SECTION 5 - DOCUMENTATION OF EVALUATION AND MANAGEMENT ...hsc.usf.edu/NR/rdonlyres/D4696149-1020-455C-8FEB-9DEEC0BBF… · Web viewDOCUMENTATION OF EVALUATION AND MANAGEMENT SERVICES

File Code Number: 05.08

DOCUMENTATION OF EVALUATION AND MANAGEMENT SERVICES

(See 1998 HCFA Documentation Guidelines for Evaluation and Management services)

In 1997 the Health Care Financing Administration (HCFA) introduced new guidelines for Evaluation and Management (E/M) services with the intent of clarifying the specific exam elements required for each level of exam. These new guidelines resulted in confusion and are currently under reconsideration. Because of the pending resolution, HCFA currently honors both the "new" 1998 and the prior guidelines published in 1994, whichever is most advantageous to the physician. The only difference between the 1994 and 1998 guidelines are in the HPI section of the History component and the Exam component. HCFA considers the 1998 guidelines to be the appropriate supportive detail for the various exam levels.

The College expects sufficient detail in the medical records to accurately both define the need for and describe the care provided to patients. The detail must be sufficient to support the level of service submitted for billing. The 1994 guidelines will be used as the College minimum standard in conducting internal reviews. The 1998 guidelines should be used as illustrative examples of how to appropriately document the exam component. Documentation templates may be used as an aid in meeting the guidelines.

WHAT IS CONSIDERED AN EVALUATION AND MANAGEMENT SERVICE

Evaluation and Management (E/M) services are services performed with the purpose of evaluating or managing the patient's care. E/M services describe the nature and amount of physician work and documentation. E/M services are categorized by place of service (such as physician's office, hospital, nursing facility, home); or type of service (such as office visits, consultations, critical care, care plan oversight); or patient status (such as new patient, established patient, or newborn).

SELECTION OF THE APPROPRIATE LEVEL OF E/M SERVICE

Documentation of E/M services should follow the general principles (pg. 5) and address the established components needed for coding the services for billing purposes. Simply stated, it is the documentation that determines what may appropriately be billed. The descriptors for the levels of E/M services recognize seven components. The first three (history, examination, and medical decision making) are considered the KEY components in selecting a level of E/M service. The next three (counseling, coordination of care, and nature of presenting problem) are considered contributory factors in the majority of encounters. The final component is time, which is discussed in Time/Coordination of Care (pg. 56).

1USF COM Standards of Conduct & Policies Section 5 - Documentation, Coding, and Billing of Healthcare Services, Revised April 2000Documentation of Evaluation & Management Services


KEY COMPONENTS (CPT codes 99201 - 99215, 99218 -99236, 99241 - 99285, 99301 - 99313, and 99321 - 99350)

Each of the three components are comprised of various parts and/or elements of documentation as shown below:

HISTORY

History is comprised of four parts: chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family and social history (PFSH).

CC is defined as a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words. The chief complaint is required for all E/M services. If the Chief Complaint is documented by anyone other than the physician such as ancillary staff, the physician must restate the chief complaint in his/her documentation.

HPI is a chronological description of the development of the patient's present illness from the first sign/or symptom or from the previous encounter to the present. There are eight recognized descriptive elements that constitute the HPI which are listed below with examples of each in parentheses.

1. Location - Specifically where in/on the body the signs/symptoms occurred (right, left, upper, lower, posterior, anterior, distal, proximal, 3rd digit);

2. Quality - An adjective qualifier of the type of sign/symptom, usually not measurable in degrees (sharp, cramping, stabbing, throbbing, hot, shooting, crushing);

3. Severity - An adjective qualifier describing the degree of severity or intensity (pain scale 1-10, worst, improving, unable to…, severe, moderate, fell 6 feet);

4. Duration - From what starting point is the onset of they sign/symptom? (2 days, 1 hour, since yesterday, until today);



5. Timing - Indication of the number of occurrences or frequency of the sign/symptom (increase, decrease, constancy) within the duration (2x, daily, constant, intermittent, sporadic, frequent, 30 minutes after);

6. Context - The who/what/when/where/why/how of circumstances precipitating or surrounding the event of the sign/symptom that does not change the event (occurred at.., during.., while.., insidious onset, fell from porch);

7. Modifying factors - What medication or action was taken to attempt to change the sign/symptom, what helped or did not help? (exacerbated by, relieved by, worsens when, not affected by, took with no relief); and

8. Associated signs and symptoms - What other signs/symptoms does the patient have at presentation? (nausea with vomiting, head injury - no LOC, pain in right arm and shoulder)

For billing, the HPI must be documented by the physician and is categorized as either Brief (1 to 3 elements) or Extended (at least 4 elements). If using the 1998 HCFA Documentation Guidelines, an Extended HPI is expanded to include at least 4 elements or the status of at least 3 Chronic or inactive conditions.

ROS is an inventory of body systems obtained through a series of questions seeking to identify signs/symptoms which the patient may be experiencing or has experienced. There are14 recognized systems which constitute the ROS which are listed below with examples of each in parentheses.

1. Constitutional symptoms (weight change, weakness, fever, fatigue, chills);

2. Eyes (vision, pain, redness, excessive tearing, double vision, glaucoma, cataracts, decrease in visual acuity);

3. Ears, Nose, Mouth, Throat (recent decrease in hearing, tinnitus, vertigo, earaches, infection, discharge, frequent colds, nosebleeds, sinus trouble, sore throats, difficulty swallowing, hoarseness);

4. Cardiovascular (high blood pressure, rheumatic fever, murmurs, chest pain/discomfort, palpitations, dyspnea, orthopnea, edema, recent EKGs or heart tests);

5. Respiratory (cough, sputum shortness of breath, pain on inspiration, hemoptysis, wheezing, asthma, bronchitis, emphysema, pneumonia, pleurisy, recent chest x-ray);

6. Gastrointestinal (difficulty swallowing, heartburn, nausea, vomiting, diarrhea, constipation, melena, hematochezia, rectal bleeding, abdominal pain, jaundice);

7. Genitourinary (hematuria, frequency, urgency, retention, discharge, sores, lumps, LMP, regularity of period, dysmenorhea, menopausal symptoms, complications of pregnancy, birth control, recent pap smears);

8. Musculoskeletal (muscle or joint pain, stiffness, arthritis, backache, swelling, redness, tenderness, weakness or limit of motion or activity);

9. Integumentary (Skin)/Breasts ( rashes, itching, lumps, sores, dryness, color change, change in hair or nails, pain, nipple discharge, recent mammograms);



10. Neurological (dizziness, fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, difficulty walking, dysphasia);

11. Psychiatric (nervousness, tension, mood change including depression, memory);

12. Endrocrine (diabetes, thyroid disease, excessive sweating, excessive thirst, heat or cold intolerance);

13. Hematologic/Lymphatic (anemia, easy bruising, liver or gallbladder problems); and

14. Allergic/Immunologic (immunizations, allergies, HIV testing)For billing, the ROS is categorized as either Problem pertinent (pertinent positive and negative responses for the system related to the problem), Extended (pertinent positive and negative responses for 2 to 9 systems), or Complete (pertinent positive and negative responses for 10+ systems). Documentation such as "all other systems unremarkable" may be made after the documentation of at least 2 systems to infer that all remaining systems were reviewed and no significant findings were noted. In these cases the ROS is considered "Complete" for billing purposes.

PFSH is a review of one to three areas. The patient's: Past History (experiences with illness, operations, injuries, and treatments); Family History (medical events including diseases which may be hereditary

or place the patient at risk); and/or Social History (age appropriate review of past and current activities).

PFSH is not necessary for interval histories (subsequent hospital care, follow-up inpatient consults, and subsequent nursing home care). For billing, the PFSH is categorized as either Pertinent (1 item from any 1 area) or Complete (1 item from any 2 areas for established patients, and 1 item for all 3 areas for new patients and initial consults).

The ROS and/or PFSH may be recorded by ancillary staff, a student, the patient, or a patient representative. However, the physician must document his/her review of the information and make a note supplementing or confirming the information recorded by others for such information to be considered for billing purposes.

For example, a medical student interviews the patient and completes a new patient history form that captures the patient's ROS and PFSH. The physician reviews this form with the patient and documents "reviewed NP history form with patient and no changes noted ".

A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated, if appropriate, the previous information. The review and update may be documented by noting the date and location of the earlier ROS and/or PFSH and describing any new information or noting there has been no change. (See Appendix B -- Example 1)



The extent of HPI, ROS, and PFSH that is obtained and documented is dependant upon clinical judgement and the nature of the presenting problem.

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition (poor historian, incapacitated, treatment urgency) or other circumstance that precludes obtaining a history. In this situation, the history would be considered Comprehensive. (See Appendix B -- Example 2)

The History component has been categorized into four levels: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive. In addition to the Chief Complaint, the three elements described above (HPI, ROS, PFSH) must be met or exceeded to support a specific level of History. (Refer to History table on pg 5. of Appendix A).

EXAMINATION (EXAM)

Exam is the physical examination of the patient by the physician. This is the primary area where the 1994 and 1998 documentation guidelines differ. Again, either guideline may be used. However, HCFA considers the 1998 guidelines to be superior in providing supportive exam detail. The type (multi-system vs. single system) and content of the exam are selected by the examining physician and are based upon clinical judgement, the patient's history, and the nature of the presenting problem. The physician need not specify in the documentation which guideline (1994 vs. 1998) is being used however the content of the documentation must clearly support one.

The 1994 HCFA Documentation Guidelines recognize 7 body areas and 10 organ systems for the purposes of defining the various levels. The body areas are: Head, including face; neck; chest, including breasts and axilla; abdomen; genitalia, groin, buttocks; back; and each extremity. The organ systems are: eyes; ears, nose, mouth and throat; respiratory; cardiovascular; GI; GU; musculoskeletal; skin; neurologic; psychiatric; hematologic/lymphatic/immunologic. For billing, the content of the exam is categorized into four levels:

1. Problem Focused- a limited exam of the affected body area/organ system (1 body area or system);

2. Expanded Problem Focused - a limited exam of the affected body area/organ system and any other symptomatic or related body area(s)/organ system(s) (2-4 systems including the affected area);

3. Detailed - an extended exam of the affected body area(s)/organ system(s) and any other symptomatic or related body area(s)/organ system(s) (5-7 systems including the affected area); and



4. Comprehensive - a general multi-system exam or complete exam of a single organ system and other symptomatic or related body area(s)/organ system(s) (8 or more systems).

The 1998 HCFA Documentation Guidelines categorize the exam into two types: General Multi-system and Single Organ System. Any physician, regardless of specialty, may perform either a General Multi-System or one of the following Single Organ System exams: Cardiovascular; Ears, Nose, Mouth and Throat; Eyes; Genitouinary (female); Genitourinary (male); Hematologic/Lymphatic/Immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin.

Each level of exam identifies a number of elements in a specific body system/area(s) that must be performed and documented. Specific abnormal and relevant negative findings of the exam of the affected or symptomatic body system/area(s) should be documented. A notation of "abnormal" without elaboration is insufficient. Abnormal or unexpected findings of the exam of any asymptomatic body system/area(s) should also be described. A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings relative to unaffected organ system/area(s). In addition, a statement should be made explaining why any required elements were not performed (i.e. "does not apply for age of patient").

The content and documentation requirements for each type and level of exam are summarized in detail in the HCFA Guidelines (Refer to pgs. 11 - 41 of Appendix A ).

MEDICAL DECISION MAKING

Medical Decision Making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the Number of diagnoses or management options to be considered; the Amount and/or complexity of data (medical records, diagnostic test, and/or other information that must be obtained, reviewed and analyzed); and the Risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

Number of diagnoses or management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. For each encounter, documentation should include: An assessment, clinical impression, or diagnosis (may be explicitly stated or

implied in documented management plans). Established diagnosis should reflect a.) improved, well controlled, resolving or resolved; or, b.) inadequately controlled, worsening, or failing to change as expected.

The initiation of, or changes in, treatment (patient instructions, nursing instructions, therapies, and medications)

Referrals and/or consultations requested or advice sought (to whom or where)



There are four levels of Number of diagnosis/management options: Minimal (one); Limited (two); Multiple (three); Extensive (four or more).

Amount and/or Complexity of Data to be Reviewed is based on the types of diagnostic testing ordered or reviewed; a decision to obtain and review previous medical records and/or obtain history from sources other than the patient; and any discussion of contradictory or unexpected test results with the physician who performed or interpreted the test. Documentation should include: the type of diagnostic services ordered, planned, scheduled, or performed at

the E/M service review of diagnostic tests decision to obtain previous medical records or relevant findings from review

of these records ( "old records reviewed" or "additional history obtained from family" without elaboration is insufficient)

direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician

results of discussion of lab, radiology or other diagnostic test with the physician who performed or interpreted the study

There are four levels of Amount/Complexity of Data to be Reviewed: Minimal (one); Limited (two); Moderate (three); Extensive (four or more).

Risk is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. Documentation should include: comorbidities/underlying diseases or other factors that increase the complexity

of MDM by increasing the risk of complications, morbidity, and/or mortality type of surgical or invasive diagnostic procedure ordered, planned, or

scheduled at E/M encounter specific surgical or invasive diagnostic procedure performed at the time of

E/M encounter referral for a decision to perform a surgical or invasive diagnostic procedure

on an urgent basisThe risk of the presenting problem is based on the risk related to the disease process anticipated between the present encounter and the next one. The 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 (minimal, low, moderate, high) in any one category (presenting problem, diagnostic procedure, or management options) determines the overall risk. Because the determination of risk is complex and not readily quantifiable, a table of risk containing common clinical examples was included in HCFA's Documentation Guidelines. (Refer to the Table of Risk on pg. 46 of Appendix A. )

The Medical Decision Making (MDM) component has been categorized into four levels: Straightforward, Low Complexity, Moderate Complexity, and High Complexity. Two of the three elements described above (Diagnoses or Management



Options, Amount of Data to be Review, Risk) must be met or exceeded to support a specific level of MDM. (Refer to table on pg. 42 of Appendix A).

CHOOSING THE APPROPRIATE LEVEL OF E/M SERVICE

Performance and documentation of one key component (i.e. exam) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service. The level of E/M service is dependent on the performance and documentation of a specified number of key components for that particular category of E/M service.

All three key components (history, exam, and decision) must meet or exceed the requirements for a particular level of E/M service for the following categories (in general, these are new or initial services):

Outpatient visits, new patient Hospital admissions Hospital observation Outpatient consultations Initial inpatient consultations Confirmatory consultations, outpatient or inpatient Emergency department services Comprehensive nursing facility assessments Domiciliary care, new patient Home care, new patient

Two of the three key components must meet or exceed the requirements for a particular level of E/M service for the following categories (in general, these are follow-up or subsequent services):

Outpatient visits, established patient Subsequent inpatient visits Follow-up inpatient consultations Subsequent nursing facility care Domiciliary care, established patient Home care, established patient

When the required number of key components are not met for a particular category of E/M service, the service is not billable. The service may not be billed as another category of E/M service. For example, if only an exam and decision are performed/documented for a hospital admission, this service is not billable. It may not be billed as another category such as a subsequent inpatient visit. Similarly, if only one component (i.e. exam) is performed/documented for a subsequent hospital visit it may not be billed.

Refer to the Evaluation and Management section of the CPT-4 book to assign the appropriate CPT code for the level of service for a particular category of service.



TIME/COORDINATION OF CARE

In the case where counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or outpatient setting, floor/unit time in the hospital or nursing facility), TIME is considered the key or controlling factor to qualify for a particular level of E/M services. Documentation should include the total length of time of the encounter, the length or ratio of counseling/coordination of care time, and a description of the counseling and/or activities to coordinate care. Medicare’s documentation guidelines describe counseling/coordination of care as a discussion of one or more of the following: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management or treatment options; instructions for management or treatment and/or follow-up; importance of compliance with chosen management or treatment options; risk factor reduction; and patient education. If a particular level of E/M service is supported by documenting counseling and/or coordination of care time, the three key components (history, exam, decision) need not be met at that level of service. However, the key components are a part of the basic documentation principals discussed on pg. 5 and should not simply be omitted. Dictation time or time spent obtaining, reviewing or interpretation of previous records or test results is not included in the time spent counseling or providing coordination of care.

Note: In a teaching setting, it is only the teaching physician's (Faculty MD) time spent providing the counseling/coordination of care that is recognized for billing purposes. (See IV.(c) for further clarification).

For those categories of E/M service that are driven by time, (Hospital Discharge, Critical Care, Care Plan Oversight, Physician Standby services, and Prolonged services), the time spent by the Teaching Physician (Faculty MD) providing these services must be documented to support billing the service.

SPECIAL RULES FOR CERTAIN EVALUATION AND MANAGEMENT SERVICES

CONSULTATIONS

There are two basic categories of consultation services: Consultations and Confirmatory Consultations.

Consultations are services provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician with the intent that the requesting physician will continue the care of thespecific problem. Consultations may be provided in an inpatient or outpatient setting to new or established patients. A consultation may include the



initiation of diagnostic and/or therapeutic services to help the consulting physician render his/her opinion or advice. The consulting physician may assume the care of the patient for that specific problem or entirely after his/her evaluation at the patient's or requesting physician's request, and still bill the initial visit as a consultation. The consulting physician must document the communication of his/her opinion/advice to the requesting physician. This may be done by documentation in the progress note or by sending a letter to the requesting physician. If the only documentation for the consultation is the letter to the requesting physician, it may be used to support the level of billing based only on the content detail of the letter.

In contrast, if the referring physician verbally, or in writing, transfers complete responsibility of treatment for a portion of or all of the patient's care at the time of the request for consultation, it may not be billed as a consultation. This service would then be billed as an outpatient visit or subsequent inpatient visit.

Documentation to support billing for a consultation must include the "4 R's":1. The request for evaluation from the requesting physician; 2. The reason the consultation was requested;3. The consulting physician's history, exam, and the opinion/advice

rendered; and any other services that were ordered or performed at the time of the visit to help conclude an opinion/advice; and

4. A report of communication of the advice/opinion by the consulting physician back to the requesting physician.

NOTE: Because the word "referral" has been used in the medical community when referring to a consultation, it is important that the physician's documentation clearly identify the REASON for the consultation. For example, beginning a note with, "Thank you for referring Mr. Jones. As you know, he has a cardiac condition." does not identify the reason for the consultation. But starting a note with "Thank you for referring Mr. Jones for evaluation of his atrial fibrillation." clearly identifies the reason for the consult. Another typical phrase used in the medical community is at the closing of letters. Closing a letter with “Thank you for the referral,” or “Thanks for letting me participate in the care of Mr. Jones.” does not support communication of the advice/opinion rendered by the consultant. By closing with “Thank you for letting me see Mr. X in consultation. My recommendation is…”, this element of the consultation is clearly supported.

(See Appendix B -- Example 3). If partial or total care of the patient is assumed after the consulting physician renders his/her opinion/advice, the consulting physician should document the request by the patient or requesting physician to treat the patient. In the case of inpatient consultations or at facilities where the requesting and consulting physicians use integrated medical records, it is



recognized that a separate report to the requesting physician may not occur and the consulting physician's documented evaluation is sufficient.

Confirmatory Consults may be provided in any setting to new or established patients. These are services provided by a physician whose second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure. Confirmatory consultations are requested by someone other than a physician, such as the patient, patient's family, or third party payor. A physician providing a confirmatory consultation is expected to provide an opinion and/or advice only.

Documentation for confirmatory consultations should include the request for evaluation and by whom, and the consulting physician's history, exam, and opinion/advice. (See Appendix E -- Example 4).

Any services provided subsequent to the opinion are billed at the appropriate level of visit and not as a Confirmatory Consultation.



CRITICAL CARE

Critical Care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or critical injury acutely impairs one or more vital organ systems such that the patient’s survival is jeopardized.. Critical Care is usually, but not always, given in a critical care unit. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient and, therefore, cannot provide services to any other patient during the same period of time. Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care in a teaching setting is the time spent by the Faculty physician engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. . Time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Time spent in activities that occur outside of the unit or off the floor, or time spent discussing/treating other patients may not be reported as critical care since the physician is not immediately available to the patient. Time spent waiting for tests results or waiting for the arrival of consultants is also not considered Critical Care time. Services included in reporting Critical Care are: interpretation of cardiac output measurements, chest x-rays, blood gases, gastric intubation, temporary transcutaneous pacing, ventilator management, vascular access procedures, and information data stored in computers such as ECG's, blood pressures, and hematologic data.

Documentation must state that the patient is critically ill or injured and the reason constant physician attendance is required. The time the physician spent providing Critical Care services must also be documented. Documentation may state total Critical Care time for a given date, or if not continuous, the beginning and ending times of each interval the physician provided these services. Critical Care is used to report the first 30 – 74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code. The total time the teaching physician spent providing Critical Care on a given date of service is billed in increments after the initial 30 minutes. Refer to the table in the Critical Care section of the E/M section in the CPT book for further explanation.

Note: In a teaching setting, it is only the teaching physician's time spent providing Critical Care services that is recognized for billing purposes. (See pg. 17) for further clarification).



PREVENTIVE MEDICINE SERVICES

Evaluation and management of infants, children, adolescents and adults may be preventive in nature when the patient presents with no signs/symptoms or complaints (ie. well woman exams, well child exams, school/sports physicals, routine/annual physicals). The extent and focus of the services will largely depend on the age of the patient, but includes a "comprehensive history and exam", counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures.

The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief complaint or present illness. The comprehensive exam of preventive medicine services is not synonymous with the comprehensive exam required in the key components of an E/M service. Rather, it refers to the recommended physician intervention standards set and published by preventive medicine agencies (ie. American Academy of Pediatrics; U.S. Preventive Services Task Force, CDEC Immunization Practices Advisory Committee; Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure).

Documentation for preventive services should include a comprehensive Review of Systems, Past-Family-Social History, as well as a comprehensive assessment/history of pertinent risk factors for the patient. Documentation should also include a multi-system exam, with the extent of the exam based on the patient's age and history.

If an abnormality is encountered or a pre-existing problem is addressed in the process of performing the Preventive service, and if the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, both may be billed by appending the –25 modifier to the E/M code . Although it is appropriate from a CPT perspective to report an E/M code to address a problem encountered during a preventive care service, health plans may question reimbursing for two types of service in the same encounter. Documentation must show that the problem-oriented service required performance of the key components over and above those that occurred in the preventive service. Unusual or frequent use, compared to regional data, of modifier –25 is likely to result in a focused review to assure that both services actually warrant payment.

CARE PLAN OVERSIGHT

Care Plan Oversight (CPO) services involve the physician overseeing the care of the patient, yet not seeing the patient (face-to-face) during an extended period of time (i.e. 30-day period). The physician directs and coordinates the care the patient receives from other health care professionals/agencies. The patient must



be under the care of a home health agency or a hospice, or be a nursing home facility patient. The patient must also require complex or multidisciplinary care modalities and/or recurrent supervision of therapy beyond that normally provided in the pre- and post-encounter work done as part of the E/M service.

Documentation must reflect all services performed in the 30 day period and time involvement for each. (See Appendix E -- Example 5).

In order to bill CPO services, the physician must document a minimum of 15 minutes of CPO services in a 30 day period. Services of office staff (such as reviewing charts, performing diagnostic tests, making phone calls) are not considered part of the physician service. Only one provider may report CPO during a 30 period.


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SECTION 5 - DOCUMENTATION OF EVALUATION AND MANAGEMENT ...hsc.usf.edu/NR/rdonlyres/D4696149-1020-455C-8FEB-9DEEC0BBF… · Web viewDOCUMENTATION OF EVALUATION AND MANAGEMENT SERVICES