Evaluation and Management Services Presentation

Report

After this presentation, you should be able to:
› Know that E/M stands for
› Know the 3 components of the E/M
› Distinguish different categories of E/M
› Understand levels of complexity
› Level Medical Decision Making
› Know when modifiers apply (and look them up)
› Appropriately document according to E/M level

E/M
› Professional face-to-face service between doctor and
patient
› Documentation to support the above
› S: History
› O: Physical
› A: Decision Making
› P: Decision Making
Categories of E/M Services
 Elements of the E/M Visit
 Modifiers

PPO patient seen by your partner last year, consult
requested by the ED, you see the patient and
document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established
PPO patient seen by your partner last year, consult
requested by the ED, you see the patient and
document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established
Medicare patient seen by your partner last year,
consult requested by the ED, you see the patient
and document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established
Medicare patient seen by your partner last year,
consult requested by the ED, you see the patient
and document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established
Medicare patient never seen by you or your
partner, consult requested by the ED, you see
the patient and document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established
Medicare patient never seen by you or your
partner, consult requested by the ED, you see
the patient and document

Encounter type?
A. Hospital/inpatient new
B. Hospital/inpatient consultation
C. Office/outpatient new
D. Office/outpatient consultation
E. Office/outpatient established

Office or other outpatient (includes ED)
› New (requires all 3 key components)
› Established (2 of 3 components)

Hospital inpatient
› Initial hospital care (3 components)
› Subsequent hospital care (2 of 3 components)
› Hospital discharge

Consultations
› Office or other outpatient
› Initial inpatient

Office or other outpatient
› New (requires all 3 key components of E/M)
 Never seen by your group
 Seen by you or group member more than 3 years ago
› Established (2 of 3 components of E/M)
 Not New visit
 Not Consultation

Consultations
› Definition
“A consultation is defined as a type of service provided
by a physician whose opinion or advice regarding
evaluation and/or management of a specific problem is
requested by another physician or other appropriate
source.”

Consultations
› Guidelines
 The consultant’s opinion is requested by another
physician
 Documentation of verbal or written request
 Documentation of consultant’s opinion
 Consultant may initiate treatment
 Communication of consultant’s opinion to the
requesting physician

Consultations
› Situations
 Requests between physicians of the same group
 Report consultation code if guidelines are met
 Initiation of treatment
 Usually stems from medical decision making portion of the E/M
service
 “Even though treatment is initiated, the initial service is still
considered a consultative visit.”
 If the consulting physician assumes care, the initial service
should be reported as a consult.

Consultations
›Medicare eliminated
this whole category
Categories of E/M Services
 Elements of the E/M Visit
 Modifiers

Wrist pain, dull, constant, with numbness
ROS Gen: weight gain, CV: none
H/O DM

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)
Wrist pain, dull, constant, with numbness
ROS Gen: weight gain, CV: none
H/O DM

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)

Detailed level
› HPI-ROS-PFS
4-2-1
Wrist pain, sharp, dull, throbbing, aching
ROS 10+
PMH: none, PSH: none, Meds: none

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)
Wrist pain, sharp, dull, throbbing, aching (2 elements)
ROS 10+
PMH: none, PSH: none, Meds: none

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)
Wrist pain, constant, worsening, with numbness
ROS 10+
PMH: none, FHx: Heart disease, SocHx: +EtOH

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)
Wrist pain, constant, worsening, with numbness
ROS 10+
PMH: none, FHx: Heart disease, SocHx: +EtOH

History type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)

History
› CC (1 element)
 Describe reason for visit
 Every visit must have the CC stated

History
› HPI (4 elements)
 Location: site of the problem
 Quality: sharp, dull, throbbing
 Severity: minor, moderate, severe
 Duration: intermittent, constant
 Timing: with exercise, nightly, after meals
 Context: worsening, recurrent
 Modifying factors: rest, heat, cold, elevation
 Associated symptoms: numbness, tingling

History
› ROS (10 elements)
 Constitutional
 Eyes
 Ear, nose, throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary







Musculoskeletal
Integumentary
Neurologic
Psychiatric
Endocrine
Hematologic
Immunologic

History
› PFSH (3 elements)
 Past history
 Illnesses
 Operations
 Allergies
 Family history
 Social history
 Occupation
 Tobacco and alcohol use
History
CC
HPI
ROS
PFSH
Problem focused
1
1-3
0
0
Expanded problem
1
1-3
1
0
Detailed
1
4
2-9
1
Comprehensive
1
4
10
3
No distress, intact cap refill in all fingers
B UE: nontender except over palpable dorsal wrist
mass, functional ROM, no dislocations, no
atrophy, no wounds

Exam type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)
No distress, intact cap refill in all fingers
B UE: nontender except over palpable dorsal wrist
mass, functional ROM, no dislocations, no
atrophy, no wounds

Exam type?
A. Problem focused (level 1)
B. Expanded problem focused (level 2)
C. Detailed (level 3)
D. Comprehensive (levels 4 and 5)

Physical examination—Musculoskeletal
› Constitutional (2 elements)
› Cardiovascular and/or lymphatic (1 element)
› Musculoskeletal (17 elements)
› Skin (4 elements)
› Neuropsychiatric (5 elements)

Physical examination—Musculoskeletal
› Constitutional (2 elements)
 Vital signs (any 3 of the following items)






Temperature
Pulse
Respiration
Blood pressure
Height
Weight
 General appearance

Physical examination—Musculoskeletal
› Cardiovascular and/or lymphatic (1 element)
 Pulse
 Capillary refill
 Skin perfusion
 Edema
 Lymph node palpation

Physical examination—Musculoskeletal
› Musculoskeletal (17 elements)
 Gait examination
 In 4 of 6 body areas: (head/neck, trunk, 4 extremities)




Inspect/palpate
Assess ROM
Assess stability
Assess strength, tone, atrophy, or spasticity

Physical examination—Musculoskeletal
› Skin (4 elements)
 In 4 of 6 body areas: (head/neck, trunk, 4 extremities)
 Inspection and/or palpation

Physical examination—Musculoskeletal
› Neuropsychiatric (5 elements)
 Coordination
 Reflexes (deep tendon or pathologic)
 Sensation
 Orientation
 Mood and affect
Physical examination
Elements
Problem focused
1
Expanded problem
6
Detailed
12
Comprehensive
All
Problem: New fracture, HTN, DM
Risk: Major surgery with risk factors
Data: Reviewed films

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)
Problem: New fracture, HTN, DM (HIGH)
Risk: Major surgery with risk factors (HIGH)
Data: Reviewed films (LOW)

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)
Problem: F/U fracture with displacement
Risk: ORIF
Data: Reviewed films

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)
Problem: F/U fracture with displacement (LOW)
Risk: ORIF (MOD)
Data: Reviewed films (LOW)

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)
Problem: New onset numbness, DM stable
Risk: Major surgery
Data: Read EMG report

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)
Problem: New onset numbness, DM stable (HIGH)
Risk: Major surgery (MODERATE)
Data: Read EMG report (STRAIGHTFORWARD)

Decision type?
A. Straightfoward (levels 1 and 2)
B. Low (level 3)
C. Moderate (level 4)
D. High (level 5)

Decision making
› Number of diagnosis/management options
› Risk of complications
› Amount/complexity of data reviewed

Decision making
› Number of diagnosis/management options
 Self-limited or minor problem
 Established problem
 Worsening problem
 New problem, no additional workup
 New problem, additional workup planned
 Add up points
 Score = 1, 2, 3, 4+
1
1
2
3
4

Decision making
› Risk of complications
 Minimal
 Suture removal, lab tests, rest
 Low
 Two minor problems, sprain, order PT/OT, minor surgery without
risk factors
 Moderate
 Two chronic illness, CT, MRI, aspiration, Rx, fx management, major
surgery without risk factors, minor surgery with risk factors
 High
 Illness with severe exacerbation, abrupt neurological change, major
surgery with risk factors, emergency surgery

Decision making
› Amount/complexity of data reviewed
 Order test
 Review test result
 Discuss test with performing physician
 Decide to obtain records
 Review and summarize records
 Review x-ray or specimen
 Add up points
 Score = 1, 2, 3, 4+
1
1
1
1
2
2
Decision making
Options
Risk
Data
Straightforward
1
Minimal
1
Low complexity
2
Low
2
Moderate
complexity
3
Moderate
3
High complexity
4
High
4
(2 of 3)

How do you decide level of service?
› Components
 History
 Physical examination
 Decision making
› New patients and consultations
 Need all 3 components
 Code for lowest component
› Established patients
 Code for 2 out of 3 components
New or
Consult
Level 1
Level 2
Level 3
Level 4
Level 5
History
Problem
focused
Expanded
problem
Detailed
Comprehensive
Comprehensive
Physical
Exam
Problem
focused
Expanded
problem
Detailed
Comprehensive
Comprehensive
Decision
making
Straightforward
Straightforward
Low
complexity
Moderate
complexity
High
complexity
Return
Level 1
Level 2
Level 3
Level 4
Level 5
History
None
Problem
focused
Expanded
problem
Detailed
Comprehensive
Physical
Exam
None
Problem
focused
Expanded
problem
Detailed
Comprehensive
Decision
making
None
Straightforward
Low
complexity
Moderate
complexity
High
complexity
Categories of E/M Services
 Elements of the E/M Visit
 Modifiers


What are modifiers?
› Modifiers indicate that a service or procedure has
been altered by circumstance but not changed in
definition

How are modifiers reported?
› Two digits appended to CPT code
 Example: 99214-25
Patient presents with new finger triggering after
carpal tunnel release

Codes?
A. Postop-24 (unrelated E/M during postop)
B. Return-24
C. Postop-25 (separate E/M on day of procedure)
D. Return-25
Patient presents with new finger triggering after
carpal tunnel release

Codes?
A. Postop-24 (unrelated E/M during postop)
B. Return-24
C. Postop-25 (separate E/M on day of procedure)
D. Return-25
New patient seen in ED for radius fracture, and
then taken to surgery the same day

Codes?
A. Inpatient consult and surgical code (radius ORIF)
B. Outpatient consult and surgical code
C. Inpatient consult-57 (decision for major surgery) and
surgical code
D. Outpatient consult-57 and surgical code
E. Surgical code only
New patient seen in ED for radius fracture, and
then taken to surgery the same day

Codes?
A. Inpatient consult and surgical code (radius ORIF)
B. Outpatient consult and surgical code
C. Inpatient consult-57 (decision for major surgery) and
surgical code
D. Outpatient consult-57 and surgical code
E. Surgical code only
New patient seen in ED for radius fracture, and
then decision to schedule surgery next week

Codes?
A. Inpatient consult and surgical code (radius ORIF)
B. Outpatient consult and surgical code
C. Inpatient consult-57 (decision for major surgery) and
surgical code
D. Outpatient consult-57 and surgical code
E. Surgical code only
New patient seen in ED for radius fracture, and
then decision to schedule surgery next week

Codes?
A. Inpatient consult and surgical code (radius ORIF)
B. Outpatient consult and surgical code
C. Inpatient consult-57 (decision for major surgery) and
surgical code
D. Outpatient consult-57 and surgical code
E. Surgical code only

CPT modifiers
-21: Prolonged E/M services
-24: Unrelated E/M during postop period
New problem, management of complication, etc.
-25: Significant and separate E/M on the same day of
procedure
Note: chief complaint should be different than
diagnosis, and procedure should be separately
documented from the E/M note
-57: Decision for surgery
Appended to E & M code that resulted in the decision
for surgery

Leveling an E/M visit
› 58 y/o RHD male
› Motorcycle accident
› Left wrist pain

Leveling an E/M visit
› History (comprehensive)
 CC (1)
 Left wrist injury
 HPI (4)
 58 y/o RHD male sustains a motorcycle injury (context) this
morning (timing), and has sharp pain (quality) in the left wrist
(location).
 ROS (10)
 PFSH (3)
 The patient has hypertension (past). Family history includes
heart disease (family). He smokes 1 ppd x 23 yrs (social).

Leveling an E/M visit
› Physical examination (comprehensive)
 Constitutional (2)
 T: 98.4, P 72, B/P 152/90 (3 vital signs)
 The patient appears well developed and is in moderate distress
(general appearance).
 Cardiovascular (1)
 He has good capillary refill in all fingertips of the left hand
without lymphedema.

Leveling an E/M visit
› Physical examination (comprehensive)
 Musculoskeletal (17)
 The patient is on bedrest, and gait cannot be examined (1).
 Examination of the left upper extremity shows gross deformity
at the wrist (1). ROM (1) and strength (1) is decreased due to
pain. There is no joint laxity but definite motion across the
fracture site (1) on examination.
 Examination of the right upper and bilateral lower extremities
reveals no tenderness (3), functional ROM (3), no dislocations
(3), and no atrophy/weakness (3).

Leveling an E/M visit
› Physical examination (comprehensive)
 Skin (4)
 No wounds are present on bilateral upper (2) and bilateral lower
extremities (2).
 Neuropsychiatric (5)
 Patient has normal fine motor control (coordination). Babinski is
symmetrically downgoing (reflex). He has intact sharp-dull
differentiation to the radial, median, and ulnar nerve
distributions of the left hand (sensation). He is oriented person,
place, and time (orientation). His mood and affect are
appropriate (mood and affect).

Leveling an E/M visit
› Decision making (2 of 3 components)
 Number of options
 This patient presents with a new problem, and no further
workup is necessary (3 points). He also has HTN, which is stable
at this time (1 point). HIGH
 Risk of complications
 I recommend major surgery, with open treatment. His risk
factors include HTN and tobacco use. HIGH
 Complexity of data
 I ordered x-ray films (1 point), and have personally reviewed
them. The findings show a left distal radius fracture with intraarticular comminution (2 points). MODERATE

Leveling an E/M visit
Decision making (2 of 3)
Options
Risk
Data
Straightforward
1
Minimal
1
Low complexity
2
Low
2
Moderate complexity
3
Moderate
3
High complexity
4
High
4

Leveling an E/M visit
New patient
Level 1
Level 2
Level 3
Level 4
Level 5
History
Problem
focused
Expanded
problem
Detailed
Comprehensive
Comprehensive
Physical Exam
Problem
focused
Expanded
problem
Detailed
Comprehensive
Comprehensive
Decision
making
Straightforward
Straightforward
Low
complexity
Moderate
complexity
High
complexity

Selecting the correct category
 A 30 y/o patient presents to your office for redness and
swelling in the forearm. You obtain the history, perform
examination, and order blood tests. You admit the
patient on the same day for treatment. After
completion of your office hours that day, you see him in
the hospital.

Selecting the correct category
 A 30 y/o patient presents to your office for redness and
swelling in the forearm. You obtain the history, perform
examination, and order blood tests. You admit the
patient on the same day for treatment. After
completion of your office hours that day, you see him in
the hospital.
› You will not separately report the office visit and the initial hospital care.
› Only the initial hospital care (99221-99223) is reported.

Selecting the correct category
 A 30 y/o patient presents to your office on Wednesday
for redness and swelling in the forearm. You obtain the
history, perform examination, and order blood tests.
You admit the patient on the same day for treatment.
On Thursday, you make rounds and see him as an
inpatient. The patient is seen again on Friday.

Selecting the correct category
 A 30 y/o patient presents to your office on Wednesday
for redness and swelling in the forearm. You obtain the
history, perform examination, and order blood tests.
You admit the patient on the same day for treatment.
On Thursday, you make rounds and see him as an
inpatient. The patient is seen again on Friday.
› You report the Wednesday office E/M code (99201-99205).
› You also report the appropriate initial hospital care code (99221-99223) for
Thursday, which is when you had his first inpatient encounter.
› Rounds on Friday will be reported as subsequent hospital care (9923199233).

Selecting the correct category
 Dr. A (ED physician) requests your opinion and advice
regarding the patient’s displaced tibia fracture. The
request and the need for the consultation are
documented. You perform the consultation, document
your opinion and advice, and communicate this opinion
and advice to Dr. A. You then assumes responsibility for
the management by taking her to the OR the same day.

Selecting the correct category
 Dr. A (ED physician) requests your opinion and advice
regarding the patient’s displaced tibia fracture. The
request and the need for the consultation are
documented. You perform the consultation, document
your opinion and advice, and communicate this opinion
and advice to Dr. A. You then assumes responsibility for
the management by taking her to the OR the same day.
› You report your E/M services as an office or other outpatient consultation
(99241-99245), with -57 modifier appended.
› You also report the procedure code for treatment of tibial fracture using
intramedullary device (27759).

Modifiers
 Your patient presents for post-op visit after R carpal
tunnel release. At the same visit, he brings up a new
complaint of L long finger stiffness and triggering, worse
in the morning.

Modifiers
 Your patient presents for post-op visit after R carpal
tunnel release. At the same visit, he brings up a new
complaint of L long finger stiffness and triggering, worse
in the morning.
› For post-op visit, the E/M code is usually 99024.
› But he has a new complaint, unrelated.
› The E/M code for the L long finger trigger should be reported, with modifier:
99213-24.

Modifiers
 Your patient presents for post-op visit after R carpal
tunnel release. At the same visit, he brings up a new
complaint of L long finger stiffness and triggering, worse
in the morning. You decide to inject the L long finger
with Kenalog, and you perform the procedure in your
office.

Modifiers
 Your patient presents for post-op visit after R carpal
tunnel release. At the same visit, he brings up a new
complaint of L long finger stiffness and triggering, worse
in the morning. You decide to inject the L long finger
with Kenalog, and you perform the procedure in your
office.
› The E/M code for the L long finger trigger should be reported (99213).
 Because this is within the post-op period, add modifier -24.
 For decision for minor office procedure, add modifier -25.
› Report the injection of tendon sheath (20550).
 Unrelated procedure during post-op period (-79).
› Final code set: 99213-24-25, and 20550-79.

History





CC
HPI (4)
ROS (10)
PFSH (3)
Examination
 General, cardiovascular,
gait, 4/6 extremities, skin,
neuropsychiatric (29)

Decision (2/3)
 Options
 Risks
 Data

After this presentation, you should be able to:
› Know that E/M stands for
› Know the 3 components of the E/M
› Distinguish different categories of E/M
› Understand levels of complexity
› Level Medical Decision Making
› Know when modifiers apply (and look them up)
› Appropriately document according to E/M level

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