3/20/2017
Compliance Update
Nancy Enos, FACMPE, CPC-I, CPMA, CEMC, CPC
March 16, 2017
MA/RI MGMA Payer Day
Agenda
• NGS updates to E/M Guidance
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History
Exam
Medical Decision Making
Time
• Delays in implementation
• Now scheduled to be effective 6/1/2017
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History
• Will NGS accept HPI elements from more than one condition/complaint
to be counted cumulatively?
Answer: Yes, credit will be given on HPI elements from more than one
condition, not necessarily grouped per condition.
• If a provider documents “10-point review of systems negative unless
noted in the HPI” does the provider get credit for a complete review of
systems?
Answer: Findings noted during the ROS should be entered as such, with an
entry of “all other systems reviewed and negative” when applicable.
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Examination
• Please clarify the number of organ systems and/or body areas for which there must be
documentation of examination at the various levels of E&M coding.
Answer: NGS has revised examination guidelines relative to body areas and organ
systems, particularly as applicable to the EPF and detailed levels of E&M coding. This
change will be effective for dates of service on and after 2/1/2017, to allow for provider
education and adaptation. These coding expectations are in alignment with other CMSauthorized reviewing entities. In addition, the different expectations for the EPF and
Detailed examinations will eliminate previous ambiguity on the EPF and detailed
requirements.
For documentation of services on and after 6/1/2017, examination requirements will be
as follows:
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PF examination: 1 body area or organ system
Mid-level EPF examination: 2-5 body areas or organ systems
Higher level detailed examination: 6-7 body areas or organ systems
High level comprehensive examination: 8 or more organ systems
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Medical Decision Making
• Please clarify MDM credit granted for problems considered “new” to the examiner. Does this apply for
each provider who sees the patient for the first time, including same-specialty group members? Are the
rules the same in both the inpatient and outpatient environment?
Answer: NGS medical directors have reconsidered this standard and authorized a change that will be
effective for services on and after 6/1/2017. The NGS Medical Review tool will also be modified to reflect
this new standard.
The reference to a problem as “new to examiner” is being changed to a problem as “new to patient”. This
reference is changing to clarify the issue for same-specialty provider groups, many of whom have submitted
questions on this issue. Providers in a same-specialty group are considered by CMS as one entity, and this
concept applies in both the inpatient and outpatient setting. As such, a patient’s problem can only be “new”
to members of a same-specialty group practice on one occasion, and is considered to be a known problem
beyond initial presentation and documentation. If a problem has been recognized and addressed by one
group provider, it is not considered new to another group provider who sees the patient on a subsequent
basis. This is especially true because the first provider should have documented the problem, plan of
approach and diagnostic findings, which should now be available to the second provider.
When a patient presents with a new problem, not previously addressed within a same-specialty group
practice, this factor of MDM may be appropriately assessed, based on whether additional workup is or is not
being planned.
Number of Diagnoses or Treatment Options
Identify each problem or treatment option mentioned in the record. Enter the number in each of the
categories in Column B in the table below. (There is a maximum number in two categories.)
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Amount and/or Complexity of Data Reviewed
For each category or reviewed data identified, circle the
number in the Points column. Total the points.
Final Result for Complexity
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Time
If the physician documents total time and indicates that counseling or
coordinating care dominates (more than 50%) the encounter, time may
determine level of service. Documentation may refer to: prognosis,
differential diagnosis, risks, benefits of treatment, instructions,
compliance, risk reduction and/or discussion with another health care
provider
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