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of that should be documented for patient history. They are 1) history of present illness (HPI), which includes the chief compliant (CC), 2) review of (organ) systems (ROS), and 3) review of past medical, family and social history (PFSH). Generally, the medical assistant or nurse will document the patient’s CC and HPI. The CC, according to CMS, should be “a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter”. Most physician offices use a history form template, and the patient fills in the blanks for the review of systems. For all patients, all three components of the history, e.g., HPI, ROS and PFSH are required to be documented for a “complete” history, or 2 components for a “pertinent” history. Key #2: Physical Exam (PE) There are two sets of Official Coding Guidelines published by CMS that particularly affect the physical exam component of EM. They are the 1995 Evaluation and Management Documentation Guidelines and the 1997 Evaluation and Management Documentation Guidelines. See Chart 2: 1995 and 1997 EM Physical Exam Guidelines: Source Original Chart, Criteria from CMS Guidelines To determine the level of physical exam performed using the 1995 guidelines, the coder should count the number of organ systems or body areas examined and documented by the physician. To determine the EM level of the physical exam using the 1997 guidelines, the coder should count “elements” of a particular organ system examined. The 1995 guidelines are generally used by primary care physicians (PCPs), because they tend to look at more organ systems in their examination of the patient. Specialty physicians tend to use the 1997 guidelines because they tend to examine one or fewer organ systems and focus on a single organ system. For example, an ophthalmologist obviously exams eyes; therefore, they will get credit for the “elements” that they exam during the eye exam. The coder will count the exam elements that the physician has documented and then choose the level of exam based on those elements. For example, if the ophthalmologist does all 12 examination bullet points in Illustration 2, then they will get credit for a “detailed” examination. In order for the ophthalmologists to get credit for a comprehensive physical exam, they would have to examine additional organ systems in addition to the eye. In total, the 1997 guidelines define twelve categories of single system examinations (SSE), including psychiatry, neurology, dermatology, gastrointestinal, cardiology, respiratory, musculoskeletal, genitourinary, ear nose and throat (ENT), and hematologic/lymphatic/immunologic.
Key #3: Medical Decision Making (MDM) Next is determining the level of the physician’s medical decision making (MDM). The MDM refers to the level of risk and difficulty involved in the diagnosing, treatment, and medical planning that is involved in an EM visit. The MDM may be straight forward, low complexity, moderate complexity or high complexity. See Chart 3: Decision Making (RISK table) SF: Straight Forward Minimal 1 LC: Low Complexity Limited 2 MC: Moderate Complexity Multiple 3 Minimal 1 Limited 2 Multiple 3 Extensive >4 Minimal 1 Low Moderate High
HC: High ComplexityExtensive >4 Key #4: TIME
Time is a “time” component of the EM codes. However, time does not take precedence of appropriate documentation of the history, physical and medical decision making. If a physician documents a comprehensive EM service is less than the time allotted, he still may charge for the comprehensive service. Similarly, if the physician takes more time than allotted to document the same comprehensive visit, he may still only charge according to the document elements of the visit. The only exception to this is with counseling and coordination of care. Some E/M is time dependant like critical care and in this specific case the exact time spent must be documented. See Critical care section below. Key #5: Counseling, and/or Coordination of Care When counseling and/or coordination of care comprises more than 50% of the time spent during an EM visit, then time may be considered the key or controlling factor to qualify for a particular level of E/M service. However, several criteria must be met. First, the physician’s “time” must be spent “face–to-face” with either the patient or the patient’s family. For inpatient, if the physician is just on the hospital unit floor charting and doing other tasks, which are not face-to-face with the patient or patient’s family, then this time does not count towards the EM service. Second, the counseling must be fully documented, e.g., what was said, done, planned and so forth. Third, time should be documented. If this is a time-driven EM, then start time and stop times for the face-to-face encounter should be documented in the PHR. Key #6 Choosing an EM Level Now we will summarize the documented history, physical exam and medical decision making and choose a level of EM. Here are several scenarios of EM for new and established patients. Remember when choosing an level, a new EM service requires all 3 components to be at the highest level in order to choose that
particular code, versus an established EM service only requires 2 out of 3 to choose a level. Example #1: New office patient with detailed history, detailed physical exam and moderate complexity MDM documented. Code: 99203 Example #2: Established office patient with an expanded problem focused (EPF) history, a detailed physical exam and moderate complexity MDM. Code: 99214. Outpatient consultation with a comprehensive history and physical exam, with high complexity medical decision making. Code 99245 An inpatient consultation with a detailed history, comprehensive physical exam with moderate decision making. Code 99253. The codes 99291 and 99292 are used for critical care. They are both time-driven EM codes and therefore, time must be documented in the PHR. They are reported based on the physician’s time spent face-to-face providing critical care services directly to the patient, as well as, for time spent on the unit coordinating and supervising the critical care. If the physician goes on and off the unit, then they should document “in” and “out” times in the PHR. Time may be summated at the end of the critical care services so that the physician gets credit for all of the time spent on the case. However, time spent off the unit is not to be added to the total critical care time. Certain services are “included” in the critical care codes when performed during a critical care encounter. The coder should not code separately cardiac output measurements and interpretations (codes 93561, 93562), chest x-ray readings (codes 71010, 71015, 71020), pulse oximetry monitoring (codes 94760, 94761, 94762), and EKG's; blood pressures, hematologic data, 99090; gastric intubation (codes 43762, 91105) , temporary transcutaneous pacing, (code 92953) , ventilator management (codes 94656, 94657, 94660, 94662) and vascular access procedures (codes 36000, 36410, 36415, 36540 and 36600). All other services may be coded in addition to the critical care codes, such as a bronchoscopy (code 31622) Swan Ganz catheter placement (code 93503) or intubation (code 31500). If both critical care and a procedure were performed in the same day, the coder should append the critical care EM codes with a -25 modifier. Any critical care which is provided in less than 30 minutes should not coded as critical care. The physician and coder would code the appropriate EM code. However, for critical care services that are 30-74 minutes, the coder would code 99291 times 1 unit of service. For the second 30 minutes of critical care provided, the coder would code 99292 and then add a unit for each additional 30 minutes.
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