6/17/2016
Coding Series –
Part 2 – Evaluation and
Management
Guidelines and Best
Practices
Shatondra Surulere, MBA, RHIA, CCS, CCS-P, CHTS-PW,
AHIMA Approved ICD-10 Trainer and Ambassador
Senior Consultant, Revenue Cycle Consulting
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Creating a Sustainable Future for Healthcare Organizations
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Today’s Presenter
Shatondra Surulere, MBA, RHIA, CCS, CCS-P, CHTS-PW,
AHIMA Approved ICD-10 Trainer and Ambassador
Senior Consultants, Revenue Cycle Consulting
Shatondra Surulere has nearly 15 years of experience in health
information management and coding. Throughout her career, her
primary focus has been with inpatient and outpatient coding,
chargemaster and HIM/Coding management. Prior to joining Quorum,
Shatondra served as the coding compliance and inpatient coding
manager for Parkland Health and Hospital System. During her time in
that role, she successfully lowered discharge not final billed accounts,
redesigned the outpatient coding department to include credentialed
coders and worked on the project as a beta site for the
implementation of computer assisted coding programs.
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Welcome and
Introductions
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Agenda
E&M Documentation Basics
History Component
CMS 1995 Exam Component
CMS 1997 Exam Component
Medical Decision Making Component
Procedure Coding
Modifier Coding
Questions
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E&M
Documentation
Basics
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CMS ‘95 & ‘97 E&M Guidelines
Classification of Evaluation and Management (E/M) Services
• E&M section is divided into
broad categories including, but
not limited to:
• Subcategories

New patient

Established patient

Office or Other Outpatient Services

Initial visit

Hospital Observation Services

Subsequent visit

Hospital Inpatient Services

Consultations

Emergency Department Services

Critical Care Services
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CMS ‘95 & ‘97 E&M Guidelines
General Principles of Medical Record Documentation
• Medical record should be complete and legible
• Documentation for patient encounter should include:
Reason for the encounter and relevant history, physical examination
findings, and prior diagnostic test results
 Assessment, clinical impression, or diagnosis
 Plan for care
 Date and legible identity of the observer

• If not documented, the rationale for ordering diagnostic and
other ancillary services should be easily inferred
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CMS ‘95 & ‘97 E&M Guidelines
General Principles of Medical Record Documentation
If not documented, rationale for ordering diagnostic and other ancillary services should be
easily inferred
Past and present diagnoses should be accessible to the treating and/or consulting physician
Appropriate health risk factors should be identified
The patient's progress, response to and changes in treatment, and revision of diagnosis should
be documented
The CPT and ICD-10-CM codes, reported on the health insurance claim form or billing
statement, should be supported by the documentation in the medical record
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CMS ‘95 & ‘97 E&M Guidelines
Documentation of E&M Services
• Descriptors for the levels of E/M services recognize seven
components, which are used in defining the levels of E/M
services. Components include:
History
 Examination
 Medical decision making
 Counseling
 Coordination of care
 Nature of presenting problem
 Time

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CMS ‘95 & ‘97 E&M Guidelines
The 1995 & 1997 CMS E&M Guidelines outline the
documentation requirements for each E&M code
Three Key Components
Chief Compliant
History
DG: The medical record
should clearly reflect the
chief complaint.
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Physical
Examination
Medical
Decision
Making
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History
Component
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CMS ’95 & ‘97 E&M History
Chief Complaint (CC)
• Definition: A concise statement, describing symptom,
problem, condition, diagnosis, or other factor explaining
reason for the encounter, usually stated in the patient's words
Chest pain
 Follow up for diabetes, hypertension, and hyperlipidemia
 Shortness of breath
 Ankle pain following a fall
 Swollen wrist
 Left ear pain
 Nasal congestion

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CMS ’95 & ‘97 E&M History
History of Present Illness (HPI)
• Definition: chronological description of the development of the patient’s
present illness from the first sign and/or symptom to the present








Location – left breast, lower abdomen, right hand, bilateral ears, chest
Quality – sharp, dull, burning, stabbing, aching, fullness
Severity – worse, sever, mild, or a rating of the severity (e.g. scale 1-10)
Duration – since yesterday, started two weeks ago
Timing – this morning, after eating, after working out, wakes me up at night
Context – happens when standing, sitting, after eating certain foods
Modifying factors – taking aspirin for pain, OTC doesn’t help, ice makes it feel
better
Associated signs and symptoms – migraine with aura and nausea, coughing
causes chest pain
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CMS ’95 & ‘97 E&M History
History of Present Illness (HPI) Levels
• Brief and extended HPIs distinguished by the amount of detail
needed to accurately characterize the clinical problem(s)
• Brief HPI consists of one to three elements of the HPI

DG: Medical record should describe one to three elements of the
present illness (HPI)
• Extended HPI consists of four or more
elements of the HPI

DG: Medical record should describe four or
more elements of the present illness (HPI)
or associated comorbidities
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CMS ’95 & ‘97 E&M History
History of Present Illness (HPI) Levels
• Status of chronic disease



Status of at least three chronic or inactive conditions
Counts as an Extended HPI
1997 guideline; however, payors will allow providers to use it if they are
following the 1995 guidelines
• Example


“Patient here today for follow-up of stable hypertension, which is
asymptomatic, currently uncontrolled diabetes mellitus type II, home sugars
ranging from 200-250, and controlled hypothyroidism on levothroxine, also
asymptomatic.
Cannot simply be a statement of what the patient for follow up of HTN,
Diabetes, and Hypothyroidism to meet the guideline requirements
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CMS 1995 E&M History
Review of Systems (ROS)
Definition: inventory of body systems obtained through a series of questions to
identify sign/symptoms which the patient may be experiencing or have experienced
• Constitutional
• Musculoskeletal
• Eyes
• Integumentary
• Ears, nose, mouth, throat
• Neurological
• Cardiovascular
• Psychiatric
• Respiratory
• Endocrine
• Gastrointestinal
• Hematologic/Lymphatic
• Genitourinary
• Allergic/immunologic
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CMS 1995 E&M History
Review of Systems (ROS) Levels
• A problem pertinent ROS inquires about the system directly related
to the problem(s) identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system
related to the problem should be documented.
• An extended ROS inquires about the system directly related to the
problem(s) identified in the HPI and a limited number of additional
systems.

DG: The patient's positive responses and pertinent negatives for two to nine
systems should be documented.
DG = Documentation Guideline
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CMS 1995 E&M History
Review of Systems (ROS) Levels
• A complete ROS inquires about the system(s) directly related to the problem(s)
identified in the HPI plus all additional body systems

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent
negative responses must be individually documented. For the remaining systems, a notation
indicating all other systems are negative is permissible. In the absence of such a notation, at
least ten systems must be individually documented.
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CMS 1995 E&M History
Past History, Family History, and Social History (PFSH)
Past History
Family History
• the patient's past
experiences with
illnesses,
operations,
injuries and
treatments
• a review of
medical events in
the patient's
family, including
diseases which
may be hereditary
or place the
patient at risk
Social History
• an age
appropriate
review of past
and current
activities
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CMS ’95 & ‘97 E&M History
Past History, Family History, and Social History (PFSH)
Pertinent PFSH:
•Review of the history area(s) directly related to
the problem(s) identified in the HPI
• DG: At least one specific item from any of the
three history areas must be documented for a
pertinent PFSH.
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Complete PFSH:
•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.
• DG: At least one specific item from two of the
three history areas must be documented for a
complete PFSH…
• DG: At least one specific item from each of the
three history areas must be documented for a
complete PFSH…
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CMS ’95 & ‘97 E&M History
Best Practices E&M History Documentation
• Clearly document the chief complaint (the problem vs.
“follow – up”)
• Include specific documentation regarding the presenting
problem (status of chronic problems)
• Document positives and negatives for the patient’s review of
systems
Be specific
 “All other systems negative”
 Reference any review of system documentation completed by
patient or nursing staff

• Document the patient’s past, family and social history

Include details vs. “non-contributory”
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CMS ’95 & ‘97 E&M History
Polling Question #1
Chief
Complaint
Nasal congestion
HPI
The patient is seen in the office today for
nasal congestion and drainage. It has been
going on for the last week. The patient feels
some pressure in his sinuses
b. Expanded problem-focused
ROS
Per HPI, all others negative.
c. Detailed
PFSH
Medical History: None
Surgical History: None
Family History: Mom with HTN
Social History: Non-smoker
What level of a history is
documented here for a new patient
office visit?
a. Problem-focused
d. Comprehensive
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CMS ’95 & ‘97 E&M History
Polling Question #1
What level of a history is
documented here for a new patient
office visit?
b. Expanded problem-focused
Chief
Complaint
Nasal congestion
HPI
The patient is seen in the office today for
nasal congestion and drainage. It has been
going on for the last week. The patient feels
some pressure in his sinuses
ROS
Per HPI, all others negative.
PFSH
Medical History: None
Surgical History: None
Family History: Mom with HTN
Social History: Non-smoker
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CMS 1995 Exam
Component
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CMS 1995 E&M Exam
1995 E&M Exam Documentation
Problem-focused:
• Limited
examination of
the affected body
area or organ
system
Expanded
problem-focused:
• Limited
examination of
the affected body
area or organ
system and other
symptomatic or
related organ
system(s)
Detailed:
Comprehensive:
• Extended
examination of
the affected body
area(s) and other
symptomatic or
related organ
system(s)
• General, multisystem
examination or
complete
examination of a
single organ
system
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CMS 1995 E&M Exam
1995 E&M Exam Documentation Body Areas
• Head, including the face
• Neck
• Chest, including breasts and
axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, including spine
• Each extremity
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CMS 1995 E&M Exam
1995 E&M Exam Documentation Organ Systems
• Constitutional (e.g., vital signs,
general appearance)
• Skin
• Eyes
• Psychiatric
• Neurologic
• Ears, nose, mouth, and throat
• Hematologic/lymphatic/immunologic
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
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CMS 1995 E&M Exam
Exam Documentation Requirements
1 body area or organ
system documented
Problem-Focused
Expanded ProblemFocused
2-4 body areas or organ
system documented
Detailed
Comprehensive
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5-7 body areas or organ
system documented.
8 or more body areas/organ systems
or complete exam of a single organ
system
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CMS 1995 E&M Exam
1995 E&M Exam Documentation Guidelines
• DG: Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be documented

Notation of "abnormal” without elaboration is insufficient
• DG: Abnormal or unexpected findings of the examination of the unaffected or
asymptomatic body area(s) or organ system(s) should be described
• DG: A brief statement or notation indicating "negative" or "normal" is sufficient
to document normal findings related to unaffected area(s) or asymptomatic
organ system(s)
• DG: The medical record for a general, multi-system examination should include
findings for about 8 or more of the 12 organ systems
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CMS 1995 E&M Exam
System/Body Area
Element of Examination
Constitutional
Blood Pressure 120/75, respirations 20,
temperature 96.8 degrees, Patient is
alert with no distress noted.
Ears
External inspection of ears is normal,
exam of tympanic membranes is
normal,
b. Expanded problem-focused
Nose, Mouth and
Throat
Exam of oropharynx and nasal mucosa
moist
c. Detailed
Respiratory
Auscultation of lungs is clear.
d. Comprehensive
Cardiovascular
Auscultation of heart, RRR, no
murmurs
Abdomen
Soft, non-distended
Polling Question #2
What level of exam is
documented here based on
1995 guidelines?
a. Problem-focused
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CMS 1995 E&M Exam
Polling Question #2
What level of exam is
documented here based on
1995 guidelines?
c. Detailed
System/Body Area
Element of Examination
Constitutional
Blood Pressure 120/75, respirations 20,
temperature 96.8 degrees, Patient is
alert with no distress noted.
Ears
External inspection of ears is normal,
exam of tympanic membranes is
normal,
Nose, Mouth and
Throat
Exam of oropharynx and nasal mucosa
moist
Respiratory
Auscultation of lungs is clear.
Cardiovascular
Auscultation of heart, RRR, no
murmurs
Abdomen
Soft, non-distended
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CMS 1997 Exam
Component
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CMS 1995 E&M Exam
1997 E&M Exam Documentation
• Problem-focused: Limited examination of the affected body area or
organ system
• Expanded problem-focused: Limited examination of the affected body
area or organ system and any other symptomatic or related organ
system(s)
• Detailed: Extended examination of the affected body area(s) or organ
system(s) and any other symptomatic or related body area(s) or organ
system(s)
• Comprehensive: General, multi-system examination, or complete
examination of a single organ system and other symptomatic or related
body area(s) or organ system(s)
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CMS 1997 E&M Exam
General Multi-System Exam Documentation Requirements
Problem-Focused
Expanded
Problem-Focused
Detailed
Comprehensive
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•
1-5 elements identified by a bullet (.) in one or more organ systems
or body areas.
•
At least 6 elements identified by a bullet in one or more organ
systems or body areas.
•
•
Includes at least 6 organ systems or body areas
For each system/area documentation of at least 2 elements identified by
a bullet or at least twelve elements identified by a bullet in two or more
organ systems or body areas
•
•
Should include at least nine organ systems or body areas.
For each system/area documentation of all elements of the examination
identified by a bullet should be performed or at least 2 elements
documented identified by a bullet for each organ system or body area.
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CMS 1997 E&M Exam
1997 E&M General Multi-System Exam
• Each bulleted item is
considered one
element
• Example of a problem
focused exam (1-5
elements)
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CMS 1997 E&M Exam
Single System Exam Documentation Requirements
Problem-Focused
Expanded
Problem-Focused
Detailed
Comprehensive
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•
1-5 elements identified by a bullet (.) whether in a box with a shaded or
unshaded border.
•
At least 6 elements identified by a bullet (.) whether in a box with a shaded
or unshaded border.
•
Examinations other than the eye and psychiatric examinations should include
performance and documentation of at least twelve elements identified by a
bullet (.), whether in a box with a shaded or unshaded border
• Should include performance of all elements identified by a bullet (•), whether
in a shaded or unshaded box. Documentation of every element in each box with
a shaded border and at least one element in a box with an unshaded border is
expected.
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CMS 1995 E&M Exam
Tips for E&M Physical Exam Documentation
• The extent of examinations performed and documented is dependent
upon clinical judgment and the nature of the presenting problem(s). A
general multi-system examination or a single organ system examination
may be performed by any physician, regardless of specialty.

DG: Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be documented
o
Notation of "abnormal” without elaboration is insufficient
DG: Abnormal or unexpected findings of the examination of the unaffected or
asymptomatic body area(s) or organ system(s) should be described
 DG: Brief statement or notation indicating "negative" or "normal" is sufficient to
document normal findings related to unaffected area(s) or asymptomatic organ
system(s)

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CMS E&M Medical Decision Making
Medical Decision Making Components (MDM)
Number of
Diagnosis
Emphysema
Chronic
Bronchitis
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Asthma
Complexity of
Data
Complications
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CMS E&M Medical Decision Making
Medical Decision Making Component Findings from Review
• Medical decision making component


Number of diagnosis or management options
o
Generally, decision making with respect to a diagnosed problem is easier than
that for an identified but undiagnosed problem
o
Diagnosis should correlate to the E&M level assigned based on documentation
Amount and/or Complexity of Data to be Reviewed
o
Document all diagnostic test review/ordered
–
Prescriptions
–
Tests, radiology, labs
–
Procedures
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CMS E&M Medical Decision Making
Polling Question #3
What level of medical decision making is
documented by the provider for this new
patient visit?
a. Straightforward
b. Low
c. Moderate
d. High
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Assessment
Acute Rhinitis-I will start him on OTC
Claritin
Acute Sinusitis-I will start on
Amoxicillin for one week.
Patient to return if there are
continued problems.
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CMS E&M Medical Decision Making
Polling Question #3
What level of medical decision making is
documented by the provider for this new
patient visit?
Assessment
Acute Rhinitis-I will start him on OTC
Claritin
Acute Sinusitis-I will start on
Amoxicillin for one week.
c. Moderate
Patient to return if there are
continued problems.
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CMS E&M Medical Decision Making
Tips for Medical Decision Making Documentation
• Document all relevant diagnosis and impressions

Including “probable, rule out,” signs and symptoms
• Document all conditions/response to treatment

Referrals/consultations
• Document the review of lab, rad, other tests


"WBC elevated" or "chest x-ray unremarkable“
Document your visualization/interpretation of images, tracings, or tests
• Document all procedures performed or ordered
• Document all Prescriptions drug management
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CMS E&M Medical Decision Making
Tips for Medical Decision Making Documentation (continued)
• Time documentation

Counseling/Coordination of Care dominates (more than 50%) of encounter
o
o
o
o
o
o
o

Test results, impressions
Prognosis
Risks/benefits of treatment
Patient instructions for management/follow-up
Importance of compliance of treatment
Risk factor reduction
Patient and family education
Total length of time of the should be documented and the record should
describe the counseling and/or activities to coordinate care
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CMS E&M Medical Decision Making
Tips for Medical Decision Making Documentation (continued)
• DG: For each encounter, an assessment, clinical impression, or diagnosis should
be documented. It may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation.
For a presenting problem with an established diagnosis, record should reflect whether the
problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately
controlled, worsening, or failing to change as expected.
 For a presenting problem without an established diagnosis, assessment or clinical
impression may be stated in the form of differential diagnoses or as a "possible,"
"probable," or "rule out" (R/O) diagnosis

• DG: Initiation of, or changes in, treatment should be documented. Treatment
includes a wide range of management options including patient instructions,
nursing instructions, therapies, and medications.
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CMS E&M Medical Decision Making
Tips for Medical Decision Making Documentation (continued)
• DG: If referrals are made, consultations requested or advice
sought, the record should indicate to whom or where the referral
or consultation is made or from whom the advice is requested
• DG: Comorbidities/underlying diseases or other factors that
increase the complexity of medical decision making by increasing
the risk of complications, morbidity, and/or mortality should be
documented
• DG: If a surgical or invasive diagnostic procedure is ordered,
planned, or scheduled at the time of the E/M encounter, the type of
procedure (e.g., laparoscopy) should be documented
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E&M
Documentation and
Coding Examples
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Case Study #1
History Component
• History of present illness: 39 year old female presents with: follow up
• CHRONIC PROBLEMS:

Anxiety, Migraine, Allergic rhinitis, GERD (gastroesophageal reflux disease), PCOD (polycystic
ovarian disease), Postmenopausal HRT (hormone replacement therapy), Depression
• Chronic Problems:

GERD: Status: Recurrent. Additional information: PRN meds. Comments: Doing good with this
but the insurance will not cover the omeprazole, but they will cover the OTC version.

Depression: Status: Stable. The patient is feeling better with welbutrin. Comments: She is
seeing a marriage counselor and they are seeing a therapist.

Anxiety. Status: Stable. The patient is taking medications regularly. Additional information:
retry fluoxetine, failed lexapro; celexa; paxil;viibryd; fluoxetine; effexor; zoloft. Comments: This
is better on the meds.
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Case Study #1
History Component
• Past medical/surgical history

Allergies, reviewed: no changes

Hysterectomy 2008

Broke arm in 7th grade

EGD 2014
• Past social history

Primary language is English

Marital status: Married

Tobacco: Former smoker
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• Review of systems
System
Negative
Constitutional
Fever
Respiratory
Cough and dyspnea
Cardiovascular
Chest pain and irregular
heartbeat/palpitations
Gastrointestinal
Abdominal pain, nausea
and vomiting
Genitourinary
Positive
The patient is postmenopausal (Occurred
at age 32. The
menopause was
hysterectomy).
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Case Study #1
History Component
• Established patient
• Detailed history




HPI-status GERD, depression, and anxiety
ROS-constitutional, respiratory, cardiovascular, gastrointestinal,
genitourinary
PMFSH-medical and social
All three elements in the table must be met
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Case Study #1
Exam Component
• Physical Exam:
 Vitals: BP 120/80, Ht 62in, Wt. 181lbs
 Constitutional: Well developed.
 Neck/Thyroid: Inspection reveals symmetry. Palpation reveals trachea midline and
mobile. No thyromegaly or thyroid nodules detected.
 Lymphatic: No cervical or supraclavicular adenopathy.
 Respiratory: Lungs clear to auscultation. Respiratory effort is normal.
 Cardiovascular: Rate and Rhythm: Heart rate is regular. Rhythm is regular. No
edema is present. Vascular: Pulses: Carotid pulses: normal.
 Extremities: No edema is present.
 Psychiatric: The patient is negative for anhedonia, is not agitated, is not anxious,
does not have pressured speech, and does not have suicidal ideation. The patient
demonstrates the appropriate mood and affect.
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Case Study #1
Exam Component
• Detailed exam

Seven body areas/organ system documented
o
o
o
o
o
o
Constitutional: appearance and vitals
Neck: exam of neck and thyroid
Lymphatic: cervical or supraclavicular nodes
Respiratory: auscultation and respiratory effort is normal.
Cardiovascular: auscultation, peripheral edema, exam of carotid arteries
Psychiatric: mood/affect
• Detailed exam guideline

Detailed -- an extended examination of the affected body area(s) and other
symptomatic or related organ system(s)
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Case Study #1
Medical Decision Making Component
• Assessment/Plan:
Depression (311), Stable. Same meds.
Improved. See me in 4mos.
 Anxiety (300.00), Stable. As above
 GERD (gastroesophageal reflux disease)
(530.81), Recurrent. Insurance states
she has to have the prilosec otc. This
will be a step down. Will see how she
does. May need to try a stronger PPI if
she fails this.

• Number of diagnosis

Multiple

None

Moderate
• Amount/complexity of data
• Risk of diagnosis
• Active medications (prescriptions)

Prilosec OTC 20 mg tablet, delayed
release
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Case Study #1
Medical Decision Making Component
• Assessment/Plan:
• Moderate medical decision making
Depression (311), Stable. Same
meds. Improved. See me in 4mos.
 Anxiety (300.00), Stable. As above
 GERD (gastroesophageal reflux
disease) (530.81), Recurrent.
Insurance states she has to have the
prilosec otc. This will be a step down.
Will see how she does. May need to
try a stronger PPI if she fails this.

• Active Medications (Presciptions)

Prilosec OTC 20 mg tablet, delayed
release
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Case Study #1
Established Patient Office Visit E&M
• Recommended E&M Code 99214
 A detailed history, a detailed exam, and moderate medical
decision making
• Recommended based on the history, exam, and medical
decision making
• At least two components must be met for an established
patient (office visit)
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Case Study #2
History Component
• History of Present Illness: this 31 year, female presents with: laceration
cut distal to lateral L. index finger at work while cutting tomatoes
• Allergies: Latex
Review of Systems
Negative
Constitutional
Chills, fatigue, fever
Gastrointestinal
Nausea and vomiting
Musculoskeletal
Back pain and joint pain
Hematology
Easy bleeding and easy bruising
Positive
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Case Study #2
History Component
• New admission
• History component is expanded problem-focused
HPI-location, context
 ROS-constitutional, gastrointestinal, musculoskeletal, hematology
 PMFSH-medical

• Three elements in the table must be met
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Case Study #2
Exam Component
Physical Exam:
Vitals: Temp 98, Pulse 81, BP 120/80, Ht 5’9”, Wt 165lbs
Constitutional: Well developed.
Eyes: Right No injection. PERRLA. Left No injection. PERRLA.
Ears: Right: Unremarkable to inspection. Left: Unremarkable to
inspection.
Nose / Mouth / Throat:
External Nose: is unremarkable
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Case Study #2
Exam Component (continued)
Neck / Thyroid: Inspection reveals symmetry.
Respiratory: Chest can be described as symmetric. Lungs clear to auscultation.
Respiratory effort is normal.
Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs.
Abdomen: Symmetric - no distention.
Integumentary: First visible lesion: lesion(s) appear on left, lateral index finger,
The lesion is 1 cm. in size. The type of lesion is laceration(s). The status is stable.
Musculoskeletal: Normal range of motion, muscle strength, and stability in all
extremities with no pain on inspection.
Psychiatric: The patient is not oriented to time, place, person, or situation. The
patient does not demonstrate the appropriate mood or affect.
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Case Study #2
Exam Component (continued)
• The documentation supports a comprehensive exam

Nine body areas/organ systems documented
Constitutional: appearance and vitals
o Eyes: conjunctiva, pupils
o ENT: Inspection
o Respiratory: auscultation and respiratory effort is normal
o Abdomen: Palpation
o Musculoskeletal: Inspection of affected limb
o Integumentary: Inspection
o Cardiovascular: auscultation
o Psychiatric: mood/affect, orientation
o
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Case Study #2
Exam Component (continued)
• Comprehensive Exam Guideline
 Comprehensive -- a general multi-system examination or
complete examination of a single organ system.
 DG: The medical record for a general multi-system examination
should include findings about 8 or more of the 12 organ
systems.
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Case Study #2
Medical Decision Making Component
• Assessment/Plan:

Laceration of left index finger w/o foreign body
• Procedures:


Laceration Repair: Patient Consent obtained.
Laceration prepped and draped using sterile
technique. Intermediate neck/hand/feet wound of
less than 2.5 cm was cleansed. Indication is 883.0. It
was anesthetized using 1% lidocaine 1 - 2 mL. The
following sutures were used in today's visit: 5.0
Dermalon™. A sterile dressing was then applied and
wound care instructions discussed. The patient was
asked to return in 7 - 10 days for suture removal.
• Number of diagnosis

Minimal
• Amount/complexity of data

Minimal
• Risk of diagnosis

Moderate
Comments: Four Ethilon 5-0 sutures to left lateral
2nd finger flap injury. Hemostasis noted. Pt
tolerated well.
• Active medications (prescriptions)

Tramadol 50 mg tablet
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Case Study #2
Medical Decision Making Component
• Assessment/Plan:

• Straightforward medical decision making
Laceration of left index finger w/o foreign body
• Procedures:

Laceration Repair: Patient Consent obtained.
Laceration prepped and draped using sterile
technique. Intermediate neck/hand/feet wound of
less than 2.5 cm was cleansed. Indication is 883.0. It
was anesthetized using 1% lidocaine 1 - 2 mL. The
following sutures were used in today's visit: 5.0
Dermalon™. A sterile dressing was then applied and
wound care instructions discussed. The patient was
asked to return in 7 - 10 days for suture removal.

Comments: Four Ethilon 5-0 sutures to left lateral
2nd finger flap injury. Hemostasis noted. Pt
tolerated well.
• Active Medications (Prescriptions)

Tramadol 50 mg tablet
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Case Study #2
New Patient Office Visit E&M
• Recommended E&M Code 99202
 The documentation supports an expanded problem-focused
history, a comprehensive exam, and straightforward medical
decision making
• Recommended based on the history, exam, and medical
decision making
• All three components must meet or exceed the
requirements to qualify for a new patient (office, new
patient)
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CPT Coding
Overview
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CPT Overview
CPT Coding Findings from Review
Make sure to code/bill
procedures performed by the
physician when they are
separately billable
Procedures should be based Example
on documentation by the • Patient seen for cerumen
provider
impaction removal with
instrumentation and the
procedure 69210 was billed;
however, the procedure was
not documented.
• Patient seen for removal of skin
tags; however the code for
excision of benign lesions was
assigned
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Modifier Coding
Overview
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Modifier Overview
Modifier Coding Findings from Review
• Commonly used modifiers
25 - Significant,
Separately
Identifiable Evaluation
and Management
Service
57 - Decision for
surgery
AI - Principal physician
of record (inpatient
E/M's, CMS)
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24 - Unrelated E/M by
same physician during
the global post-op
period)
32 - Mandated
services
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References
• Current Procedural Terminology 2016
• CMS 1995 Documentation Guidelines Evaluation and
Management Services
• CMS 1997 Documentation Guidelines Evaluation and
Management Services
 https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-NetworkMLN/MLNProducts/downloads/ReferenceII.pdf
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Quorum Learning Institute Recordings and Videos: Come Visit Our Library
http://videos.qhr.com/
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Program Evaluation
• Thank you for joining us today. We value your feedback and hope that you will
take a few minutes to evaluate this program so that we may continue to improve
and bring you the quality educational programming you expect.
• As a reminder, you will have two opportunities to complete an evaluation and
receive a completion certificate:

At immediate conclusion of webinar

Post event: within two business days of the webinar, you will receive an email containing
links to the online evaluation and a recording of this webinar
• Upon completing the online evaluation, you will receive an email with a link to
access your completion certificate.
• If you have questions or need assistance, please contact
[email protected].
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For More
Information
Contact:
[email protected]
(800) 233-1470, ext. 4513
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Creating a Sustainable Future for Healthcare Organizations
Intended for internal guidance only, and
not as recommendations for specific
situations. Readers should consult a
qualified attorney for specific legal
guidance.
Creating a Sustainable Future for Healthcare Organizations
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