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Evaluation and Management (E/M) Documentation Guidelines Made

Simple – Part 1

Presented by:

Kathy Mills Chang, MCS-P, CCPC, CCCA

KMC University

Today’s Training Plan

• Recognize and apply E/M documentation requirements for history and consultation

• Properly execute the four sub-components of history to be documented for new and established patient documentation

• Properly execute the appropriate documentation for chiropractic examination components necessary to meet E/M

documentation requirements

• Reproduce quality documentation components within history and examination for new and established patients

•Distinguish necessary elements of E/M documentation guidelines necessary for various levels of coding

Method to the MadnessThe Difference? Documentation and Intent

Another Difference? NP vs. EP

NP= If the patient has never been to your office, has only seen a different provider specialty in your office, or it’s been at least 3 years since they have seen you or another provider of your specialty

Evaluation + Management (E/M)

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Breaking News-09/2018 Interesting Proposal

Can We Imagine A World Where…. If only Carriers Will Follow This…

But That May Be the Future….

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1995 vs. 1997 Guidelines

• History and Medical Decision Making are virtually identical

• 1995’s guidelines are more vague and general and 1997’s are structured based on specialty

• Majority of difference is in examination element

What is Documentation and Why is it Important?

Key Components1-2-3

Three Key Components-#1 History

• The first and most important element

• Determines the level of service necessary for all the rest

• Can’t rely on only what the patient fills out

• The art of consultation is critical

Biggest Errors We See

1. Using the patient’s written history alone

2. Forgetting to include the patient’s history with notes records sent

3. Lack of expansion by the provider on important points

4. No history on re-exams

Big Error! Consultations 99241-99245

•A consultation is not history

•A reason that FREE consultations are an issue

•Key components are the same as NP/EP EM coding

•Consulting provider CAN assume treatment

•Required elements slightly different

•A documented referral to the consulting provider and a written report of findings from the consulting provider back to the referring provider

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HistoryKey Components

Chief Complaint (CC)

• A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter

• Usually stated in the patient’s own words

• The medical record should clearly reflect the CC.

Chief ComplaintComponents of HPI

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HPI Section

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Review of Systems

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Past, Family and Social History (PFSH)

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History = Detailed

The Weakest Link

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1995 Examination Guidelines

•Focus is on body areas and organ systems vs. bullets in 1997• Levels listed

for coding purposes are the same

1995 Examination Guidelines

1995= Rules Rules Rules

Cardiovascular Exam

Examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)

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For Example… Circle this Bullet if Performed

Lymphatic Exam

•Palpation of lymph nodes in neck, axillae, groin, and/or other location

•Notation of any abnormalities or notation of within normal limits

For Example…

Circle this Bullet if Performed Extremity Exam

•Extremities are covered as a part of the musculoskeletal examination

•Extremities are not required, but may apply on a patient by patient basis.

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Skin Exam

• Inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes, lesions, cafe-au-lait spots, ulcers) in four of the following six areas:•1) head and neck, 2) trunk,

3) right upper extremity, 4) left upper extremity,•5) right lower extremity,

and 6) left lower extremity

For example…

Skin Has Multiple Options

Head and Neck = 1 Trunk = 1 R&L UE = 2

Four Bullets Earned for Three Lower

Exam Levels!

Neurological Exam•Test coordination (e.g.,

finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)•Examination of deep

tendon reflexes and/or nerve stretch test with notation of pathological reflexes (e.g., Babinski)

Neurological Exam

•Examination of sensation (e.g., by touch, pin, vibration, proprioception)

•Orientation to time, place and person

•Mood and affect (e.g., depression, anxiety, agitation)

Mood, Affect, Appearance

•Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed? •Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span? •Speech: Is it normal in tone, volume and quantity? •Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?

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Mood, Affect, Appearance•Awareness of environment, also referred to as

orientation: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year? •Mood: How do they feel? You may ask this directly

(e.g. "Are you happy, sad, depressed, angry?"). Is it appropriate for their current situation? •Affect: How do they appear to you? This interpretation

is based on your observation of their interactions during the interview. Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, appropriate.

Circle All that Have Been Performed

Constitutional Exam• Measurement of any three of the following seven vital signs:

1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)• General appearance of patient (e.g., development, nutrition,

body habitus, deformities, attention to grooming)

For Example

Count These Elements if Performed Musculoskeletal Exam

•This is the primary and most significant portion of the exam you will most typically perform

•Although you may always do these things, they must be documented in a particular manner

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Musculoskeletal Exam•Examination of gait and

station• Identify gross

abnormalities in the gait• Observe the patient

walking into the room; how they get up and down from the exam table•Heel/Toe Walking and/or

Romberg’s Test• Is the Gait slow, or

limited by pain?

For example…

Count this Element if Performed General Musculoskeletal

Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity

General Musculoskeletal

• Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions•Assessment of range of motion with notation of any

pain (e.g., straight leg raising), crepitation or contracture•Assessment of stability with notation of any

dislocation (luxation), subluxation or laxity•Assessment of muscle strength and tone (e.g., flaccid,

cog wheel, spastic) with notation of any atrophy or abnormal movements

For Example…

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Multiple Bullets AvailableMultiple Bullets Available

Multiple Bullets Available Multiple Bullets Available

Multiple Bullets AvailableWhat About Comprehensive?

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Score The Examination

Examination = Detailed Established Patient- Detailed

E/M Knowledge Pays Off in Better Documentation

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Need Help? [email protected]

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mailto:[email protected]

today’s training plan evaluation and ... - kmc university guideline… · kmc university...

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