e/m physician and hospital

Evaluation & Management Coding

Physician vs. Hospital

HP3A part of Navigant Consulting

MdHIMA Annual MeetingBaltimore Convention Center; Baltimore, Maryland

June 5, 2008

Table of Contents

Section 1 »Definition and Uses

Section 2 »Physician E/M Services

Section 3 » Hospital E/M Services

Section 4 » Physician and Hospital E/M Comparison

Section 5 » Questions?

Section 6 » About Your Speaker & NCI

Definition and Uses

Section 1

What are Evaluation and Management Services?

» A category of billing for physician and facility services that focuses on understanding the patient's problems and arranging a care plan to help.

» Evaluation and Management Services most often include› Emergency Room Visits

› Inpatient Consultations

› Outpatient Clinic Visits

» Most often referred to as E/M services.

Physician E/M Services

Section 2

Physician E/M Component Overview

» To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or already established.

» The physician then uses the presenting illness as a guiding factor and his clinical judgment about the patient’s condition to determine the extent of key elements of service to be performed.

» The key elements of service are:› History;› Examination; and› Medical Decision Making.

» The three key components appear in the AMA descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services.

» EXCEPTION: in visits which consist predominately of counseling or coordination of care, the time spent is key in determining the level of E/M.CMS Evaluation and Management Services Guide – March 2006

Physician Key Component - History

» Documentation of patient history includes some or all of the following elements:› Chief Complaint (CC)

› History of Present Illness (HPI)

› Review of Systems (ROS)

› Past, Family, And/Or Social History (PFSH)

» The elements documented will determine the level of history for the E/M level.

Physician Key Component - Examination

» There are two types of examinations that can be performed during a patient’s visit:› General multi-system examination

› Single organ system examination

» Below are the body areas and organ systems that are recognized according to the Current Procedural Terminology (CPT) book:

Physician Key Component - Examination

» The elements documented will determine the level of examination for the E/M level.

Physician Key Component – Medical Decision Making

» Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:› Number of possible diagnoses and/or management options;

› Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and

› Risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

Physician Key Component – Medical Decision Making

» To qualify for a given type of medical decision making, two of the three elements must either be met or exceeded.

Hospital E/M Services

Section 3

Hospital E/M Overview

» Separate CPT/HCPCS codes have yet to be established to describe E/M services provided within a facility.

» Hospitals are permitted to utilize “physician” E/M to capture charges for services provided.› Physicians – expertise› Hospitals – overhead

» To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or already established.

» Hospitals are to create their own system for determining visit level. › In Maryland this has been established by the HSCRC.› Outside of Maryland, various methods are utilized

‒ Point systems‒ Time-Based‒ Severity-Based

» It is not an expectation of payers that levels reported by the physician and facility for the same patient, same encounter will be at the same level.

Hospital E/M – Maryland HSCRC

» Emergency Department Visits› Clinical Care Time (CCT)

‒ Level I 0-<15 minutes

‒ Level II 15-<30 minutes

‒ Level III 30<60 minutes

‒ Level IV 60<120 minutes

‒ Level V 120+ minutes

› Includes all procedures and services performed by ED staff

» Outpatient Clinic Visits› Clinical Care Time (CCT)

‒ Level I 0-10 minutes

‒ Level II 11-25 minutes

‒ Level III 26-45 minutes

‒ Level IV 46-90 minutes

‒ Level V 91+ minutes

› Procedures can be reported separately

Physician and Hospital E/M Comparison

Section 4

New vs. Established Patient

» E/M codes will often differ between new and established patients.

» Criteria differs between physician and hospital reporting of E/M services.› Physician

‒ New vs. Established

◦ Pertains to whether a patient has been seen by a provider or a fellow provider from the same specialty of the same group practice within the past 3 years

› Hospital‒ New vs. Established

◦ Pertains to whether or not the patient already has a medical record number

◦ If patient had use of that medical record number within the past 3 years, the patient is considered an established patient to the hospital

◦ The same patient could be “new” to a physician or department, but “established” to the hospital

Level Determination

» Physician

› Level determination for physicians can be complex.

› Subject to great scrutiny.

» Hospital

› Level determination for hospitals remains to be unstructured.

› Not easily scrutinized.

Reportable CPT/HCPCS

» E/M Services do not always share the same CPT/HCPCS when reporting services performed by a physician or on behalf of a facility.

Section 5

About Your Speaker & Navigant Consulting

Section 6

SpeakerCaroline Rader, MBA, MSHCA, CHC

» Associate Director, Coding/Documentation

» Baltimore, Maryland

» Experience

› 10+ years of billing compliance, charge description master and revenue cycle experience

‒ Industry and Consulting

‒ Maryland HSCRC and APC

» Contact Information:

› Email: [email protected]

› Phone: 410-463-9867

› Fax: 866-861-0084

mailto:[email protected]

NCI Healthcare Provider Practice Group

» Our comprehensive services to healthcare providers include:

› Performance improvement

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We believe there are key differentiators that drive Navigant Consulting’s unique approach to assisting our clients.

e/m physician and hospital

Documents

em level

physician em servicessection

outpatient services

home services

hospital inpatient services

hospital observation

hospital em servicessection

management services