Evaluation and Management coding is a medical coding process in support of medical billing. Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters. Show
E/M standards and guidelines were established by Congress in 1995 and revised in 1997. It has been adopted by private health insurance companies as the standard guidelines for determining type and severity of patient conditions. This allows medical service providers to document and bill for reimbursement for services provided. 1995 Documentation Guidelines I. Introduction WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?
An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.
II. GENERAL PRINCIPLES OF MEDICAL RECORD
DOCUMENTATION 1. The medical record should be complete and
legible.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. II. DOCUMENTATION OF E/M SERVICES The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:
The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area. As an example, newborn records may include under history of the present illness (HPI) the details of mother’s pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.
The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).
o describing any new ROS and/or PFSH information or noting there has been no change in the information; and o noting the date and location of the earlier ROS and/or PFSH. Definitions and specific documentation guidelines for each of the elements of history are listed below. CHIEF
COMPLAINT (CC) HISTORY OF PRESENT ILLNESS (HPI) Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). A brief HPI consists of one to three elements of the HPI. An extended HPI consists of four or more elements of the HPI. REVIEW OF SYSTEMS (ROS) For purposes of ROS, the following systems are recognized: A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH) For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH. A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI. A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services. B. DOCUMENTATION OF EXAMINATION For purposes of examination, the following body areas are recognized: For purposes of examination, the following organ systems are recognized: The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations. C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.
Each of the elements of medical decision making is described on the following page. NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.
AMOUNT AND/OR
COMPLEXITY OF DATA TO BE REVIEWED RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk. Table of Risk
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
What information is included in a diagnostic procedure report?The date of the examination or procedure. The name of the examination or procedure. The results of the examination or procedure—any pertinent positive or negative information. The diagnostic impression, if one is given.
Which of the following forms list frequently used diagnosis and procedural codes?CMAA Practice Exam 3. Which of the following actions should a MAA take when scheduling a new patient for a physical examination?CMAA REVIEW. Which of the following information is included in an explanation of benefits?What Is Included in Your EOB? The EOB contains the following information: Your name, or the name of your dependent (whoever received the service) Your (or your dependent's) health insurance ID or policy number, and the claim number.
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