Evaluation and Management Services Leveling a Service & 2021 - PowerPoint PPT Presentation

Evaluation and Management Services Leveling a Service & 2021 Changes

Evaluation and Management Services Office or Outpatient Non-Face-to-Face Hospital Observation Special E&M Services Hospital Inpatient Newborn Care Services Consultations Delivery/Birthing Room Attendance and Resuscitation Emergency Department Inpatient Neonatal Intensive Care & Peds & Neonatal Critical Care Critical Care Cognitive Assessment Care Plan Nursing Facility Care Management Domiciliary, Rest Home or Custodial Care Pyschiatric Collaborative Care Management Home Visits Transitional Care Management Prolonged Services Advanced Care Planning Case Management General Behavioral Health Integration Care Management Care Plan Oversight Unlisted E&M Preventative Medicine

Evaluation and Management Services are scored based on three key components: Time and Medical Necessity are also elements that can be considered when scoring an E&M service.

History

Chief Complaint All evaluation and management services that are not preventative in nature, must have a chief complaint. The chief complaint is the reason for the encounter (in the patient’s own words) and can be included in the HPI. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC. Should not be simply “follow up” or “routine appointment” without further clarifying what condition or illness is being treated.

Status of 1 -2 Status of 1 -2 Status of 3 Status of 3 Chronic Chronic Chronic Chronic Status of Chronic Conditions OR Conditions Conditions Conditions Conditions HPI (History of Present Illness) Elements H □ Loca�on □ Severity □ Timing □Modifying factors Extended (4 Extended (4 or □ Quality □Dura�on □ Context □Associated signs and symptoms Brief (1-3) Brief (1-3) or more) more) I ROS (Review of Systems) □Cons�tu�onal (wt loss, etc) □ Eyes □ Ears, nose, mouth, throat S □ Endocrine □Musculoskeletal T □ Cardiovascular □Genitourinary □ Neurological □ Gastrointes�nal □ Hematological/Lymph □ Psychological Pertinent to O □ Integumentary □ Respiratory □Allergy/Immuno problem (1 Extended (2- □ All others nega�ve None system) 9 systems) *Complete R ** Complete (2 or 3 history Y PFSH (Past, Family, Social History) areas None None Pertinent areas) Problem Expanded Focused Problem Focused Detailed Comprehensive Complete ROS: 10 or more systems or the pertinent positives and/or negatives of some systems with a statement “all others negative”. **Complete PFSH : 2 history areas: a) Established Patients - Office (Outpatient) Care; b) Emergency Department. 3 history areas: a) New Patients - Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care; c) Initial Hospital Observation; d) Initial Nursing Facility Care. NOTE: For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Please refer to procedure code descriptions.

History of Present Illness OR HPI Elements Status of Chronic Conditions A chronological description of the development of the It is not enough to simply list the patients chronic present illness from the 1st sign to present day conditions. You MUST document the status of those conditions: Example: Patient presents with 3 days of itchy rash on his right hand. Has tried OTC Benadryl with no relief “Type 2 Diabetes well controlled on metformin” “HTN uncontrolled” “Osteoporosis on calcium –stable” If the condition can be considered either acute or chronic (ex: bronchitis), you must document as “chronic” in order to obtain credit

Describe the Symptoms Sample Words Where the problem, pain, or symptom occurs Location Chest, lung, leg Description of the problem, symptom, or pain Quality Burning, dull, scratchy, constant, red Description of the severity of symptoms Severity Pain scale (1-10) mild, moderate, severe How long the problem, symptom, or pain has Duration Today, weeks, months persisted When a problem, symptom, or pain occurs Timing Upon wakening, after meals, intermittently Instances that can be associated with the Context Sitting, standing, working, MVA problem, symptom, or pain Actions taken to make the problem, symptom, or Modifying Factors With ice, OTC meds, heat pain better or worse Other problems, symptoms, or facts that occurs Assoc. Signs & Symptoms Severe headaches also cause when the primary issue occurs nausea, rapid heart beat during shoulder pain

Review of Systems 14 systems are recognized: • • Constitutional Musculoskeletal • • Eyes Integumentary • • Ears, Nose, Mouth, Throat Neurological • • Cardiovascular Psychiatric • • Respiratory Endocrine • • Gastrointestinal Hematic/Lymphatic • • Genitourinary Allergy/Immunologic A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. You must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

Past, Family, and Social History Past History: The patient’s past experiences with illnesses, allergies, operations, injuries and treatments, and medications Family History: A review of medical events in the patient’s family, including age at death, diseases which may be hereditary or place the patient at risk Social History: An age-appropriate review of past and current activities (occupation, schooling, smoking, alcohol/tobacco use, marital status, etc.)

Who Can Document The History? A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: • Describing any new ROS and/or PFSH information or noting there has been no change in the information; and • Noting the date and location of the earlier ROS and/or PFSH. Ancillary staff may record the HPI, ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the information.

What If History Cannot Be Obtained? If history cannot be obtained (ex: patient intubated, intoxicated, demented) credit may be considered if the documentation reflects: • Which components could not be obtained • Why they could not be obtained • Any attempts to obtain the history from other sources such as caregivers or roommates

Sample Scoring HPI Elements CHIEF COMPLAINT: A 47-year-old white female  Location  Quality presents with concern about possible spider bite  Duration  Severity to the left side of her neck.  Context  Timing  Associated Signs and Symptoms  Modifying Factors SUBJECTIVE: This 47-year-old white female presents with concern about possible spider bite Review of Systems to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and  Constitutional  Integumentary redness around the skin her left posterior shoulder  Eyes  Neurologic about two days ago. It seems to be getting a little bit larger in size, and she saw some red streaks  ENT  Psychiatric extending up her neck. She has had no fever. The  Cardiovascular  Endocrine area is mildly sore. She complains of no nausea,  Respiratory  Hem / lymph headaches, trouble breathing, palpitations, or muscle aches.  Gastrointestinal  Allergy / immunologic  Genitourinary  All others negative CURRENT MEDICATIONS: Generic Maxzide,  Musculoskeletal Climara patch, multivitamin, Tums, Claritin, and vitamin C. PFSH ALLERGIES: No known medicine allergies.  Past  Family  Social