Download Elizabeth Ellis - Billing and Coding

What’s In Your Wallet?
Houston Area Nurse
Practitioners
November 4, 2016
Elizabeth Ellis DNP, RN, FNP-BC, FAANP
Pam Conrad, CMOM
Elizabeth Knight, CPC,CCSPC, CMC,CMOM,CMIS
Disclosures
• Dr. Ellis has no affiliations to disclose
• Elizabeth Knight has no affiliations to disclose
Objectives
• Define and discuss the key components of
basic coding, documentation, compliance,
terminology and compliance audits for the new
NP graduate
• Discuss the components and definitions of
Direct NP billing and Incident-To Billing per
CMS Rules and Regulations
Objectives Cont.
• Demonstrate the components and
application of current Evaluation and
Management 1995 & 1997 guideline
practices
• Apply and demonstrate the basic
components for documenting Welcome to
Medicare Visits
Objectives Cont.
• Discuss the basic components of monthly
productivity reports and how the NP
provider can improve their performance
Billing
• Important to document NP productivity
– Independent and Incident To Billing
• Know your employers practice
• Be knowledgeable
– Implications
– components
– risk
What Is In your Wallet?
• As a new and/or experienced NP there are
several key areas that will increase your
financial productivity
– Proper Coding-Know your Coding Team
– Proper Charting-Know your trainers
– Compliance-Know your representative
• Federal, State and Corporate
– Welcome to Medicare Visits/Annual visits
– Level IV Patient Visits
Documentation Guidelines
for
Evaluation & Management Services
Developed by:
American Medical Association
and
Centers for Medicare & Medicaid
Services (CMS/HCFA)
Documentation Guidelines
for
Evaluation & Management Services
1995
1997
1998
1999
2000
Purpose of the Medical Record
(Per CMS)
* Plan patient’s immediate treatment
* Monitor patient care over time
* Communicate with other health care
professionals for continuity of care
* Accurate and timely claims
payment
* Appropriate utilization review and
quality of care evaluations
* Collection of data for research and
education
Purpose?
What do payers want and
why?
• The site of service;
• the medical necessity and appropriateness of the
diagnostic and/or therapeutic service provided;
and,
• that services provided have been
accurately reported.
Not to pay!!!!????
Objectives of 1995
Documentation Guidelines
Guidelines should be:
• Consistent with CPT clinical
descriptors and definitions
• Widely accepted by providers and
• minimize changes in record-keeping
• Interpreted and applied uniformly
across the country
Differences in 1995 and
1997 Guidelines
• Content of general multi-system exam
defined with greater clinical specificity
• Documentation requirements for general
multi-system exam changed
• Editorial changes made in the definitions
of four types of exams
• Content and documentation requirements
defined for exam pertaining to ten organ system
Documentation Guidelines
1995/1997
Oh,No!
General Principles of Medical
Record Documentation
The medical record should be complete and legible.
The documentation of each patient encounter should
include:
– Subjective reason for the encounter and relevant
history
– Objective physical examination findings and prior
diagnostic test results
– Assessment, clinical impression or diagnosis
– Plan for care
– Date and legible identity of the observer.
General Principles of Medical
Record Documentation
• Past and present diagnoses should be
accessible
• Identify appropriate health risk factors
• Patient’s progress, response to
changes in treatment
• The CPT and ICD-10-CM codes on
CMS 1500 should be supported by the
documentation in the medical record
Select the Appropriate Level of E/M
Services Based on the Following:
• Method One: Three Key Components
History
Exam
Medical Decision Making
• Method Two: Two Key Components
• Method Three: Time
Documentation of E/M Services
• Documentation Guidelines reflect needs of
typical adult population. For certain groups
of patients, the recorded information may
vary slightly from that described here and
may have additional or modified
information:
–
–
–
–
infants
children
adolescents
pregnant women
DOCUMENTATION OF
HISTORY
Determine the Extent of
History Obtained
The extent of the history is dependent upon clinical judgement and on the
nature of the presenting problem(s). The levels of E/M services
recognize four types of history that are defined as follows:
Problem focused: chief complaint; brief history of present illness or
problem.
Expanded problem focused: chief complain; brief history of present
illness; problem pertinent system review.
Detailed: chief complaint; extended history of present illness; problem
pertinent system review extended to include a review of a limited
number of additional systems; pertinent past, family and/or social
history directly related to the patient’s problems.
Comprehensive: chief complaint; extended history of present illness;
review of systems which is directly related to the problem(s) identified
in the history of the present illness plus a review of all additional body
systems; complete past, family and/or social history.
Each type of history includes some or
all of the following elements.
• Chief Complaint
(CC)
• History of Present
Illness (HPI)
• Review of Systems
(ROS)
• Past, Family, and/or
Social History
(PFSH)
Documentation of History
• DG: The CC, ROS and PFSH may be listed as separate
elements of history, or they may be included in the
description of the history of the present illness.
• DG: A ROS and/or a PFSH obtained during an earlier
encounter does not need to be re-recorded if there is
evidence that the provider reviewed and updated the
previous information. The review and update may be
documented by:
- describing any new ROS and/or PFSH information or
noting there has been no change in the information;
and
- noting the date and location of the earlier ROS and/or
PFSH.
Documentation of History
• DG: The ROS and/or PFSH may be recorded by
ancillary staff or on a form completed by the
patient. To document that the provider reviewed
the information, there must be a notation
supplementing or confirming the information
recorded by others.
• DG: If the provider is unable to obtain a history
from the patient or other source, the record should
describe the patient’s condition or other
circumstance which precludes obtaining a history.
Documentation of History
Chief Complaint (CC)
The CC is a concise statement describing the
symptom, problem, condition, diagnosis,
provider recommended return, or other factor
that is the reason for the encounter (usually
stated in patient’s own words).
• DG: The medical record should clearly
reflect the chief complaint.
-HISTORY-
CC : “Stuffy nose”
HPI: New patient states she began having increased nasal congestion about three weeks
ago. She states the problem is sometimes quite severe and is worse when she goes
outside. She is concerned she may be developing seasonal allergies. She says the congestion
is often associated with watery eyes and can last for several hours at a time.
Medications: HCTZ 12.5 mg po qd .
PMH : is positive for hypertension
ROS
Ears, Nose, Mouth and Throat - Negative for epistaxis, sore throat or decreased hearing
Pulmonary - Negative for cough, hemoptysis, SOB
Documentation of History
Chief Complaint (CC)
“To qualify for a given
level, all three
elements of the table
must be met. A chief
complaint is
indicated for all
levels.”
Documentation of History
History of Present Illness (HPI)
The HPI is a chronological description of the development of the patient’s present
illness from the first sign and/or symptom or from the previous encounter to the
present. It includes the following elements:
- location
- quality
- severity
- duration
- timing
- context
- modifying factors
- associated signs and symptoms
Brief and extended HPIs are distinguished by the amount of detail needed to
accurately characterize the clinical problem(s).
Documentation of History
History of Present Illness (HPI)
A brief HPI consists of one to three elements of the HPI
• DG: The medical record should describe one to three
elements of the present illness (HPI)
An extended HPI consists of at least four elements of the HPI
or the status of at least three chronic or inactive conditions.
• DG: The medical record should describe at least four
elements of the present illness (HPI), or the status of at least
three chronic or inactive conditions.
1997/1995
-HISTORY-
HPI
New patient states she began having increased nasal congestion about three weeks ago. She
states the problem is sometimes quite severe and is worse when she goes outside. She is
concerned she may be developing seasonal allergies. She says the congestion is often
associated with watery eyes and can last for several hours at a time.
-HISTORYSEVERITY
LOCATION
DURATION
HPI:
HPI: New patient states she began having increased nasal congestion about three weeks
ago. She states the problem is sometimes quite severe and is worse when she goes
outside. She is concerned she may be developing seasonal allergies. She says the congestion
is often associated with watery eyes and can last for several hours at a time.
SIGNS &
SYMPTOMS
MODIFYING
FACTOR
TIMING
Documentation of History
Review of Systems (ROS)
The following systems are recognized:
- Constitutional
symptoms (eg, fever, weight loss)
- Eyes
- Ears, nose, mouth, throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
- Integumentary (skin and/or breast)
Documentation of History
Review of Systems (ROS)
• Problem
pertinent
• Extended
• Complete
Documentation of History
Review of Systems (ROS)
A problem pertinent ROS inquires about the system directly
related to the problem identified in the HPI.
• DG: The patient’s positive responses and pertinent negatives for
the system (1) related to the problem should be documented.
An extended ROS inquires about the system directly related
to the problem(s) 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.
Documentation of History
Review of Systems (ROS)
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 negative is permissible.
In the absence of such a notation, at least ten systems must
be individually documented.
-HISTORY-
ROS
Ears, Nose, Mouth and Throat - Negative for epistaxis, sore throat or decreased hearing
Pulmonary - Negative for cough, hemoptysis, SOB
2.
RESPIRATORY
1. ENMT
Documentation of History
Past, Family and/or Social History
(PFSH)
• The PFSH consist of a review of three
areas:
– Past History
– Family History
– Social History
Documentation of History
Past, Family and/or Social
History (PFSH)
• Pertinent
• Complete
Past History
A review of the patient’s past experiences
with illnesses, operations, injuries, and
treatments that include significant
information about:
–
–
–
–
–
–
–
prior major illnesses & injuries
prior operations
prior hospitalizations
current medications
allergies (e.g., drug, food)
age appropriate immunization status
age appropriate feeding/dietary status
Family History
A review of medical events
in the patient’s family that
includes significant information
about:
– the health status or cause of death of
parents, siblings, and children
– specific disease related to problems
identified in the CC or HPI and/or ROS
– disease of family members which may be
hereditary or place the patient at risk
Social History
An age appropriate review of past and current
activities that include significant information
about:
–
–
–
–
–
–
–
marital status and/or living arrangements
current employment
occupational history
use of drugs, alcohol, and tobacco
level of education
sexual history
other relevant social factors
Documentation of History
Past, Family and/or Social History
(PFSH)
A pertinent PFSH is a 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.
•
Documentation of History
Past, Family and/or Social
History (PFSH)
A complete PFSH is a review of all three
PFSH history areas.
• DG: At least one specific item from each of the
three history areas must be documented for a
complete PFSH for the following categories of E/M
services:
Office or other outpatient services, new patient; hospital
observation services; hospital inpatient services, initial care;
consultations; comprehensive nursing facility assessments;
domiciliary care, new patient; and home care, new patient.
Documentation of History
Past, Family and/
or Social History (PFSH)
A complete PFSH is of a review of
all three PFSH history areas.
• DG: At least one specific item from two
of three history areas must be documented
for a complete PFSH for the following E/M services:
Office or other outpatient services, established patient; emergency
department; subsequent nursing facility care; domiciliary care,
established patient; and home care, established patient.
-HISTORYPFSH
Medications: HCTZ 12.5 mg po qd .
PMH : is positive for hypertension
CURRENT
MEDICATIONS/
TREATMENT
ILLNESS
TWO ELEMENTS OF PAST
MEDICAL HISTORY
DOCUMENTATION OF
EXAMINATION
Documentation of Examination
The levels of E/M services are based on four types of
examination that are defined as follows:
• Problem Focused - a limited examination of the affected
body area of organ system
• Expanded Problem Focused - a limited examination of the
affected body or organ system and other symptomatic or
related organ system(s)
• Detailed - an extended examination of the affected body
area(s) and other symptomatic or related organ system(s)
• Comprehensive - a general multi-system examination or
complete examination of a single organ system
Documentation of
Examination
Exam for general multi-system and the
following single organ systems:
- Cardiovascular
- Ears, nose, mouth, & throat
- Eyes
- Genitourinary (female)
- Genitourinary (male) - Musculoskeletal
- Neurological
- Psychiatric
- Respiratory
- Skin
- Hematologic/lymphatic/immunologic
- Constitutional
Documentation of Examination
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. A notation of
“abnormal” without elaboration is insufficient.
DG: Abnormal or unexpected findings of the examination of
any 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).
Documentation of Examination
General Multi-System Exams
Problem Focused
Should include performance
and documentation
· of one to five elements
identified by a bullet ()
in one or more organ system(s)
or body area(s).
1997
Documentation of Examination
General Multi-System Exams
Expanded Problem Focused
Should include performance and
documentation
of at least six elements identified by a
bullet ()
in one or more organ system(s) or body
area(s).
1997
Documentation of Examination
General Multi-System Exams
Detailed
Should include at least six organ systems or body areas.
For each system/area selected, performance and
documentation of at least two elements identified by a
bullet () is expected. Alternatively, a detailed
examination may include performance and documentation
of at least twelve elements identified by a bullet () in
two or more organ systems or body areas.
1997
Documentation of
Examination
General Multi-System Exams
Comprehensive
Should include at least nine organ systems or body
areas. For each system/area selected, all elements of the
exam identified by a bullet () should be performed,
unless specific directions limit the content of the exam.
For each area/system, documentation of at least two
elements identified by a bullet () is expected.
1997
Documentation of Examination
Single Organ System Exams
• Problem Focused - should include performance and documentation of
one to five elements identified by a bullet (), whether in a box with a
shaded or unshaded border.
• Expanded Problem Focused - should include performance and
documentation of at least six elements identified by a bullet (),
whether in a box with a shaded or unshaded border.
• Detailed - exams other than the eye and psychiatric exams should
include performance and documentation of at least twelve elements
identified by a bullet (), whether in a box with a shaded or unshaded
border.
• Comprehensive - should include performance of all elements
identified by a bullet (), whether in a box with a shaded or unshaded
border. Documentation of every element in a box with a shaded
border and at least one element in a box with an unshaded border
is expected.
1997
Documentation of Examination
General Multi-System Exams
Constitutional - Vitals, general appearance
Eyes - Inspection, pupils, optic discs
ENT Mouth - External inspection, AC/TM, hearing,
turbinates, lips/teeth/gum, oropharynx
Neck - Neck, thyroid
Respiratory - Effort, percussion, palpation, auscultation
CV - Palpation, auscultation, carotid, femoral arteries, abd.
aorta, pedal pulses, extremity edema
Chest - Breasts, palpation
1997
Documentation of Examination
General Multi-System Exams
GI - Masses, hepatospleenomegaly, hernia, rectum, occult
blood
GU - Male/Female
Lymphatic - Neck, axillae, groin, other
Musculoskeletal - Gait, digits/nails, misalignment, ROM,
subluxation, strength/tone
Skin - Inspection, palpation
Neurologic - Deficits, reflexes, sensation
Psychiatric - Judgement, orientation, memory,
affect/mood
1997
Documentation of Single System
Exam - Cardiovascular
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION




Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Inspection of teeth, gums
and palate

Inspection of oral mucosa with notation of presence of
pallor or cyanosis

Jugular veins

Thyroid
Respiratory:

Effort

Auscultation
Cardiovascular:

Palpation

Auscultation

GI (Abdomen):

Presence of masses or
tenderness

Liver and spleen

Musculoskeletal:

Exam back w/ notation of
kyphosis or scoliosis

Exam gait w/ notation of ability to undergo exercise
testing and/or participation in exercise programs
Extremities:

Inspection and palpation of digits and nails
Skin:

Inspection and/or palpation of skin and subcutaneous
tissue
Neuro / Psych:
Brief assessment of mental status
including:
Constitutional:

Measurement of any three
(3) of the following seven
vital Signs:
Eyes:

Inspection of conjunctivae
and lids
ENT:

Neck:

Orientation to time,
place, person




Temperature
Height
Weight (may be measured and
recorded by ancillary staff)

Measurement of blood
Exam:
pressure in two or more
 Carotid arteries
extremities when
 Abdominal aorta
indicated
 Femoral arteries
Occult blood from patients who are being considered
for thrombolytic or anticoagulant therapy
Mood and affect

General appearance of patient


Pedal pulses
Extremities for peripheral edema
and/or varicosities
Assessment
of muscle
strength and
tone w/
notation of
any atrophy
and
abnormal
movements
1997
Documentation of Single System
Exam - Ear, Nose, Throat
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION
Constitutional:

Measurement of any three
(3) of the following seven
vital signs:




Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Head and Face:

Inspect head and face

Palpation and/or percussion of face w/ notation of
presence or absence of sinus tenderness
Eyes:

Ears, Nose, Mouth
and Throat:

Test ocular motility
including primary gaze
alignment
Otoscopic exam of external
 External inspection of
auditory canals and tympanic
ears and nose
membranes including pnemo Inspect nasal mucosa,
otoscopy w/ notiation of
septum and turbinates
mobility of membranes
 Inspect lips, teeth,
Assess hearing w/ tuning forks
gums
and clinical speech reception
thresholds
Neck
 Thyroid

Neck:

Respiratory:

Cardiovascular:

Lymph:

Neuro / Psych:

Inspect chest for symmetry,
expansion and/or assess
respiratory effort
Auscultation


Auscultation

Exam peripheral vascular system by
observation and palpation

Temperature
Height
Weight (may be measured and
recorded by ancillary staff)
Exam oropharynx: oral
mucosa, hard/soft
palates, tongue, tonsils
and posterior pharynx
Inspect pharyngeal
walls and pyriform
sinuses

Palpation of lymph nodes in neck, axillae,
groin and/or other location
Test cranial nerves w/
Brief assessment of mental
notation of any deficits
status including:



Orientation to time,
place, person



Exam salivary
glands
Mirror exam (adults
only) of larynx
including condition
of the epiglottis,
false vocal cords,
true vocal cords and
mobility of larynx


General appearance of patient
Assessment of ability to
communicate and quality of voice

Assessment of
facial strength

Mirror exam (adults
only) of nasopharynx
including appearance
of mucosa, adenoids,
posterior choanae
and eustachian tubes
Mood and affect
1997
Documentation of Single System
Exam - Eye
SYSTEM / BODY
AREA
Eyes:
ELEMENTS OF EXAMINATION



Neuro / Psych:
Test visual acuity
Gross visual field
testing by
confrontation
Test ocular motility
including primary
gaze alignment


Brief assessment of mental status
including:
Exam pupils and

irises including
shape, direct and
consensual reaction,
size and mophology

 Slit lamp exam of
the corneas
including
epithelium, stroma,
endothelium, tear
film
Orientation to time,
 Mood and affect
place, person
Inspect bulbar and
palpebral
conjunctivae
Exam ocular
adnexae including
lids, lacrimal glands,
lacrimal drainage,
orbits and
preauricular lymph
nodes


Slit lamp exam of
the anterior
chambers including
depth, cells, flare
Slit lamp exam of
the lenses including
clarity, anterior and
posterior capsul,
cortex, nucleus

Measure intraocular
pressures (adults and
trauma/infectious
disease-free patients)
Ophthalmoscopic exam
through dilated pupils
(unless contraindicated)
of:
 Optic discs
including size, C/D
ratio, appearance
and nerve fiber layer
 Posterior segments
including retina and
vessels
1997
Documentation of Single
System Exam - Genitourinary
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION
Constitutional:

Measurement of any three
(3) of the following seven
vital signs:




Neck:

Neck

Thyroid
Respiratory:

Effort

Auscultation
Cardiovascular:


Exam peripheral vascular system by
observation and palpation
Chest (Breasts):
Auscultation of heart w/
notation of abnormal sounds
and murmurs
[ See Genitourinary (Female) ]
GI (Abdomen):

Masses or tenderness
GU: (Male) 

Inspect anus and
perineum
GU: (Female) 
At least seven (7) of the
following eleven
elements:
Lymph:

Skin:

Neuro / Psych:
Brief assessment of mental status
including:
Presence or absence of 
hernia
Exam of genitalia
 Scrotum
including:
 Epididymides
 Testes






Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Liver and spleen


Inspect and palpation of breasts
Digital rectal exam including sphincter tone,
presence of hemorrhoids, rectal masses

Temperature
Height
Weight (may be measured and
recorded by ancillary staff)

Urethral meatus
Penis
Occult blood test
when idicated
Digital rectal
exam including:
Pelvic Exam:
 External genitalia
 Urethral meatus
 Urethra



Bladder
Vagina
Cervix
General appearance of patient



Prostate gland
Seminal vesicles
Sphincter tone, presence of
hemorrhoids, rectal masses



Uterus
Adnexa/parametria
Anus and perineum
Palpation of lymph nodes in neck, axillae,
groin and/or other location
Inspect / palpation of skin and subcutaneous tissue

Orientation to time,
place, person

Mood and affect
1997
Documentation of Single System Exam
Hematological/Immunologic/Lymphatic
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION




Constitutional:

Measurement of any three
(3) of the following seven
vital signs:
Head and Face:

Palpation and/or percussion of face w/ notation
of presence or absence of sinus tenderness
Eyes:

Inspection of conjunctivae and lids
Ears, Nose, Mouth
and Throat:


Inspect nasal mucosa,
septum, turbinates
Neck:

Otoscopic exam of external
auditory canals and
tympanic membranes
Neck

Thyroid
Respiratory:

Effort

Auscultation
Cardiovascular:

Auscultation

GI (Abdomen):

Masses or tenderness

Exam peripheral vascular system by
observation and palpation
Liver and spleen
Lymph:

Extremities:

Palpation of lymph nodes in neck, axillae,
groin and/or other location
Inspect / palpation of digits and nails
Skin:

Inspect / palpation of skin and subcutaneous tissue
Neuro / Psych:
Brief assessment of mental status
including:

Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Orientation to time,
place, person





Temperature
Height
Weight (may be measured and
recorded by ancillary staff)
Inspect teeth and gums


General appearance of patient
Exam oropharynx
Mood and affect
1997
Documentation of Single System
Exam - Musculoskeletal
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION




Constitutional:

Measurement of any three (3)
of the following seven vital
signs:
Cardiovascular:

Exam peripheral vascular system by observation and palpation
Lymph:

Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal:

Exam of gait
and station
Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Exam of joint(s), bone(s) and muscle(s) /
tendon(s) of four of the following six areas:
1)
2)
3)
4)
5)
6)
Head and neck
Spine, ribs, pelvis
Right upper extremity
Left upper extremity
Right lower extremity
Left lower extremity
Extremities:
[ See musculoskeletal and skin ]
Skin:
Inspect / palpation of skin and
subcutaneous tissue in four (4)
of the following six areas:
Neuro / Psych:



1)
2)
3)
Head and neck
Trunk
Right upper extremity



Temperature
Height
Weight (may be measured and
recorded by ancillary staff)

General appearance of patient
The exam of a given area includes:
 Inspection, percussion and/or palpation w/ notation of any
misalignment, asymmetry, crepitation, defects, tenderness, masses
or effusions
 Assessment of range of motion w/ notation of any pain, crepitation
or contracture
 Assessment of stability w / notation of any dislocation, subluxation
or laxity
 Assessment of muscle strength and tone w/ notation of any
atrophy or abnormal movements
4)
5)
6)
Left upper extremity
Right lower extremity
Left lower extremity
Test coordination
Exam of deep tendon reflexes and/or nerve stretch test w/ notation of pathological reflexes
Sensation
NOTE:
For the comprehensive level of
exam, all four of the elements
identified by a bullet must be
performed and documented for
each of the four anatomic areas.
For the three lower levels of exam,
each element is counted separately
for each body area. For example,
assessing range of motion in two
extremities constitutes two
elements.
NOTE: For the comprehensive level, the exam of all four anatomic areas
must be performed and documented. For the three lower levels of exam,
each body area is counted separately. For example, inspect/palpation of the
skin and subcutaneous tissue of two extremities constitutes two elements.
Brief assessment of
mental status including:


Orientation to time, place, person
Mood and affect
1997
Documentation of Single System
Exam - Neurological
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION



Constitutional:

Measurement of any
three (3) of the
following seven vital
signs:
Eyes:

Cardiovascular:

Ophthalmoscopic exam of optic
discs and posterior segments
Carotid arteries
Musculoskeletal:

Exam of gait and station
Extremities:
[ See musculoskeletal ]
Neuro:
Evaluation of higher integrative functions including:
 Orientation to time, place and person
 Recent and remote memory
 Attention span and concentration
 Language
 Fund of knowledge
Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity






Respiration
Temperature
Height
Weight (may be measured and
recorded by ancillary staff)

Auscultation
General appearance of patient
Exam of peripheral vascular system by
observation and palpation
Assessment of motor function including:
 Muscle strength in upper and lower extremities
 Muscle tone in upper and lower extremities w/ notation of any atrophy or abnormal movements
Test the following cranial nerves:
 2nd cranial nerve
 3rd, 4th, and 6th cranial nerves
 5th cranial nerve
 7th cranial nerve




8th cranial nerve
9th cranial nerve
11th cranial nerve
12th cranial nerve



Exam of sensation
Exam of deep tendon reflexes in
upper and lower extremities w/
notation of pathological reflexes
Test coordination (also fine motor
coordination in young children)
1997
Documentation of Single System
Exam - Psychiatric
SYSTEM / BODY
AREA
Constitutional:
ELEMENTS OF EXAMINATION

Measurement of any three (3) of the
following seven vital signs:



Musculoskeletal:

Psych:






Sitting or standing blood
pressure
Supine blood pressure
Pulse rate and regularity
Assessment of motor function including:
Muscle strength in upper and lower extremities

Muscle tone in upper and lower extremities w/ notation of any

atrophy or abnormal movements
Describe speech including: rate;
 Describe associations
volume; articulation; coherence;
 Describe abnormal or
spontaneity w/ notation of
psychotic thoughts
abnormalities
including: hallucinations;
Describe thought processes
delusions; preoccupation
including: rate of thoughts; content
w/ violence;
of thoughts; abstract reasoning;
homicidal/suicidal
computation
ideation; obsessions


Respiration
Temperature
Height
Weight (may be measured and
recorded by ancillary staff)
Exam gait and station
Describe patient’s
judgment and insight

Complete mental status
exam, including:
 Orientation to time,
place, person
 Recent and remote
memory
 Attention span and
concentration
General appearance of patient



Language
Fund of knowledge
Mood and affect
1997
Documentation of Single System
Exam - Respiratory
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION



Constitutional:

Measurement of any three (3)
of the following seven vital
signs:
Ears, Nose, Mouth
and Throat:
Neck:

Inspect nasal mucosa,
septum, turbinates
Neck
Respiratory:

Cardiovascular:

Inspect chest w/ notation of
 Assessment of

symmetry and expansion
respiratory effort
Auscultation of heart including sounds, abnormal sounds/murmurs
GI (Abdomen):

Masses or tenderness
Lymph:

Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal:

Assessment of muscle strength and tone w/ notation of any atrophy and
abnormal movements
Extremities:

Inspection / palpation of digits and nails
Skin:

Inspect or palpation of skin and subcutaneous tissue
Neuro / Psych:
Brief assessment of mental status including:





Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity

Inspect teeth and gums

Respiration
Temperature
Height
Weight (may be measured and
recorded by ancillary staff)
Exam oropharynx

Thyroid

Jugular veins

Percussion

Palpation

General appearance of patient

Auscultation
Exam peripheral vascular system by observation and palpation
Chest (Breasts):



Liver and spleen

Exam gait and station
Orientation to time, place,
person
Mood and affect
1997
Documentation of Single System
Exam - Skin
SYSTEM / BODY
AREA
ELEMENTS OF EXAMINATION



Constitutional:

Measurement of any three (3)
of the following seven vital
signs:
Eyes:

Inspect conjunctivae and lids
Ears, Nose, Mouth
and Throat:
Neck:


Inspect lips, teeth and
gums
Exam thyroid
Cardiovascular:

Exam peripheral vascular system by observation and palpation

Exam liver and spleen

Palpation of lymph nodes in neck, axillae, groin and/or other location
Extremities:

Inspection / palpation of digits and nails
Skin:


Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity




Respiration
Temperature
Height
Weight (may be measured and
recorded by ancillary staff)

General appearance of patient
Exam oropharynx
Chest (Breasts):
GI (Abdomen):

Exam anus for condyloma and
other lesions
GU:
Lymph:
Musculoskeletal:
Neuro / Psych:
Palpation of scalp and inspect hair of scalp,
eyebrows, face, chest, pubic area (when indicated)
and extremities
Inspection / palpation of skin and subcutaneous tissue
in eight (8) of the following ten areas:
 Head, including face and neck
 Back
 Neck
 Right upper extremity
 Chest, including breasts and axillae
 Left upper extremity
 Abdomen
 Right lower extremity
 Genitalia, groin, buttocks
 Left lower extremity
Brief assessment of mental status including:
 Orientation to time, place, person
 Mood and affect
NOTE:

For the comprehensive level, the exam of at least eight anatomic areas must be
performed and documented. For the three lower levels of examination, reach body
area is counted separately. For example, inspection/palpation of the skin and
subcutaneous tissue of the right upper extremity and the left upper extremity
constitutes two elements.
Inspect eccrine and apocrine glands of skin and subcutaneous tissue w/
identification and location of any hyperhidrosis, chromhidroses or
bromhidrosis
1997
- PHYSICAL EXAM -
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
ORGAN SYSTEM
CONSTITUTIONA
L
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
ORGAN SYSTEM
ENMT
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
ORGAN SYSTEM
EYES
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
ORGAN SYSTEM
RESPRITORY
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
ORGAN SYSTEM
CARDIOVASCULA
R
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
- PHYSICAL EXAM -
BODY AREA
NECK
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No
pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing
acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
DOCUMENTATION OF
DECISION MAKING
1995
&
1997
Documentation of Decision Making
Number of Diagnoses or Management Options
• 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, the 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, the assessment or clinical
impression may be stated in the form of a differential diagnoses or as “possible”,
“probable”, “rule out” (R/O) diagnoses.
• DG: The 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.
• 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.
Documentation of Decision Making
Amount and/or Complexity of Data
to Be Reviewed
• DG: If a diagnostic service (test or procedure) is ordered, planned,
scheduled, or performed at the time of the E/M encounter, the type
of service, eg, lab or x-ray, should be documented.
• DG: The review of lab, radiology and/or other diagnostic test
should be documented. An entry in a progress note such as “WBC
elevated” or “chest x-ray unremarkable” is acceptable.
Alternatively, the review may be documented by initialing and
dating the report containing the test results.
• DG: A decision to obtain old records or a decision to obtain
additional history from the family, caretaker or other source to
supplement that obtained from the patient should be documented.
Documentation of Decision Making
Amount and/or Complexity of Data
to Be Reviewed
• DG: Relevant findings from the review of old records and/or
additional history from the family, caretaker or other source
should be documented. If there is no relevant information beyond
that already obtained, that fact should be documented. A notation
of “Old records reviewed”, or “Additional history obtained”,
without elaboration is insufficient.
• DG: The results of discussion of laboratory, radiology or other
diagnostic tests with the provider who performed or interpreted the
study should be documented.
• DG: The direct visualization and independent interpretation of an
image, tracing or specimen previously or subsequently interpreted
by another provider should be documented.
Documentation of Decision Making
Risk of Significant Complications,
Morbidity, and/or Mortality
• 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, eg,
laparoscopy, should be documented.
• DG: If a surgical or invasive diagnostic procedure is performed at the
time of the E/M encounter, the specific procedure should be
documented.
• DG: The referral for or decision to perform a surgical or invasive
diagnostic procedure on an urgent basis should be documented.
- MEDICAL DECISION MAKING -
Assessment
Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
OTC acetaminophen and diphenhydramine
Saline nasal flushes
Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk
of exacerbating her hypertension
-
MEDICAL DECISION MAKING -
COMPLEXITY OF MEDICAL
DECISION MAKING
TWO NEW PROBLEMS TO
EXAMINER NO ADDITIONAL
WORKUP
Assessment
Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
OTC acetaminophen and diphenhydramine
Saline nasal flushes
Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk of
exacerbating her hypertension
3
3
-
MEDICAL DECISION MAKING AMOUNT AND/OR
COMPPLEXITY OF DATA
REVIEWED
NONE
Assessment
Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
OTC acetaminophen and diphenhydramine
Saline nasal flushes
Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk of
exacerbating her hypertension
3
3
0
- MEDICAL DECISION MAKING RISK
PRESENTING
PROBLEMS &
MANAGEMENT
OPTIONS
Assessment
Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
OTC acetaminophen and diphenhydramine
Saline nasal flushes
Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk
of exacerbating her hypertension
3
3
0
3
3
0
3
3
0
Documentation of an Encounter
Dominated by Counseling or
Coordination of Care
• DG: If a provider elects to report the level
of service based on counseling or
coordination of care, the total length of time
of the encounter (face-to-face or floor time,
as appropriate) should be documented and
the record should describe the counseling
and/or activities to coordinate care.
What is Counseling?
Counseling is a discussion with a patient
and/or family concerning one or more of the
following areas:
• diagnostic results, impressions, and/or
recommended diagnostic studies;
• prognosis;
• risks and benefits of management (treatment) options;
• instructions for management and/or follow-up;
• importance of compliance with chosen management
options;
• risk factor reduction; and
• patient and family education.
Select the Appropriate Level of E/M
Services Based on the Following:
In the case where counseling and/or
coordination of care dominates (more than
50%) the provider/patient and/or family
encounter (face-to-face time in the outpatient
setting or floor/unit time in the hospital), then
time is considered the key or controlling
factor to quality for a particular level of
E/M services. The extent of counseling
and/or coordination of care must be
documented in the medical record.
The
End!