Contents
About the authors...............................................................................................................................vii
Introduction ..........................................................................................................................................xi
Importance of auditing E/M codes......................................................................................xi
Common auditing errors: What you may see when auditing your practice .......................xii
E/M-related resources ........................................................................................................xii
E/M guidelines: 1995 vs. 1997..........................................................................................xiv
From an auditor’s view: Documentation essentials ...........................................................xiv
Administrative buy-in ........................................................................................................xv
How this book will help you ............................................................................................xvi
How this book is organized ..............................................................................................xvi
How to use the CD-ROM ...............................................................................................xvii
What’s included on your CD-ROM ................................................................................xviii
Acronyms used in this book .............................................................................................xix
Continuing education instructional guide ...................................................................................xxi
Chapter 1: Choosing an E/M code .....................................................................................................1
E/M code components .........................................................................................................2
Consultations.....................................................................................................................18
Test your knowledge..........................................................................................................21
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Chapter 2: Performing a risk assessment ......................................................................................23
High-risk areas to monitor ................................................................................................24
Five steps to include...........................................................................................................26
Risk data categories...........................................................................................................29
Items that can affect risk ...................................................................................................30
Test your knowledge..........................................................................................................32
Chapter 3: E/M audit structure...............................................................................................................33
Getting started ...................................................................................................................33
Choosing an auditor ..........................................................................................................34
Preaudit preparations.........................................................................................................35
Deciding when to audit......................................................................................................38
Establishing a baseline .......................................................................................................39
Tracking audit results ........................................................................................................42
Auditing teaching physicians .............................................................................................43
Establishing an audit cycle.................................................................................................43
Scoring providers using a matrix .......................................................................................44
Other audit considerations ................................................................................................47
Test your knowledge..........................................................................................................49
Chapter 4: Using an audit tool..........................................................................................................51
Sample medical record documentation ..............................................................................51
History ..............................................................................................................................52
Exam .................................................................................................................................56
Medical decision-making ...................................................................................................60
Final audit results ..............................................................................................................66
Test your knowledge..........................................................................................................67
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Chapter 5: Packaging your audit .....................................................................................................69
Audit reports to include.....................................................................................................70
Additional documents to consider .....................................................................................72
Test your knowledge..........................................................................................................73
Chapter 6: Devising a compliance plan...............................................................................................75
Plan overview ....................................................................................................................75
Audit policy/procedure ......................................................................................................76
New provider orientation ..................................................................................................76
Outlier providers ...............................................................................................................78
Ongoing education ............................................................................................................79
Test your knowledge..........................................................................................................84
Answers......................................................................................................................................................85
Sample medical record examples........................................................................................................93
New patient office visits (codes 99201–99205) .................................................................95
Established patient office visits (codes 99211–99215) .....................................................101
Consultation office visits (codes 99241–99245) ..............................................................105
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Chapter
1
Choosing an E/M code
For the purposes of this book, we will focus on the following three physician-office-visit E/M
code categories:
• 99201–99205 (new patient): Codes in this category identify E/M services that providers
render to a new patient, meaning one who has not been seen by a provider who bills with
that practice’s tax identification number or one who has not been seen in the past three
years. Consider as new an established patient who presents for a visit after three years.
• 99211–99215 (established patient): Codes in this category identify services that providers
render to an established patient, meaning one who has already been seen at the practice (in
the same specialty) within the past three years.
• 99241–99245 (consultation): Codes in this category identify services that consulting
providers render to patients after another provider has requested their specialized opinion.
NOTE THAT ALTHOUGH CHAPTER 1 WALKS YOU THROUGH HOW TO ASSIGN AN E/M CODE, WE
HAVE ALSO PROVIDED SUPPLEMENTAL CHAPTERS THAT EXPLAIN THE REQUIREMENTS FOR EACH
LEVEL OF SERVICE. THIS INFORMATION IS LOCATED IN THE
ON THE
“SUPPLEMENTAL CHAPTERS” FOLDER
CD-ROM. REFER TO THE BACK OF THE BOOK FOR SAMPLE MEDICAL RECORDS TO USE
WHEN READING THESE SUPPLEMENTAL CHAPTERS.
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Chapter 1
E/M code components
The following seven components contribute to assigning a specific E/M code within each
code category:
• History
• Exam
• Medical decision-making (MDM)
• Counseling
• Coordination of care
• Nature of presenting illness
TIP
• Time
Providers and auditors often refer to the history, exam, and MDM components as the
three key components because they largely help determine the level of service.
History
A patient’s history consists of the following four subsections, each of which an auditor must review
during an audit:
• chief complaint (CC)
• history of present illness (HPI)
• review of systems (ROS)
• past, family, and social history (PFSH)
CC
The CC is the explanation or brief statement as to why the patient presented to the office. CMS documentation guidelines require the medical record to clearly reflect the CC. As an auditor, look for
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words that address a condition, previous diagnosis, symptom, or other reason the patient may have
presented for the visit.
TIP
Note that providers should NOT document “patient in for follow-up” or “patient returns
today” as the CC. When possible, they should document exactly what the patient identifies as the reason for presenting to the office. For example, “Patient in today for followup for blood pressure check” is acceptable.
HPI
The HPI is a description of how the patient developed his or her present illness, starting with the first
sign/symptom. The HPI can be either brief (i.e., one to three factors) or extended (i.e., four or more
factors), depending on the number of descriptors the provider includes in his or her documentation.
HPI descriptors can include the following:
• Associated signs and symptoms: Other signs/symptoms that accompany the main symptom
• Location: Site of the problem/symptom
• Quality: Description or characteristics of the problem/symptom
• Severity: Intensity, degree, or measure of the symptom
• Duration: Length of time the problem/symptom has existed
• Timing: Regularity of occurrence, when the problem or symptom occurs
• Context: Events surrounding the symptom
• Modifying factors: Actions attempted that may relieve/exacerbate/not impact the symptom
Consider the following documentation example that highlights several HPI descriptors.
E X A M P L E
“Mrs. Jones is here today for intense pain in her right upper quadrant (RUQ) that
started rather suddenly just after eating a burger and fries for lunch. She took
TUMS®, which did not give her any pain relief.”
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The underlined words and phrases in the example help identify the following four descriptors, thus
categorizing this example as an extended HPI:
• Intense = Severity
• RUQ = Location
• After eating = Context
• Took Tums = Modifying factor
FOR MORE INFORMATION ON THESE DESCRIPTORS, SEE THE HPI REFERENCE TOOL IN THE “TOOLS”
FOLDER ON THE ACCOMPANYING CD-ROM.
ROS
A provider performs a ROS to take inventory of the patient’s body systems and better define the
problem, clarify the diagnosis, identify any necessary tests, or define a baseline. To perform a ROS,
the provider asks the patient/guardian a series of questions—either verbally or via a form—that
addresses one or more of the following body systems:
• Constitutional
• Eyes
• Ears, nose, mouth, throat (ENT)
• Cardiovascular
• Respiratory
• Gastrointestinal (GI)
• Genitourinary (GU)
• Musculoskeletal
• Integumentary (skin/breasts)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic
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FOR MORE INFORMATION ON THESE SYSTEMS, SEE THE ROS REFERENCE TOOL IN THE “TOOLS”
FOLDER ON THE ACCOMPANYING CD-ROM.
Depending on how many systems the provider reviews, the ROS will be pertinent (i.e., one system
reviewed), extended (i.e., at least two systems reviewed), or complete (i.e., at least 10 systems reviewed).
A complete ROS requires the provider to note the pertinent positive and negative findings for 10 or
more systems, or review all systems and document positive and negative findings. A provider can also
document one or more pertinent positive and negative findings and also include the statement “all
other systems negative.”
For example, “No fever, no vomiting, wet cough, restless while sleeping; all other systems negative”
would meet the criteria for a complete ROS; the provider documented the pertinent positive and
negative findings and reviewed all of the remaining systems and deemed them negative.
If the provider had only documented “all other systems negative” or “all systems negative,” this
would not support any level for an ROS. At a minimum, the provider must document one system,
in addition to stating “all other systems negative” to justify a complete ROS.
Because anyone—including office staff, family members, the patient, or the provider—can obtain an
ROS, some providers choose to use a form that the patient fills out to collect the information. Other
times, a nurse or other provider may obtain the information. When this is the case, the provider must
always document that he or she reviewed the information and sign and date the record.
Note that “all other systems negative” implies that the provider reviewed all 14 systems
TIP
and that each system was negative. Watch for providers who excessively document “all
other systems negative.” For example, when a patient presents with a sore throat and the
provider documents the pertinent positive and negative findings and then adds the statement, “All other systems negative,” question whether the provider actually reviewed all
14 systems and whether his or her services were medically necessary.
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Consider the following documentation example:
E X A M P L E
“Patient states she is having a difficult time sleeping and has recently lost seven
pounds without dieting. She no longer has the night sweats that she mentioned
during her last visit. She no longer has joint/muscle aches. I reviewed her history
form in the chart and signed and dated it today.”
The underlined words/phrases above help identify the following systems reviewed:
• Difficult time sleeping = Constitutional
• Weight loss = Constitutional
• Night sweats = Endocrine
• Joint muscle aches = Musculoskeletal
Only count each system once, despite the number of times the provider reviews that particular system. In this example, credit three systems and classify this as an extended ROS. If the provider had
also stated, “I also reviewed remainder of the ROS and found everything to be negative/unchanged
other than what was documented above,” credit the provider with a complete ROS for this note.
PFSH
The PFSH is an overall look at the patient’s past medical history, as well as any social or familial
factors that might influence his or her present condition. There are three elements of the PFSH:
1. Past history: Information about past injuries, operations, allergies, illnesses, current
medications, etc.
2. Social history: Information about the patient’s social habits, such as use of drugs/
alcohol/tobacco, marital status, etc.
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3. Family history: Information about medical events in the patient’s family, such as diseases that
may be hereditary or place the patient at risk.
Note that no patient history can be “unremarkable” or “negative.” The following examples would
not support a PFSH:
• Past medical history: Negative
• Social history: Negative
• Family history: Unremarkable
However, when a provider documents “no known drug allergy,” this would count as a history element under past medical history because it shows that the provider actually evaluated the patient and
did not find any allergies.
If the provider cannot obtain the history information needed for a particular level of service, that
provider must state why he or she could not obtain the information. For example, the patient might
be a child, be comatose or unable to talk, or have dementia.
There are two types of PFSH:
1. Pertinent. According to the 1995 and 1997 guidelines, a pertinent PFSH is a review of the
history area(s) directly related to the problem(s) identified in the HPI. The physician must
document at least one specific item from any of the three history areas.
2. Complete. A complete PFSH is one in which the physician reviews two or all three of the
PFSH history areas, depending on the category of the E/M service. Services that include a
comprehensive assessment/reassessment of the patient by their nature require the physician
to review all three history areas. A review of two of the three history areas is sufficient for
other services.
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Chapter 1
Overall extent of the history
Once you determine the CC, HPI, ROS, and PFSH, determine the overall history level. The exam
will fall into one of the following history levels:
• Problem-focused: CC, brief HPI
• Expanded problem-focused: CC, brief HPI, problem-pertinent ROS
• Detailed: CC, extended HPI, problem-pertinent ROS extended to include a review of a
limited number of additional systems, pertinent PFSH directly related to patient’s problems
• Comprehensive: CC, extended HPI, ROS directly related to the patient’s problem(s) as
identified in the HPI, as well as a review of all additional body systems, complete PFSH
TIP
The provider does not need to repeat the ROS and PFSH during each visit of an established
patient. Instead, he or she should document reviewing the forms and finding no change
since the previous visit on a particular date of service. When there has been a change, the
provider should document that change and then sign/date the ROS and identify the location
of that information.
Keep the following points in mind regarding a patient’s history:
• The provider must document the CC and HPI.
• When the provider does not personally document the ROS or PFSH, he or she must still state
that he or she reviewed the information and sign/date the forms or the area where the information is documented in the record. For an electronic medical record, the provider must refer
to the specific note using the date of service and location of the note, as well as document
any changes from previous visits.
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Time
Time refers to the total time the provider spends with the patient during the visit. In certain circumstances, time will be the key controlling factor in determining the level of service. To bill based
on time in the practice setting, the provider must spend face-to-face time with the patient.
When more than 50% of the care provided is devoted to counseling/coordination of care, a provider
can bill based on time spent. The provider must document the following:
• Total length of the patient encounter
• Amount of the total time spent counseling/coordinating care for the patient
• Any relevant history, exam, and MDM discussed with the patient
Consider these examples of proper time-based billing:
EXAMPLES
• “Today’s visit was 30 minutes in length and more than half of the visit was
spent discussing treatment options for managing migraines, as stated above.”
• “Today’s visit was 20 minutes in length, all of which was spent discussing
birth control options.”
• “I spent a total of 25 minutes with the patient, 15 minutes of which was spent
coordinating treatment options for his chronic lower back pain.”
• “Today’s consultation was 45 minutes in length, and more than 30 minutes
were spent discussing surgical options for her torn meniscus.”
Exam
The requirements for the exam depend on whether the provider uses the 1995 or the 1997 guidelines.
Note that the CD-ROM provides an in-depth discussion of how to level various scenarios for new
patients, established patients, and consultations using the 1995 versus the 1997 guidelines. This
information is located in the “Supplemental chapters” folder on the CD-ROM.
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Chapter 1
There are four types of exams:
1. Problem-focused—The provider performs a limited exam of the affected body
area/organ system
2. Expanded problem-focused—The provider performs a limited exam of the affected body
area/organ system and other symptomatic or related systems
3. Detailed—The provider performs an extended exam of the affected body area and other
symptomatic or related systems
4. Comprehensive—The provider performs a general multisystem exam or a complete exam
of a single organ system
Using the 1995 guidelines
The 1995 guidelines require the provider to review specific organ systems. These guidelines can be
followed for one of the following types of exams:
• Constitutional
• Eyes
• ENT
• Lymph
• Respiratory
• Cardiovascular
• GI
• GU
• Musculoskeletal
• Skin
• Neurological
• Psychiatric
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Using the 1995 guidelines, exam types are broken down as follows:
• Problem-focused: The provider must examine and document one organ system related
to the problem
• Expanded problem-focused: The provider must examine and document two to seven
additional systems
• Detailed: The provider must examine and document two to seven additional systems
and include detailed descriptions of least one organ system
• Comprehensive: The provider must examine and document eight organ systems
Using the 1997 guidelines
The 1997 guidelines differ from the 1995 guidelines in that the 1997 guidelines require providers to
document a certain number of bullets to support the exam’s level. The 1997 guidelines also give
providers the option of performing a general multi-system exam or a specialty-specific exam—also
known as the single-organ system exam.
A provider can use the 1997 guidelines for the following single-organ exam types:
• General multisystem
• Cardiovascular
• ENT
• Eye
• GI
• Hematologic/lymphatic/immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin
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According to the 1997 guidelines, the single-organ system exam and general multi-system exam each
require the following number of bullets per level:
• Problem-focused: 1–5 bullets
• Expanded problem-focused: 6–11 bullets
• Detailed: 12–17 bullets
• Comprehensive: All shaded bullets > 1 bullet from each nonshaded section
FOR MORE INFORMATION, REFER TO THE SINGLE-ORGAN EXAM TEMPLATES LOCATED IN THE
“TOOLS” FOLDER ON THE CD-ROM.
Keep in mind that eye and psychiatric exam types require fewer bullets for each of the four levels.
Refer to the 1997 guidelines for a detailed breakdown for each level.
The 1995 and 1997 guidelines also differ in that the 1997 guidelines allow a provider to document
the status of chronic or inactive conditions to help support the level of history. The 1995 guidelines
do not allow this option.
FOR A COMPLETE LIST OF BULLETS FOR THE GENERAL MULTI-SYSTEM EXAM, SEE THE GENERAL
E/M AUDIT TOOL LOCATED IN THE “TOOLS”
FOLDER ON THE CD-ROM.
MULTI-SYSTEM EXAM FORM THAT IS PART OF THE
Counting bullets
Auditors often disagree on when to count bullets because they each come from different backgrounds
and different ways of thinking. When counting a bullet, it is important to be able to justify why you
counted that bullet and/or quantity of bullets for a system/body area.
For example, you may wonder how many bullets to count when the doctor writes, “Joints normal.”
Some auditors only count two bullets because the word “joints” is plural, which means at least two.
Some count four because there are four limbs. Others might count five to include the neck. This is
an example of one of the many gray areas you may encounter when using the 1997 guidelines.
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Remember that just because another auditor might count something differently doesn’t necessarily
mean that your counting method is incorrect.
Keep in mind, however, that one bullet can mean the difference between exam levels. It is common
for auditors to say to physicians, “If you had only documented auscultation of the lungs, you would
have met the criteria for a detailed exam.” That provider might respond with, “I always listen to the
lungs, especially on this type of patient with a history of asthma.” This highlights the importance of
providers documenting everything they do, no matter how implicit or obvious it may seem to them.
Consider these two other examples of scenarios in which items that physicians examine—but rarely
document—could affect the exam’s level:
Example 1: When a provider looks in the ear at the tympanic membrane, he or she usually also looks
at the ear as well. If the provider documented looking at the ear and also documented appearance,
scars, lesions, masses, etc., this would count as a bullet under “external inspection of ears and nose.”
Example 2: When a provider looks at the throat, he or she usually also examines the lips, teeth, and
gums. Documentation that the provider performed these tasks would count as a bullet under “inspection of lips, teeth, and gums.”
Templates or checklists
CMS currently allows providers to use exam templates and checklists; however, they must use
them with caution. When used incorrectly, templates can actually affect a provider’s E/M level
assignment. When using templates or checklists, the provider should remember to document specific
abnormal and relevant findings of the examination and affected or symptomatic body area(s) or
organ system(s).
Providers should also describe abnormal and unexpected findings of any asymptomatic body
area(s) or organ system(s). Providers can document normal findings with a brief statement or
notation indicating “negative” or “normal.” For example, if a provider checks a box next to or
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Chapter 1
circles auscultation of lungs and indicates normal, it means the provider listened to the lungs and
heard nothing abnormal; this would be acceptable documentation.
It is unacceptable for a provider to document on an exam template, checklist, or dictated documentation that any organ system or body area is “abnormal” and receive credit for this in the exam. For
example, if the provider only checks a box or dictates auscultation of lungs abnormal—but does not
elaborate on what is abnormal for that system or body area—this is not sufficient.
When used appropriately, templates are good tools for any practice. Templates help promote the consistency of clinical care and documentation within a practice. They also help simplify the coding
process and encourage appropriate code assignment.
MDM
MDM involves the consideration of the
• number of diagnoses or management options
• amount and complexity of the data to be reviewed
• risk of complications, morbidity, and/or mortality
Number of diagnoses or management options
This number refers to the problems that the provider addresses on a particular date of service. An
auditor should ask the following questions when reviewing physician documentation to obtain this
information:
• If the patient presents with an established problem, did the provider document that the problem remained the same, became better, worsened, or did not respond to treatment as expected?
• Did the patient have a problem that the caregiver never addressed?
• Was another provider’s opinion/advice sought?
• Did the provider change or initiate treatment?
Depending on the assessment performed, the diagnoses/management may be minimal, limited, multiple, or extensive.
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Problems that improve or are well-controlled/resolving would typically be termed minimal or limited.
If the patient presents with several problems, the number of diagnoses/management options may be
termed multiple or extensive. On the contrary, a patient can present with one problem and that could
be termed extensive or multiple because the problem is new and the provider is sending the patient
for an additional workup.
Working differential diagnoses, such as “possible,” “probable,” “rule out,” or “questionable,”
would meet the criteria of an exam of multiple to extensive complexity. The physician may also
explicitly state or imply the applicable type of diagnosis or management option in his or her documented decisions regarding management plans or further evaluation.
Amount and complexity of the data to be reviewed
This information refers to the number and complexity of tests/labs/procedures that the provider
reviewed when evaluating the patient. An auditor should ask the following questions when reviewing
physician documentation to obtain this information:
• Did the provider initial and date any tests ordered or results reviewed?
• Did the provider decide to obtain additional history from the family/other source as well as
old records?
• Did the provider encounter any relevant findings when reviewing the old records or discussing the case with the other source? Did the provider document whether he or she
discovered any findings?
• Did the provider engage in and document any conversations that he or she had with the
individuals who performed or interpreted any tests, labs, or other studies?
• Did the provider view the actual films, tracings, or specimens, and document his or her independent interpretations?
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The amount and complexity of data to be reviewed will be minimal, limited, moderate, or extensive,
depending on the assessments performed.
Regardless of how many lab tests were ordered/reviewed, the point value will always equal one (1)
when ordering/viewing the same type of test.
For example, when a provider orders an x-ray and a magnetic resonance imaging (MRI), this only equals
one point because they are both radiology tests. However, when a provider orders a complete blood count
(CBC) and an MRI, this equals two points because the CBC is lab test and the MRI is a radiology test.
TIP
Some carriers may use points to level the amount and complexity of data reviewed as well
as the number of diagnosis or management options. Contact your carrier to determine how
it calculates MDM.
Risk of complications, morbidity, and/or mortality
Risk of complications, morbidity, and/or mortality cannot be determined by bullet points. Instead, it
is based on the level of risk of complications of the presenting problem, the diagnostic procedures
ordered, and/or the management options selected for the patient.
Ask the following questions when reviewing physician documentation to obtain this information:
• Were there any illnesses or sicknesses that could affect the complexity of the problem being
worked up?
• Did the provider document any risk factors?
• Did the provider schedule a surgery or diagnostic procedure on the same date of service? If so,
is the planned surgery major or minor? Did the provider document any associated risk factors?
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• Is the patient taking medications? If so, are they over-the-counter or prescription? Who
manages them?
• Is the problem chronic or acute?
• Did the documentation portray a mild or severe exacerbation of the patient’s issue(s)?
• Did the patient have an abrupt change in neurological status, such as a seizure?
Risk of complications, morbidity, and/or mortality will be minimal, low, moderate, or high,
depending on the assessment performed.
Always level to the highest risk. If a patient has a cold and the physician does not prescribe any
drugs or order any procedures, this is a minimal risk. If a provider offers cardiovascular imaging with
contrast, this is a moderate risk. If the physician does not order the diagnostic procedure, the risk
may still be moderate, depending on the scenario.
Whether the patient complies with the provider’s orders does not affect the level of risk. What matters is the work the provider did and the clinical decision-making performed to determine what types
of treatment should be carried out for the patient. The more acute the presenting problem or the
greater the risk of diagnostic procedures/management options, the higher the overall level of risk.
TIP
Providers should document everything they do and think while seeing a patient. Although
much of what a provider does might be inherent to that provider, revenue could be lost if the
provider does not clearly state the rationale for his or her actions. A coder and auditor can
only determine an E/M level from information clearly provided in the documentation.
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Chapter 1
Overall MDM level
Once you determine the number of diagnoses/management options, amount/complexity of the data
to be reviewed, and the risk of complications, morbidity, and/or mortality, determine the overall
MDM level. Chapter 4 explains how to determine whether the overall MDM is either straightforward, low complex, moderate complex, or high.
Consultations
A consultation occurs when a provider refers a patient to another physician who can render a specialized opinion. After the consulting provider renders his or her service to the patient, that provider
must send a report containing opinions and suggestions for treatment options back to the referring
provider. In the practice setting, the code range 99241–99245 designates consultations.
Coders, auditors, and providers often refer to the following three Rs when discussing consultations:
• Request: This refers to a written or verbal request for a consult. The referring provider or
other appropriate source makes this request and documents it in the patient’s medical record.
• Render: The consulting provider renders and documents his or her opinion—as well as any
services ordered and performed—in the patient’s medical record.
• Report: The consulting provider composes a written report and sends it back to the
requesting provider or other appropriate source.
Note that insurance carriers pay more for a consultation visit than for a new patient visit because—
although the criteria for each level of a consultation and a new patient visit are the same—a consulta-
TIP
tion usually requires more of the physician’s time and involvement.
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If the requesting provider is within the same practice/group as the referring provider and
has access to the same shared medical record, the consulting provider does not need to
send a written report back to the requesting provider.
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Consultation documentation requirements
The consulting provider’s documentation will determine whether an encounter can be classified as a
consultation. If the encounter is not documented as a consultation, it might fall into one of the following three categories:
1. Transfer of care: This type of visit occurs when a provider requests that another provider
take over/manage the patient’s complete care for the condition. The provider surrendering
care does not expect to continue caring for the patient for that particular condition after
transferring the patient. For example, when a provider begins by stating, “Thank you for
referring Mrs. Jones to me,” this is most likely a transfer of care and not a consultation.
However, if a provider states, “Dr. Smith has asked me to consult with this patient regarding
surgical options,” this encounter is most likely a consultation, assuming the remainder of the
note supports a consult and it is clear that the consulting provider rendered his or her
advice/opinion back to Dr. Smith.
2. Consultation followed by treatment: This type of visit occurs when a provider renders a
consult, and during the initial consultation, initiates diagnostic services/treatment. Report
the appropriate subsequent visit E/M code (rather than the consultation E/M code) for
future visits that the patient has with the consulting provider.
3. Preoperative clearance: This type of visit occurs when a surgeon requires preoperative clearance. For example, a surgeon may refer a patient back to his or her primary care provider to
determine whether the patient can undergo surgery while on blood pressure medication for
diabetes. Report this type of visit as a consultation when the primary care provider documents
the appropriate requirements and the visit is medically necessary (not a routine screening).
NOTE THAT WE HAVE INCLUDED AN OUTPATIENT VISIT TEMPLATE ON THE CD-ROM THAT YOU CAN
USE AS A QUICK REFERENCE GUIDE WHEN ASSIGNING AN E/M CODE. THIS DOCUMENT IS LOCATED
IN THE “TOOLS” FOLDER.
Auditing Evaluation and Management Coding
©2006 HCPro, Inc.
19
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