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 Chronic Conditions OR Status of 1 -2 Chronic Conditions Status of 1 -2 Chronic Conditions Status of 3 Chronic Conditions Status of 3 Chronic Conditions HPI (History of Present Illness) Elements □ Locaon □ Severity □ Timing □Modifying factors □ Quality □Duraon □ Context □Associated signs and symptoms Brief (1-3) Brief (1-3) Extended (4

• r more)

Extended (4 or more) ROS (Review of Systems) □Constuonal (wt loss, etc) □ Eyes □ Ears, nose, mouth, throat □ Endocrine □Musculoskeletal □ Cardiovascular □Genitourinary □ Neurological □ Gastrointesnal □ Hematological/Lymph □ Psychological □ Integumentary □ Respiratory □Allergy/Immuno □ All others negave None Pertinent to problem (1 system) Extended (2- 9 systems) *Complete PFSH (Past, Family, Social History) areas None None Pertinent ** Complete (2

• r 3 history

areas) Problem Focused Expanded Problem Focused Detailed Comprehensive

H I S T O R Y

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

HPI Elements

A chronological description of the development of the present illness from the 1st sign to present day Example: Patient presents with 3 days of itchy rash on his right hand. Has tried OTC Benadryl with no relief

Status of Chronic Conditions

It is not enough to simply list the patients chronic

• conditions. You MUST document the status of those

conditions: “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

OR

Describe the Symptoms Sample Words Location Where the problem, pain, or symptom occurs Chest, lung, leg Quality Description of the problem, symptom, or pain Burning, dull, scratchy, constant, red Severity Description of the severity of symptoms Pain scale (1-10) mild, moderate, severe Duration How long the problem, symptom, or pain has persisted Today, weeks, months Timing When a problem, symptom, or pain occurs Upon wakening, after meals, intermittently Context Instances that can be associated with the problem, symptom, or pain Sitting, standing, working, MVA Modifying Factors Actions taken to make the problem, symptom, or pain better or worse With ice, OTC meds, heat

• Assoc. Signs & Symptoms

Other problems, symptoms, or facts that occurs when the primary issue occurs Severe headaches also cause nausea, rapid heart beat during shoulder pain

Review of Systems

14 systems are recognized:

• Constitutional
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Endocrine
• Hematic/Lymphatic
• 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

CHIEF COMPLAINT: A 47-year-old white female presents with concern about possible spider bite to the left side of her neck. SUBJECTIVE: This 47-year-old white female presents with concern about possible spider bite to the left side of her neck. She is not aware of any specific injury. She noticed a little tenderness and redness around the skin her left posterior shoulder about two days ago. It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. She has had no fever. The area is mildly sore. She complains of no nausea, headaches, trouble breathing, palpitations, or muscle aches. CURRENT MEDICATIONS: Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C. ALLERGIES: No known medicine allergies.

Location Severity Timing Modifying Factors  Constitutional  Eyes  ENT  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal Quality Duration Context Associated Signs and Symptoms  Integumentary  Neurologic  Psychiatric  Endocrine  Hem / lymph  Allergy / immunologic  All others negative HPI Elements Review of Systems PFSH  Past  Family  Social

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.

Status of Chronic Conditions OR Status of 1 -2 Chronic Conditions Status of 1 -2 Chronic Conditions Status of 3 Chronic Conditions Status of 3 Chronic Conditions HPI (History of Present Illness) Elements □ Locaon □ Severity □ Timing □Modifying factors □ Quality □Duraon □ Context □Associated signs and symptoms Brief (1-3) Brief (1-3) Extended (4

• r more)

Extended (4 or more) ROS (Review of Systems) □Constuonal (wt loss, etc) □ Eyes □ Ears, nose, mouth, throat □ Endocrine □Musculoskeletal □ Cardiovascular □Genitourinary □ Neurological □ Gastrointesnal □ Hematological/Lymph □ Psychological □ Integumentary □ Respiratory □Allergy/Immuno □ All others negave None Pertinent to problem (1 system) Extended (2- 9 systems) *Complete PFSH (Past, Family, Social History) areas None None Pertinent ** Complete (2

• r 3 history

areas) Problem Focused Expanded Problem Focused Detailed Comprehensive

H I S T O R Y

Circle the entry furthest to the right in each row that best describes the level of HPI, ROS, and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle furthest to the left identifies the type of history.

Status of Chronic Conditions OR Status of 1 -2 Chronic Conditions Status of 1 -2 Chronic Conditions Status of 3 Chronic Conditions Status of 3 Chronic Conditions HPI (History of Present Illness) Elements □ Locaon □ Severity □ Timing □Modifying factors □ Quality □Duraon □ Context □Associated signs and symptoms Brief (1-3) Brief (1-3) Extended (4

• r more)

Extended (4 or more) ROS (Review of Systems) □Constuonal (wt loss, etc) □ Eyes □ Ears, nose, mouth, throat □ Endocrine □Musculoskeletal □ Cardiovascular □Genitourinary □ Neurological □ Gastrointesnal □ Hematological/Lymph □ Psychological □ Integumentary □ Respiratory □Allergy/Immuno □ All others negave None Pertinent to problem (1 system) Extended (2- 9 systems) *Complete PFSH (Past, Family, Social History) areas None None Pertinent ** Complete (2

• r 3 history

areas) Problem Focused Expanded Problem Focused Detailed Comprehensive

H I S T O R Y

Circle the entry furthest to the right in each row that best describes the level of HPI, ROS, and PFSH. If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column contains three circles, the column containing a circle furthest to the left identifies the type of history.

Status of Chronic Conditions OR Status of 1 -2 Chronic Conditions Status of 1 -2 Chronic Conditions Status of 3 Chronic Conditions Status of 3 Chronic Conditions HPI (History of Present Illness) Elements □ Locaon □ Severity □ Timing □Modifying factors □ Quality □Duraon □ Context □Associated signs and symptoms Brief (1-3) Brief (1-3) Extended (4

• r more)

Extended (4 or more) ROS (Review of Systems) □Constuonal (wt loss, etc) □ Eyes □ Ears, nose, mouth, throat □ Endocrine □Musculoskeletal □ Cardiovascular □Genitourinary □ Neurological □ Gastrointesnal □ Hematological/Lymph □ Psychological □ Integumentary □ Respiratory □Allergy/Immuno □ All others negave None Pertinent to problem (1 system) Extended (2- 9 systems) *Complete PFSH (Past, Family, Social History) areas None None Pertinent ** Complete (2

• r 3 history

areas) Problem Focused Expanded Problem Focused Detailed Comprehensive

H I S T O R Y

Examination

Levels of Examination

The levels of E/M services are based on four types of examination that are defined as follows: Problem Focused -- a limited examination of the affected body area or organ system. Expanded Problem Focused -- a limited examination of the affected body area or

• rgan system and other symptomatic or related organ system(s).

Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive -- a general multi-system examination or complete examination

• f a single organ system.

Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ GU □ Skin □ Neuro □ Psych □ Hem/lymph/imm Problem Focused Expanded Problem Focused Detailed Comprehensive Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ GU □ Skin □ Neuro □ Psych □ Hem/lymph/imm Problem Focused Expanded Problem Focused Detailed Comprehensive Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ GU □ Skin □ Neuro □ Psych □ Hem/lymph/imm Problem Focused Expanded Problem Focused Detailed Comprehensive

E X A M

1 body areas or

• rgan system

2 - 4 body areas or

• rgan systems

5-7 body areas

• r organ

systems 8 or more body areas or organ systems

E X A M

1 body areas or

• rgan system

2 - 7 body areas or

• rgan systems

4 x 4 exam 8 or more body areas or organ systems

E X A M

1 body areas or

• rgan system

2 - 7 body areas or

• rgan systems

2-7 body areas

• r organ

systems with 1 in detail 8 or more body areas or organ systems

Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ Skin □ Hem/lymph/imm □ GI □ GU □ Neuro □ Psych Problem Focused Expanded Problem Focused Detailed Comprehensive Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ Skin □ Hem/lymph/imm □ GI □ GU □ Neuro □ Psych Problem Focused Expanded Problem Focused Detailed Comprehensive Body area: □ Head, including face □ Chest, including breasts and axillae □ Abdomen □ Neck □ Back, including spine □ Genitalia, groin, buttocks □ Each extremity Organ systems: □ Constitutional (e.g. vitals, gen appearance) □ Ears, nose, mouth, throat □ Eyes □ Cardiovascular □ Respiratory □ Musculoskeletal □ Gastrointestinal □ Skin □ Hem/lymph/imm □ GI □ GU □ Neuro □ Psych Problem Focused Expanded Problem Focused Detailed Comprehensive

E X A M

1 body areas or

• rgan system

2 - 4 body areas or

• rgan systems

5-7 body areas

• r organ

systems 8 or more body areas or organ systems

E X A M

1 body areas or

• rgan system

2 - 7 body areas or

• rgan systems

4 x 4 exam 8 or more body areas or organ systems

E X A M

1 body areas or

• rgan system

2 - 7 body areas or

• rgan systems

2-7 body areas

• r organ

systems with 1 in detail 8 or more body areas or organ systems

Constitutional ♦Three vital signs ♦General appearance Eyes ♦Inspection of conjunctivae and lids ♦Examination of pupils and irises (PERRLA) ♦Ophthalmoscopic examination of discs and posterior segments Ears, Nose, Mouth, and Throat ♦External appearance of the ears and nose ♦Otoscopic exam of the external auditory canals and TMs ♦Assessment of hearing ♦Inspection of nasal mucosa, septum and turbinates ♦Inspection of lips, teeth and gums ♦Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck ♦Exam of neck (masses, symmetry, tracheal position, crepitus) ♦Examination of thyroid (masses, nodules, tenderness) Respiratory ♦Assessment of respiratory effort ♦Percussion of chest ♦Palpation of chest (tactile fremitus) ♦Auscultation of the lungs Chest (Breasts) ♦Inspection of the breasts ♦Palpation of the breasts and axillae Cardiovascular ♦Palpation of the heart (PMI) ♦Auscultation of the heart ♦Assessment of lower extremity edema ♦Examination of the carotid arteries ♦Examination of abdominal aorta ♦Examination of the femoral pulses ♦Examination of the pedal pulses Gastrointestinal (Abdomen) ♦Examination of the abdomen (masses or tenderness) ♦Examination of the liver and spleen ♦Examination for the presence or absence of hernias ♦Examination of anus, perineum, and rectum ♦Obtain stool for occult blood testing if indicated Genitourinary (Male) ♦Examination of the scrotal contents (tenderness of cord, testicular mass) ♦Examination of the penis ♦Digital rectal examination of the prostate Genitourinary (Female) ♦Examination of the external genitalia ♦Examination of the urethra ♦Examination of the bladder (fullness, masses, tenderness) ♦Examination of the cervix ♦Examination of the uterus (size, contour, position, mobility) ♦Examination of the adnexa (masses, tenderness, nodularity) Lymphatic: Palpation of lymph nodes in two or more areas: ♦Neck ♦Axillae ♦Groin ♦Other (e.g., extremities) Skin Skin ♦Inspection of skin and subcutaneous tissue (rashes, lesions, ulcers) ♦Palpation of the skin and subcutaneous tissue (induration, subcutaneous nodules, tightening) Musculoskeletal ♦Examination of gait and station ♦Inspection and/or palpation of digits and nails (clubbing, cyanosis, ischemia) Examination of the joints, bones, and muscles of one or more 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 6) Left lower extremity The examination of a given area may include: ♦Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses

• r effusions

♦Assessment of range of motion with notation of any pain, crepitation or contracture ♦Assessment of stability with notation of any dislocation, subluxation, or laxity ♦Assessment of muscle strength and tone with notation of any atrophy or abnormal movements Neurologic ♦Test cranial nerves with notation of any deficits ♦Examination of DTRs with notation of abnormal reflexes ♦Examination of sensation (touch, pin-prick, vibration, proprioception) Psychiatric ♦Description of patient’s judgment and insight Brief assessment of mental status, which may include: ♦Orientation to time, place, and person ♦Recent and remote memory ♦Mood and affect Problem Focused: 1 to 5 bullets from any organ systems Expanded Problem Focused: 6 to 11 bullets from any organ systems Detailed: 12 bullets from any organ systems Comprehensive: 2 bullets from EACH of 9 organ systems

Examination Example

PHYSICAL EXAMINATION: VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but

• irregular. Respiratory rate 25.

HEENT: Head normocephalic NECK: There was no thyroid mass palpable. CHEST: Clear except for occasional bibasilar crackles. CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Mild +1 peripheral edema in both legs. Head Back Chest Genitalia Abdomen Neck Extremities (x 2 )

Constitutional Eyes ENT Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurological Psychiatric Hem / lymph /immuno

Medical Decision Making

Final Result for complexity

A

Number diagnoses or treatment

• ptions

≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

B Highest Risk of Morbidity/Mortality

Minimal Low Moderate High

C

Amount and complexity of data reviewed ≤ 1 2 Limited 3 Multiple ≥ 4 Type of decision making Straight- forward Low Moderate High

Number of Diagnoses or Treatment Options A B X C = D Self limited or minor (stable, improved, or worsening) Max = 2 1 Established problem (to examiner); stable, improved 1 Established problem (to examiner); worsening 2 New problem (to examiner); no additional workup planned Max = 1 3 New problem (to examiner); additional workup planned 4 TOTAL

Amount and/or Complexity of Data Reviewed Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test result with performing physician 1 Decision to obtain old records and/or obtain history from someone other than the patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider 2 Independent visualization of image, tracing or specimen itself (not simply review of report) 2 Total

Risk of Complications and/or Morbidity or Mortality Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal

• One self-limited or minor problem, e.g., cold, insect bite,

tinea corporis

• Laboratory tests requiring venipuncture
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound, e.g., echo
• KOH prep
• Rest
• Gargles
• Elastic bandages
• Superficial dressings

Low

• Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled hypertension
• r non-insulin dependent diabetes, cataract, BPH
• Acute uncomplicated illnlness or injury, e.g., cystitis, allergic

rhinitis, simple sprain

• Physiologic tests not under stress, e.g.,pulmonary

function tests

• Non-cardiovascular imaging studies with contrast, e.g.,

barium enema

• Superficial needle biopsies
• Clinical laboratory tests requiring arterial puncture
• Skin biopsies
• Over-the-counter drugs
• Minor surgery with no identified risk factors
• Physical therapy
• Occupational therapy
• IV fluids without additives

Moderate

• One or more chronic illnesses with mild exacerbation,

progression, or side effects of treatment

• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain prognosis, e.g.,

lump in breast

• Acute illness with systemic symptoms, e.g., pyelonephritis,

pneumonitis, colitis

• Acute complicated injury, e.g., head injury with brief loss of

consciousness

• Physiologic tests under stress, e.g., cardiac stress test,

fetal contraction stress test

• Diagnostic endoscopies with no identified risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with contrast and no

identified risk factors, e.g., arteriogram cardiac cath

• Obtain fluid from body cavity, e.g., lumbar puncture,

thoracentesis, culdocentesis

• Minor surgery with identified risk factors
• Elective major surgery (open, percutaneous or

endoscopic) with no identified risk factors

• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with addititives
• Closed treatment of fracture or dislocation without

manipulation High

• One or more chronic illnesses with severe exacerbation,

progression, or side effects of treatment

• Acute or chronic illnesses or injuries that may pose a threat

to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

• An abrupt change in neurologic status, e.g., seizure, TIA,

weakness or sensory loss

• Cardiovascular imaging studies with contrast with

identified risk factors

• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography
• Elective major surgery (open, percutaneous or endoscopic

with identified risk factors)

• Emergency major surgery (open, percutaneous or

endoscopic)

• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care because
• f poor prognosis

Final Result for complexity

A

Number diagnoses or treatment

• ptions

≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

B Highest Risk of Morbidity/Mortality

Minimal Low Moderate High

C

Amount and complexity of data reviewed ≤ 1 2 Limited 3 Multiple ≥ 4 Type of decision making Straight- forward Low Moderate High

Final Result for complexity

A

Number diagnoses or treatment

• ptions

≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

B Highest Risk of Morbidity/Mortality

Minimal Low Moderate High

C Amount and complexity of data

≤ 1 2 Limited 3 Multiple ≥ 4 Type of decision making Straight- forward Low Moderate High Draw a line down any column with two or three circles to identify the type of decision-making in that column. Otherwise, draw a line down the column with the 2nd circle from the left.

Final Result for complexity

A

Number diagnoses or treatment

• ptions

≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

B Highest Risk of Morbidity/Mortality

Minimal Low Moderate High

C Amount and complexity of data

≤ 1 2 Limited 3 Multiple ≥ 4 Type of decision making Straight- forward Low Moderate High Draw a line down any column with two or three circles to identify the type of decision-making in that column. Otherwise, draw a line down the column with the 2nd circle from the left.

Requires 3 of 3 components

History Problem Focused Expanded Detailed Comprehensive Comprehensive Exam Problem Focused Expanded Detailed Comprehensive Comprehensive MDM Straightforward Straightforward Low Moderate High Time 10 20 30 45 60 Level 99201 99202 99203 99204 99205

Time Based Billing

When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face in the office), then time can be the considered the key or controlling factor to qualify for a particular level of E&M services. When billing based off time, documentation needs to reveal: 1. The total time spent face-to-face with the patient 2. That more than half of the time was counseling or coordinating care 3. Describes the content of counseling and/or coordinating care, such as:

• Diagnostic results
• Prognosis
• Risks and benefits of treatment options
• Impressions
• Instructions for management
• Importance of compliance with chosen treatment options
• Risk factor reductions
• Patient and family education

Example of a time-based billing statement: “I spent a total of 45 minutes with this patient in which 30 minutes was spent counseling the patient on their new diagnosis of

• diabetes. We went over her condition in detail and spent time reviewing her treatment option and dietary restrictions.”

Starting January 1, 2021

History and Examination will no longer factor into the selection of the E&M level.

• Providers should still perform and document a medically

appropriate history and exam.

• E&M level will be based on either MDM or time.

Before January 1, 2021 Starting January 1, 2021 Number of Diagnoses or Treatment Options Number and Complexity of Problems Addressed Amount and/or Complexity of Data Reviewed Amount and/or Complexity of Data to be Reviewed and Analyzed Risk of Complications and/or Morbidity or Mortality Risk of Complications and/or Morbidity or Mortality of Patient Management

Code

Level of MDM (Based on 2 out of 3 Elements of MDM)

Elements of Medical Decision Making

Number and Complexity of Problems Addressed Amount and/or Complexity of Data to be Reviewed and Analyzed *Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below. Risk of Complications and/or Morbidity or Mortality of Patient Management

99211 N/A

N/A N/A N/A

99202 99212 Straightforward

Minimal · 1 self-limited or minor problem Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment

99203 99213 Low

Low · 2 or more self-limited or minor problems;

• r

· 1 stable chronic illness;

• r

· 1 acute, uncomplicated illness or injury Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents · Any combination of 2 from the following: · Review of prior external note(s) from each unique source*; · review of the result(s) of each unique test*; · ordering of each unique test*

• r

Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Low risk of morbidity from additional diagnostic testing

• r treatment

99204 99214 Moderate

Moderate · 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;

• r

· 2 or more stable chronic illnesses;

• r

· 1 undiagnosed new problem with uncertain prognosis;

• r

· 1 acute illness with systemic symptoms;

• r

· 1 acute complicated injury Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) · Any combination of 3 from the following: · Review of prior external note(s) from each unique source*; · Review of the result(s) of each unique test*; · Ordering of each unique test*; · Assessment requiring an independent historian(s)

• r

Category 2: Independent interpretation of tests · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

• r

Category 3: Discussion of management or test interpretation · Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: · Prescription drug management · Decision regarding minor surgery with identified patient or procedure risk factors · Decision regarding elective major surgery without identified patient or procedure risk factors · Diagnosis or treatment significantly limited by social determinants of health

99205 99215 High

High · 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;

• r

· 1 acute or chronic illness or injury that poses a threat to life or bodily function Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) · Any combination of 3 from the following: · Review of prior external note(s) from each unique source*; · Review of the result(s) of each unique test*; · Ordering of each unique test*; · Assessment requiring an independent historian(s)

• r

Category 2: Independent interpretation of tests · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

• r

Category 3: Discussion of management or test interpretation · Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) High risk of morbidity from additional diagnostic testing

• r treatment

Examples only: · Drug therapy requiring intensive monitoring for toxicity · Decision regarding elective major surgery with identified patient or procedure risk factors · Decision regarding emergency major surgery · Decision regarding hospitalization · Decision not to resuscitate or to de-escalate care because of poor prognosis

Number and Complexity of Problems Addressed N/A Minimal Low Moderate High · 1 self-limited or minor problem · 2 or more self-limited or minor problems; · 1 or more chronic illnesses with exacerbation, progression, or side effects

• f treatment;

· 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;

• r
• r
• r

· 1 stable chronic illness; · 2 or more stable chronic illnesses; · 1 acute or chronic illness or injury that poses a threat to life

• r bodily function
• r
• r

· 1 acute, uncomplicated illness

• r injury

· 1 undiagnosed new problem with uncertain prognosis;

• r

· 1 acute illness with systemic symptoms;

• r

· 1 acute complicated injury

Amount and/or Complexity of Data to be Reviewed and Analyzed

N/A Minimal or None Limited Moderate Extensive (Must meet the requirements of at least 1 of the 2 categories) (Must meet the requirements of at least 1

• ut of 3 categories)

(Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests and documents Category 1: Tests, documents, or independent historian(s) Category 1: Tests, documents, or independent historian(s) Any combination of 2 from the following: Any combination of 3 from the following: Any combination of 3 from the following: · Review of prior external note(s) from each unique source*; · Review of prior external note(s) from each unique source*; · Review of prior external note(s) from each unique source*; · review of the result(s) of each unique test*; · Review of the result(s) of each unique test*; · Review of the result(s) of each unique test*; · ordering of each unique test* · Ordering of each unique test*; · Ordering of each unique test*;

• r

· Assessment requiring an independent historian(s) · Assessment requiring an independent historian(s) Category 2: Assessment requiring an independent historian(s)

• r
• r

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Category 2: Independent interpretation of tests Category 2: Independent interpretation of tests · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

• r
• r

Category 3: Discussion of management or test interpretation Category 3: Discussion of management or test interpretation · Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) · Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

Risk of Complications and/or Morbidity or Mortality of Patient Management

N/A Minimal Low Moderate High Minimal risk of morbidity from additional diagnostic testing or treatment Low risk of morbidity from additional diagnostic testing or treatment Moderate risk of morbidity from additional diagnostic testing or treatment High risk of morbidity from additional diagnostic testing or treatment Examples only: Examples only: · Prescription drug management · Drug therapy requiring intensive monitoring for toxicity · Decision regarding minor surgery with identified patient or procedure risk factors · Decision regarding elective major surgery with identified patient or procedure risk factors · Decision regarding elective major surgery without identified patient or procedure risk factors · Decision regarding emergency major surgery · Diagnosis or treatment significantly limited by social determinants of health · Decision regarding hospitalization · Decision not to resuscitate or to de-escalate care because of poor prognosis

Code

Level of MDM (Based on 2 out of 3 Elements of MDM)

Elements of Medical Decision Making

Number and Complexity of Problems Addressed Amount and/or Complexity of Data to be Reviewed and Analyzed *Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below. Risk of Complications and/or Morbidity or Mortality of Patient Management

99211 N/A

N/A N/A N/A

99202 99212 Straightforward

Minimal · 1 self-limited or minor problem Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment

99203 99213 Low

Low · 2 or more self-limited or minor problems;

• r

· 1 stable chronic illness;

• r

· 1 acute, uncomplicated illness or injury Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents · Any combination of 2 from the following: · Review of prior external note(s) from each unique source*; · review of the result(s) of each unique test*; · ordering of each unique test*

• r

Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Low risk of morbidity from additional diagnostic testing

• r treatment

99204 99214 Moderate

Moderate · 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;

• r

· 2 or more stable chronic illnesses;

• r

· 1 undiagnosed new problem with uncertain prognosis;

• r

· 1 acute illness with systemic symptoms;

• r

· 1 acute complicated injury Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) · Any combination of 3 from the following: · Review of prior external note(s) from each unique source*; · Review of the result(s) of each unique test*; · Ordering of each unique test*; · Assessment requiring an independent historian(s)

• r

Category 2: Independent interpretation of tests · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

• r

Category 3: Discussion of management or test interpretation · Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: · Prescription drug management · Decision regarding minor surgery with identified patient or procedure risk factors · Decision regarding elective major surgery without identified patient or procedure risk factors · Diagnosis or treatment significantly limited by social determinants of health

99205 99215 High

High · 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;

• r

· 1 acute or chronic illness or injury that poses a threat to life or bodily function Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) · Any combination of 3 from the following: · Review of prior external note(s) from each unique source*; · Review of the result(s) of each unique test*; · Ordering of each unique test*; · Assessment requiring an independent historian(s)

• r

Category 2: Independent interpretation of tests · Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

• r

Category 3: Discussion of management or test interpretation · Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) High risk of morbidity from additional diagnostic testing

• r treatment

Examples only: · Drug therapy requiring intensive monitoring for toxicity · Decision regarding elective major surgery with identified patient or procedure risk factors · Decision regarding emergency major surgery · Decision regarding hospitalization · Decision not to resuscitate or to de-escalate care because of poor prognosis

Time Based Codes

Time Based Billing in 2021

For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff). Physician/other qualified health care professional time includes the following activities, when performed:

• Preparing to see the patient (eg, review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals

(when not separately reported)

• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported)

and communicating results to the patient/family/caregiver

• Care coordination (not separately reported)

CPT Current Time 2021 Time 99201 10 Ø 99202 20 15-29 99203 30 30-44 99204 45 45-59 99205 60 60-74 99211 5 Minimal 99212 10 10-19 99213 15 20-29 99214 25 30-39 99215 40 40-54

Time Based Billing

Prolonged Care w/ Direct Patient Contact (Except with Office or Other Outpatient Services)

Prolonged Care w/ Direct Patient Contact Inpatient or Observation

Total Duration of Prolonged Services Code(s) Less than 30 minutes Not separately reported 30-74 minutes (30 minutes - 1

• hr. 14 min.)

99356 X 1 75-104 minutes (1 hr. 15 min.

• 1 hr. 44 min.)

99356 X 1 AND 99357 X 1 105 or more (1 hr. 45 min. or more) 99356 X 1 AND 99357 X 2 or more for each additional 30 minutes.

Prolonged Service Without Direct Patient Contact

Prolonged Service Without Direct Patient Contact

Total Duration of Prolonged Services Code(s) Less than 30 minutes Not separately reported 30-74 minutes (30 minutes - 1

• hr. 14 min.)

99358 X 1 75-104 minutes (1 hr. 15 min.

• 1 hr. 44 min.)

99358 X 1 AND 99359 X 1 105 or more (1 hr. 45 min. or more) 99358 X 1 AND 99359 X 2 or more for each additional 30 minutes.

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

Total Duration of Prolonged Services Code(s) Less than 45 minutes Not separately reported 45-74 minutes (45 minutes - 1 hr. 14 min.) 99415 X 1 75-104 minutes (1 hr. 15 min. - 1 hr. 44 min.) 99415 X 1 AND 99416 X 1 105 or more (1 hr. 45 min. or more) 99415 X 1 AND 99416 X 2

• r more for each additional

30 minutes.

Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

Total Duration of Prolonged Services for New Patients Code(s) less than 75 minutes Not separately reported 75-89 minutes 99205 X 1 and 99XXX X 1 75-104 minutes 99205 X 1 and 99XXX X 2 105 or more 99205 X 1 and 99XXX X 3 or more for each additional 15 minutes.

Use with 99205

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

Total Duration of Prolonged Services for New Patients Code(s) less than 55 minutes Not separately reported 55-69 minutes 99215 X 1 and 99XXX X 1 70-84 minutes 99215 X 1 and 99XXX X 2 85 or more 99215 X 1 and 99XXX X 3 or more for each additional 15 minutes

Use with 99215

Resources:

https://www.cms.gov/outreach-and-education/medicare-learning- network-mln/mlnproducts/downloads/eval-mgmt-serv-guide- icn006764.pdf https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged- svs-code-changes.pdf