so let's start with
the first column. The level of risk
is either minimal, low, moderate or high. I'll just give you a
sidebar in your CPT manual, I don't have any numbers or numerical values for
you to add to this, so pay close attention. The level of risk
is either minimal, low, moderate or high. Across from the level of risk, you see three columns; presenting problem,
diagnostic procedure ordered, and then the management
options selected. What you have to do is go through your encounter and really
like a Tic Tac Toe gang, identify in these three columns, what your provider is
actually doing today. Here's where it gets tricky. To qualify for a
certain level of risk, we actually look at the highest level of risk
based on these three tables. I know you're thinking, "Okay, what does that mean?" Let's say we are talking about that patient
that we saw earlier. That patient that we saw earlier, one of the management
options that was identified was, do
not resuscitate. If you look at the column
that says management options selected and you look at the
bottom box where it says, decision not to resuscitate, notice that when you go
back to the first column, which is the level of
risk, that's high. Guess what? That's as
high as you can go, so your risk of complications, morbidity or mortality
for this patient is high. Let's do another example. Let's say, you have a
patient that comes in with an acute uncomplicated illness or injury and that's their
presenting problem. You're looking at the second
column, presenting problem. Notice that an acute,
uncomplicated illness or injury is classified as
a low level of risk. At this point, you need to see if for the other two columns, based upon diagnostic procedure ordered or management
options selected, is either of those columns
going to be moderate or high. If not, you're stuck at low. Let's say that the provider for this acute uncomplicated
illness or injury, as a management option,
prescribes prescription drugs. That is moderate. The moderate now trumps the low. So unless you can get to high based upon the
diagnostic procedure order, your level of risk is
moderate for that patient. Let's look at our patient
that we just finished. We can clearly see
with the DNR status that this patient's risk
is most certainly high. I told you this theory
was complex, but this, my friends, is the table that is in your CPT
manual, table 1. Notice that there are four
types of decision making. Remember earlier, I talked about the three key components; history, exam, medical
decision-making. Well, there are four types
of medical decision-making. Straightforward, low,
moderate or high. Now, remember I had you write in your CPT manual
under diagnosis of management options that
minimal was one point, limited, two points, multiple, three points, extensive,
four points, remember that? Then for the data, I said minimal or
none, 0-1 points, limited, two points, moderate, three points,
extensive, four points. This is where all of that
is going to come into play. Then the risk you know
that that's referring to the table of risk that I just showed you
a few minutes ago. One of the things I will tell you is that new coders often find this area to be
quite, quite confusing. One of the things I
recommend that you do is really use a highlighter or something and a table like this, to figure out your
medical decision-making. Let me throw in one more rule. To qualify for a given type
of medical decision-making, what are our types of
medical decision-making? Straightforward, low,
moderate, or high. To qualify for a given type
of medical decision-making, two of the three elements in this particular table have
to be met or exceeded. Now, I know you're thinking, what the heck does that
mean? I'm glad you asked. I want you to consider the patient who we just
finished working with. Remember that patient had all of those problems and we said that their number of
diagnoses was extensive. I'm going to circle
extensive right here. Extensive essentially
includes multiple, because that's lower,
limited, and minimal. Two of the three
elements in table 1, must be met or exceeded to qualify for a type of
medical decision-making. Just real quick, let's
skip over to our risk. We said our risk
was high, remember? High also includes
the lower levels. The million-dollar question is, in which two columns, number of diagnosis and
management options, let's fill in our data, they had a blood work and some x-ray. In which two columns, going
across, straightforward, low complexity,
moderate complexity, highest complexity, do you have two or more items selected? The answer is high, because you have
extensive under number of diagnosis and management
options and you have high under the risk. Now, I know you may be wondering, that seems pretty easy maybe, this definitely takes
some time to get used to, so can you give me
another example? Absolutely. I'm going to
use a different color. Let's say you have
that patient who had the acute sprain. According to the
presenting problem table, that's the area that was
classified as a low risk, and then also remember, we said that that
patient will potentially get a prescription
drug management. Let me just go back
here to that table because I want to make
sure you understand. Example I was trying
to illustrate, the patient that had the acute uncomplicated illness or injury, so that puts us right
here in our table. Then I said, if they have
prescription drug management, that puts them over here under management
options selected, and of these three columns, I have the highest
circle in moderate, so my risk is moderate. Let's say, go back to this table, that my new patient, and am going to do a different
color, has moderate risk. I want you to see moderate risk, so I'm going to move away high. This is my new patient, moderate. Now this is, I mentioned, the patient that they
have this new problem. It's acute uncomplicated,
so new problem, and let's say there's no
additional workup plan. In the first column, what did I tell you that was? Three points. Now you're like, "Wait, what are you
talking about?" Remember, when we were over here. New problem, no additional workup plan
is three points so here, I can't draw very well,
that's three points. I'm essentially bringing
this over to this area here, so that's three points, and then let's say that there
is no data, so that here. What is the type of
medical decision-making? It is moderate because I have two columns where I meet the
requirements for moderate. Now, I know you're thinking, "I still don't get it," and it's okay because I know this
is the most complex. I'm going to use a different
color for my last example. Let's say that my
patient's problem is self-limited or minor, so for number of diagnosis or management
options, that is minimal. Let's say, in terms of data, my doctor ordered a blood work, one point from the
pathology section and ordered an x-ray. Well, then that's two points, so now I'm here. Then, let's say that he gave
them a prescription drug. Well, according to the table
of risk, that's moderate. Now, you are probably
saying, "Okay, crazy lady, how do I then determine what my type of medical
decision-making is?" If you're like me, you have to get visual with this. CPT manual says to qualify for a given type of
medical decision-making, two of the three elements in this table must be
met or exceeded. I'm visual, I've got a bubble
in my lower level here, and so I can see which two
columns do I have two bubbles. Well, across from low, I have my data bubble and
I have my risk bubble. I got two, so I'm
going to go with low. Why couldn't I go with high? Because I only had one bubble. All right guys, enough
of those bubbles. Step number 5 is pulling
it all together. You take your history, you take your exam and your
medical decision-making, and you arrive at
your final code. As you read your CPT manual, you will discover that
in some code families, such as a new patient, the code level that
you select has to be based on three components. Those three components are what? History, exam, and
medical decision-making, but in other areas such as
your established patient, you only need two of
the three components. You know we have to
have an example. Let's apply the five steps
that we have discussed. Step one was to determine
the range of code, and we said we
determined the range of code by deciding our
type of service, place of service,
and patient status. I see that my patient is a
new patient in the office. My patient is a new
patient in the office. For a new patient in the office, the range of code is 99201299205. Now, for this example, I've already gone through my documentation and
I have determined that my patient's history
was comprehensive. Their exam was detailed and the medical
decision-making is high, so I begin to explore
99201 and 99202, and 203, and 204, and 205, and I'm like, okay. Well, comprehensive is
in 99204 and 99205, but then detail is in 99203. But then high complexity medical decision-making
is in 99205, and I'm just really confused
as to which way I should go. Let me give you a visual, remember earlier I
was talking about quantifying all of
the different levels from the perspective
of the history, the exam, and the
medical decision-making. Let's take all of that and plot it into this diagram
that I've created. Notice that I mentioned that our patient had a
comprehensive history, so that's here. But then that's also here. Now, I said my patient
had a detailed exam, that's here and also here, and then I said, my medical
decision-making was high. Now, this is a new
patient in the office, and according to the CPT manual for a new patient in the office. In order to select the code, I must meet or exceed the
requirements for that code. Can I use 99205? No. Why? Because I didn't
have a comprehensive exam, my exam was detailed. Let's do something else. Remember, I said that the higher levels always
include the lower. If they did a
comprehensive history, that means that
includes 99203, 99202, 99201, and if they did
a detailed exam that includes 99202 and 99201. If they did high decision-making, that includes all
the lower levels. The question that then remains, in which area do
I have three x's? The answer is 99203. Why couldn't I have a 99204 or a 99205
because of my exam. Again, evaluation and management
can be pretty tricky. It truly does require practice, this is just a very
brief introduction. What you just learned about was the concept of
meeting or exceeding, and there are lots of different models that can be used or evaluation and management tools that you can use to
calculate your levels. If you're first starting out, I recommend that you
have a tool that you use so that you can consistently
follow the same process. Next, I want to talk about very briefly coding based on time. Because a lot of providers like to code their service
based on time, and time is one of those
contributing factors. Remember, time can contribute
to the encounter for today. But in order to code based on time and we're going to end
our discussion today on this. In order to code based on time, you have to answer yes to
these three questions. Number 1, does the
documentation reveal total time of face to face
or units of floor visit? Must answer yes. If you don't, you can stop, you can't
code based on time. Does the documentation describe the counseling and coordination of care that was provided? Here is the caveat with this, in addition to the total time as it relates to the counseling
and coordination of care, that counseling and
coordination of care must dominate more than 50 percent
of the service today. That's why the total time
has to be documented. Then the last question is, was that counseling
actually documented? Did they describe that service? You can answer yes, to these three questions. You can most certainly
fill based on time, but all of these
must be documented. Thank you so much
for listening to my evaluation and management
brief introduction. Please subscribe to
my YouTube channel, which is Dr. Campbell's
coding corner. Thank you so much and
have a great day.