Demystifying Medical Documentation
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Medical Templates Demystifying Medical Documentation
Created by The Lung Doctor for e-Medtools
A Quick Review of Medical Documentation Requirements
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Patient Encounters The Centers for Medicare and Medicaid Services (CMS) has published definitions and documentation guidelines for the key components of a medical encounter note, using CPT codes.
Created by The Lung Doctor for e-Medtools
Key Components of Documentation History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time
Key components in selecting the level of E/M services
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997 http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
Created by The Lung Doctor for e-Medtools
The History
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History Components and Levels HPI Brief
ROS N/A
PFSH N/A
Type of History Problem Focused
Brief
Problem pertinent
N/A
Expanded Problem Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
New patient evaluations MUST have at least a Detailed History
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History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words
Elements of HPI Location Brief Brief Quality Contains1-3 1-3elements elementslisted listed Contains Severity Extended Duration Extended Contains≥≥44elements elements Timing Contains ORdiscusses discusses33chronic chronicor orinactive inactiveconditions conditions OR Context Modifying factors Associated Signs and Symptoms
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Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic
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ProblemPertinent Pertinent Problem
Documentsresponses responsesto tothe thesystem system Documents directlyrelated relatedto tothe thepresenting presenting directly problem problem
Extended Extended
Documentspositive positiveand andnegative negative Documents responsesto to2-9 2-9systems systemsrelated relatedto to responses theproblem problem the
Complete Complete
Documentsall allpositive positiveand andnegative negative Documents responsesto tosystems systemsrelated relatedto tothe the responses presentingproblem problemAND ANDall allother other presenting systems(10 (10orormore moretotal) total) systems
Past, Family and Social History Past Medical History Illnesses, Operations, Injuries and Treatments
Family Medical History Include heritable diseases and those that place the patient at increased risk
Social History An age appropriate review of past and current activities Pertinent Pertinent
Documentatatleast least11item itemfrom fromANY ANYofofthe the33areas areas Document mustbe bedirectly directlyrelated relatedtotothe theproblems problemsidentified identifiedininthe theHPI HPI ItItmust
Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools
The Exam
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Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes Anextended extendedexam examof ofthe theaffected affectedbody bodyarea area An ororgans/organ organs/organsystem systemand andanother another Genitourinary (Female) or symptomaticor orrelated relatedarea area symptomatic Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Mostlevels levelsrequire requireaaminimum minimumof ofaaDetailed DetailedExam Exam Most
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Multi-organ System Exam Detailed
≥3 vital signs
BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight
≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems
Comprehensive
≥2 elements* in at least 9 organ systems or body areas *Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer
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Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements
Comprehensive Document ALL elements* *Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer
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Elements of Individual Organ Systems Constitutional ¾ Vital signs ¾ General appearance of patient ¾
Nutrition, Body habitus, Development, Deformities, Grooming
Eyes ¾ Inspection of conjunctivae and lids ¾ Exam of pupils and irises ¾ Ophthalmoscopic exam of optic discs
Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates ¾ Inspection of lips, teeth and gums ¾ Exam of oropharynx ¾ ¾ ¾ ¾
Neck ¾ Exam of neck ¾ Thyroid
Respiratory ¾ ¾ ¾ ¾
Assessment of effort Percussion of chest Auscultation Palpation of chest
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Cardiovascular ¾ ¾ ¾ ¾ ¾ ¾ ¾
Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities
Chest (Breasts) ¾ Inspection ¾ Palpation
Gastrointestinal ¾ ¾ ¾ ¾ ¾
Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Exam elements, continued Lymphatic ¾ ¾ ¾ ¾
Neck Axilla Groin Other
Musculoskeletal ¾ Gait and station ¾ Inspection, palpation digits and nails ¾ Exam of bones, joints, muscles AND 1 or more ¾ Inspection or palpation ¾ Range of motion and presence/absence of pain ¾ Stability ¾ Muscle strength and tone
Skin ¾ Inspection ¾ Palpation
Neurologic ¾ Cranial nerves ¾ Deep tendon reflexes ¾ Sensation
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Psychiatric ¾ ¾ ¾ ¾
Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect
Genitourinary Male ¾ Scrotal contents ¾ Penis ¾ Digital rectal exam of prostate gland Female ¾ External genitalia ¾ Urethra ¾ Bladder exam ¾ Cervix ¾ Uterus ¾ Adnexa/parametria 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Medical Decision Making
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Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality
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Complexity of Medical Decision Making Number of Diagnoses Or Management Options
Amount or Complexity of Data to be Reviewed
Risk of Complications Morbidity or Mortality
Complexity of Decision Making
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low
Multiple
Moderate
Moderate
Moderate
Extensive
Extensive
High
High
outofof33elements elementsmust mustbe bemet met 22out
Created by The Lung Doctor for e-Medtools
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Worksheets Calculating Documentation Levels Adaptedfrom from Adapted
HGSAdministratorsDocumentation DocumentationWorksheet Worksheet HGSAdministrators CMSMedicare MedicarePart PartBB CMS
Created by The Lung Doctor for e-Medtools
History HPI:
□
□
□1 condition □2 conditions □3 conditions
1-2
3
HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms
□
□
Brief 1-3
Extended 4 or more
Status of chronic conditions
Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative
□
□
□
□
None
Pertinent to Problem 1 system
Extended 2-9 Systems
Complete 10 or more Systems
□
□
□
None
Pertinent 1
Complete 2 or 3
Expanded Problem Focused
Detailed
Comprehensive
PFSH □Past History □Family History □Social History Problem Focused
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity
□
□
□
□
1 Body Area or System
Up to 7 Body Areas or Systems
Up to 7 Body Areas or Systems
8 or more Body Areas or Systems
Problem Focused
Expanded Problem Focused
Detailed
Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Comprehensive
Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making
• Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality
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Number of Diagnoses or Treatment Options Complexity of Medical Decision Making
A
B
x
C
Problem status
Number
Points
Self-limited or minor
Max = 2
1
Established problem (to examiner)
1
Stable or improved
Established problem (to examiner)
2
Worsening
New problem (to examiner)
Max = 1
3
No additional workup planned
New problem (to examiner)
4
Additional workup planned
Total Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
=
D Result
Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data
Points Result 1
Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT
1
Review and/or order of tests from medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain history from source other than patient
1
Review and summarization of history obtained from source other than patient
2
Independent visualization of image, tracing or specimen (NOT reviewing report)
2
TOTAL Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk
Presenting Problem
Dx Procedure Ordered
Management Options Selected
Minimal
-1 self-limited or minor problem
-Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO
-Rest -Gargles -Elastic bandages
Low
-2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury
-Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies
-OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives
Moderate
-Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury
-Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis
-Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture
High
-Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status
-Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography
-Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis
Thehighest highestlevel levelininANY ANYcategory categorydetermines determinesthe theoverall overallrisk risk The
Created by The Lung Doctor for e-Medtools
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Final Determination Complexity of Medical Decision Making A
Number of diagnoses or treatment options
≤1 Minimal
2 Limited
3 Multiple
≥4 Extensive
B
Highest risk
Minimal
Low
Moderate
High
C
Amount and complexity of data reviewed
≤1 Minimal or Low
2 Limited
3 Multiple
≥4 Extensive
Low Complexity
Moderate Complexity
High Complexity
Type of decision making Straightforward
Circlethe theappropriate appropriatedescriptions descriptionsfor forRows RowsA,A,B,B,CC Circle TheColumn Columnwith with22oror33circles circlesdetermines determinesthe thefinal finalComplexity ComplexityofofMedical MedicalDecision DecisionMaking Making The Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Determining Overall Service Levels
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Inpatient Encounters Initial Hospital Encounter Or Observation
Subsequent Inpatient Or Follow up
Requires 3 components within shaded area
Requires 2 components
History
D or C
C
C
PF
EPF
D
Examination
D or C
C
C
PF
EPF
D
SF/L
M
H
SF/L
M
H
I
II
III
I
II
III
99221 99218
99222 99219
99223 99220
99231 99261
99232 99262
99233 99263
Complexity of medical decision LEVEL Init Hosp Care Observation
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Outpatient, Consults (Outpatient, Inpatient) and ER
History
Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER
New Office / Consult / ER
Established Office
Requires 3 components within shaded area
Requires 2 components Minimal problem that may not require presence of physician
PF
EPF
D
C
PF
EPF
D
C
SF
L
M
H
V
I
II
III
IV
V
-205 -245 -255 -285
99211
-212
-213
-214
-215
PF
EPF
D
C
C
ER: PF
ER: EPF
ER: EPF
ER: D
ER: C
PF
EPF
D
C
C
ER: PF
ER: EPF
ER: EPF
ER: D
ER: C
SF
SF
L
M
H
ER: SF
ER: L
ER: M
ER: M
ER: H
I
II
III
IV
99-201 99-241 99-251 99-281
-202 -242 -252 --282
-203 -243 -253 -283
-204 -244 -254 -284
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting
□Yes □No
Does documentation describe the content of counseling or coordinating care
□Yes □No
Does documentation reveal that more than half the time was counseling or coordinating care?
□Yes □No
Documentation of Time requires that ALL of the answers to the above questions are YES Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Summary Examples Documentation Requirements
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Initial Hospital Care Must meet ALL criteria
99223
Comprehensive History and Exam High complexity Medical decision making
99222
Comprehensive History and Exam Moderate complexity Medical decision making
99221
Detailed OR Comprehensive History and Exam Straightforward or Low Complexity Medical decision making
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Initial Inpatient Consultation Must meet ALL criteria
99255 Comprehensive History AND Exam High complexity medical decision making
99254 Comprehensive History AND Exam Moderate complexity medical decision making
99253 Detailed History AND Exam Low complexity medical decision making
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New Outpatient Encounter Not a Consult Must meet ALL criteria
99205 Comprehensive History and Exam High complexity medical decision making
99204 Comprehensive History and Exam Moderate complexity medical decision making
99203 Detailed History and Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
New Outpatient Consult Must meet all criteria
99245 Comprehensive History Comprehensive Exam High complexity medical decision making
99244 Comprehensive History Comprehensive Exam Moderate complexity medical decision making
99243 Detailed History Detailed Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
Established Outpatient Encounter Must meet 2 out of 3 criteria
99215 Comprehensive History Comprehensive Exam High complexity medical decision making
99214 Detailed History Detailed Exam Moderate complexity medical decision making
99213 Expanded Problem Focused History Expanded Problem Focused Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
We hope you found this presentation helpful! Remember to thank all the patient and knowledgeable billing and coding specialists who make themselves available to answer your questions in more detail!
Created by The Lung Doctor for e-Medtools
Created by The Lung Doctor for e-Medtools
A Quick Review of Medical Documentation Requirements
Created by The Lung Doctor for e-Medtools
Patient Encounters The Centers for Medicare and Medicaid Services (CMS) has published definitions and documentation guidelines for the key components of a medical encounter note, using CPT codes.
Created by The Lung Doctor for e-Medtools
Key Components of Documentation History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time
Key components in selecting the level of E/M services
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997 http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
Created by The Lung Doctor for e-Medtools
The History
Created by The Lung Doctor for e-Medtools
History Components and Levels HPI Brief
ROS N/A
PFSH N/A
Type of History Problem Focused
Brief
Problem pertinent
N/A
Expanded Problem Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
New patient evaluations MUST have at least a Detailed History
Created by The Lung Doctor for e-Medtools
History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words
Elements of HPI Location Brief Brief Quality Contains1-3 1-3elements elementslisted listed Contains Severity Extended Duration Extended Contains≥≥44elements elements Timing Contains ORdiscusses discusses33chronic chronicor orinactive inactiveconditions conditions OR Context Modifying factors Associated Signs and Symptoms
Created by The Lung Doctor for e-Medtools
Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic
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ProblemPertinent Pertinent Problem
Documentsresponses responsesto tothe thesystem system Documents directlyrelated relatedto tothe thepresenting presenting directly problem problem
Extended Extended
Documentspositive positiveand andnegative negative Documents responsesto to2-9 2-9systems systemsrelated relatedto to responses theproblem problem the
Complete Complete
Documentsall allpositive positiveand andnegative negative Documents responsesto tosystems systemsrelated relatedto tothe the responses presentingproblem problemAND ANDall allother other presenting systems(10 (10orormore moretotal) total) systems
Past, Family and Social History Past Medical History Illnesses, Operations, Injuries and Treatments
Family Medical History Include heritable diseases and those that place the patient at increased risk
Social History An age appropriate review of past and current activities Pertinent Pertinent
Documentatatleast least11item itemfrom fromANY ANYofofthe the33areas areas Document mustbe bedirectly directlyrelated relatedtotothe theproblems problemsidentified identifiedininthe theHPI HPI ItItmust
Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools
The Exam
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Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes Anextended extendedexam examof ofthe theaffected affectedbody bodyarea area An ororgans/organ organs/organsystem systemand andanother another Genitourinary (Female) or symptomaticor orrelated relatedarea area symptomatic Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Mostlevels levelsrequire requireaaminimum minimumof ofaaDetailed DetailedExam Exam Most
Created by The Lung Doctor for e-Medtools
Multi-organ System Exam Detailed
≥3 vital signs
BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight
≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems
Comprehensive
≥2 elements* in at least 9 organ systems or body areas *Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer
Created by The Lung Doctor for e-Medtools
Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements
Comprehensive Document ALL elements* *Referto to1997 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services *Refer
Created by The Lung Doctor for e-Medtools
Elements of Individual Organ Systems Constitutional ¾ Vital signs ¾ General appearance of patient ¾
Nutrition, Body habitus, Development, Deformities, Grooming
Eyes ¾ Inspection of conjunctivae and lids ¾ Exam of pupils and irises ¾ Ophthalmoscopic exam of optic discs
Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates ¾ Inspection of lips, teeth and gums ¾ Exam of oropharynx ¾ ¾ ¾ ¾
Neck ¾ Exam of neck ¾ Thyroid
Respiratory ¾ ¾ ¾ ¾
Assessment of effort Percussion of chest Auscultation Palpation of chest
Created by The Lung Doctor for e-Medtools
Cardiovascular ¾ ¾ ¾ ¾ ¾ ¾ ¾
Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities
Chest (Breasts) ¾ Inspection ¾ Palpation
Gastrointestinal ¾ ¾ ¾ ¾ ¾
Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Exam elements, continued Lymphatic ¾ ¾ ¾ ¾
Neck Axilla Groin Other
Musculoskeletal ¾ Gait and station ¾ Inspection, palpation digits and nails ¾ Exam of bones, joints, muscles AND 1 or more ¾ Inspection or palpation ¾ Range of motion and presence/absence of pain ¾ Stability ¾ Muscle strength and tone
Skin ¾ Inspection ¾ Palpation
Neurologic ¾ Cranial nerves ¾ Deep tendon reflexes ¾ Sensation
Created by The Lung Doctor for e-Medtools
Psychiatric ¾ ¾ ¾ ¾
Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect
Genitourinary Male ¾ Scrotal contents ¾ Penis ¾ Digital rectal exam of prostate gland Female ¾ External genitalia ¾ Urethra ¾ Bladder exam ¾ Cervix ¾ Uterus ¾ Adnexa/parametria 1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Medical Decision Making
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Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality
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Complexity of Medical Decision Making Number of Diagnoses Or Management Options
Amount or Complexity of Data to be Reviewed
Risk of Complications Morbidity or Mortality
Complexity of Decision Making
Minimal
Minimal or None
Minimal
Straightforward
Limited
Limited
Low
Low
Multiple
Moderate
Moderate
Moderate
Extensive
Extensive
High
High
outofof33elements elementsmust mustbe bemet met 22out
Created by The Lung Doctor for e-Medtools
1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Worksheets Calculating Documentation Levels Adaptedfrom from Adapted
HGSAdministratorsDocumentation DocumentationWorksheet Worksheet HGSAdministrators CMSMedicare MedicarePart PartBB CMS
Created by The Lung Doctor for e-Medtools
History HPI:
□
□
□1 condition □2 conditions □3 conditions
1-2
3
HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms
□
□
Brief 1-3
Extended 4 or more
Status of chronic conditions
Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative
□
□
□
□
None
Pertinent to Problem 1 system
Extended 2-9 Systems
Complete 10 or more Systems
□
□
□
None
Pertinent 1
Complete 2 or 3
Expanded Problem Focused
Detailed
Comprehensive
PFSH □Past History □Family History □Social History Problem Focused
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity
□
□
□
□
1 Body Area or System
Up to 7 Body Areas or Systems
Up to 7 Body Areas or Systems
8 or more Body Areas or Systems
Problem Focused
Expanded Problem Focused
Detailed
Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Comprehensive
Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making
• Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality
Created by The Lung Doctor for e-Medtools
Number of Diagnoses or Treatment Options Complexity of Medical Decision Making
A
B
x
C
Problem status
Number
Points
Self-limited or minor
Max = 2
1
Established problem (to examiner)
1
Stable or improved
Established problem (to examiner)
2
Worsening
New problem (to examiner)
Max = 1
3
No additional workup planned
New problem (to examiner)
4
Additional workup planned
Total Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
=
D Result
Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data
Points Result 1
Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT
1
Review and/or order of tests from medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain history from source other than patient
1
Review and summarization of history obtained from source other than patient
2
Independent visualization of image, tracing or specimen (NOT reviewing report)
2
TOTAL Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk
Presenting Problem
Dx Procedure Ordered
Management Options Selected
Minimal
-1 self-limited or minor problem
-Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO
-Rest -Gargles -Elastic bandages
Low
-2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury
-Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies
-OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives
Moderate
-Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury
-Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis
-Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture
High
-Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status
-Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography
-Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis
Thehighest highestlevel levelininANY ANYcategory categorydetermines determinesthe theoverall overallrisk risk The
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1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997
Final Determination Complexity of Medical Decision Making A
Number of diagnoses or treatment options
≤1 Minimal
2 Limited
3 Multiple
≥4 Extensive
B
Highest risk
Minimal
Low
Moderate
High
C
Amount and complexity of data reviewed
≤1 Minimal or Low
2 Limited
3 Multiple
≥4 Extensive
Low Complexity
Moderate Complexity
High Complexity
Type of decision making Straightforward
Circlethe theappropriate appropriatedescriptions descriptionsfor forRows RowsA,A,B,B,CC Circle TheColumn Columnwith with22oror33circles circlesdetermines determinesthe thefinal finalComplexity ComplexityofofMedical MedicalDecision DecisionMaking Making The Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Determining Overall Service Levels
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Inpatient Encounters Initial Hospital Encounter Or Observation
Subsequent Inpatient Or Follow up
Requires 3 components within shaded area
Requires 2 components
History
D or C
C
C
PF
EPF
D
Examination
D or C
C
C
PF
EPF
D
SF/L
M
H
SF/L
M
H
I
II
III
I
II
III
99221 99218
99222 99219
99223 99220
99231 99261
99232 99262
99233 99263
Complexity of medical decision LEVEL Init Hosp Care Observation
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Outpatient, Consults (Outpatient, Inpatient) and ER
History
Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER
New Office / Consult / ER
Established Office
Requires 3 components within shaded area
Requires 2 components Minimal problem that may not require presence of physician
PF
EPF
D
C
PF
EPF
D
C
SF
L
M
H
V
I
II
III
IV
V
-205 -245 -255 -285
99211
-212
-213
-214
-215
PF
EPF
D
C
C
ER: PF
ER: EPF
ER: EPF
ER: D
ER: C
PF
EPF
D
C
C
ER: PF
ER: EPF
ER: EPF
ER: D
ER: C
SF
SF
L
M
H
ER: SF
ER: L
ER: M
ER: M
ER: H
I
II
III
IV
99-201 99-241 99-251 99-281
-202 -242 -252 --282
-203 -243 -253 -283
-204 -244 -254 -284
Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting
□Yes □No
Does documentation describe the content of counseling or coordinating care
□Yes □No
Does documentation reveal that more than half the time was counseling or coordinating care?
□Yes □No
Documentation of Time requires that ALL of the answers to the above questions are YES Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted
Created by The Lung Doctor for e-Medtools
Summary Examples Documentation Requirements
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Initial Hospital Care Must meet ALL criteria
99223
Comprehensive History and Exam High complexity Medical decision making
99222
Comprehensive History and Exam Moderate complexity Medical decision making
99221
Detailed OR Comprehensive History and Exam Straightforward or Low Complexity Medical decision making
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Initial Inpatient Consultation Must meet ALL criteria
99255 Comprehensive History AND Exam High complexity medical decision making
99254 Comprehensive History AND Exam Moderate complexity medical decision making
99253 Detailed History AND Exam Low complexity medical decision making
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New Outpatient Encounter Not a Consult Must meet ALL criteria
99205 Comprehensive History and Exam High complexity medical decision making
99204 Comprehensive History and Exam Moderate complexity medical decision making
99203 Detailed History and Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
New Outpatient Consult Must meet all criteria
99245 Comprehensive History Comprehensive Exam High complexity medical decision making
99244 Comprehensive History Comprehensive Exam Moderate complexity medical decision making
99243 Detailed History Detailed Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
Established Outpatient Encounter Must meet 2 out of 3 criteria
99215 Comprehensive History Comprehensive Exam High complexity medical decision making
99214 Detailed History Detailed Exam Moderate complexity medical decision making
99213 Expanded Problem Focused History Expanded Problem Focused Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools
We hope you found this presentation helpful! Remember to thank all the patient and knowledgeable billing and coding specialists who make themselves available to answer your questions in more detail!
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