Basic E/M Coding Course Flashcards
Who developed the E/M Guidelines?
The AMA together with CMS
When was the first set of guidelines released?
1995
When was the second set of guidelines released?
1997
Can you use either the 1995 or 1997 guidelines?
Yes, you can use either the 1995 or the 1997 guideline. But cannot combine the two to code the same encounter. That is, you cannot mix and match components of the 1995 and 1997 guidelines to code a patient encounter.
What are the three key elements in documentation and coding?
- History
- Physical exam
- Medical Decision-Making
How many levels of history taking are there?
There are four levels.
HPI
- Problem focused
- Expanded problem focused
- Detailed
- Comprehensive
Does the physician have to enter the chief complaint him/herself into the chart?
No.
“We are finalizing our proposal that, effective January 1, 2019, for new and established patients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”
CMS 2019 PFS Final Rule, p571
What is the implication of the 2019 Final Ruling?
- Ancillary staff or the patient would now be able to document any part of the history:
- CC
- HPI
- ROS
- PFSH
- The billing provider would simply review the information and update it as needed and note that they have done so.
- Would apply to ONLY new and established office patients.
How many elements are there in the HPI and what are they?
There are eight elements.
- Location
- Severity
- Quality
- Context
- Timing
- Duration
- Modifying factors
- Associated signs and symptoms
How many HPI elements are there in the following story?
CC: Chest pain
HPI: Patient states he developed crushing, intermittent chest pain about two hours ago described as 8/10 in severity. He notes it came on “out of the blue” while watching TV, is worse with exertion and is associated with shortness of breath.
There are eight elements.
- Location = chest
- Severity 8/10
- Quality = crushing
- Context = out of the blue, while watching TV
- Timing = intermittent
- Duration = two hours ago
- Modifying factors = worse with exertion
- Associated signs: SOB
How many HPI elements are there in the following scenario?
CC: F/U HTN
HPI: Patient here for labile arterial HTN which has been moderately severe at times. Blood pressure has been persistently elevated at home with no normal readings. He has had HTN for at least 10 years after having been discovered incidentally during a routine physical. Denies any associated symptoms such as pounding headaches or blurry vision. BP has not improved with a low salt diet.
There are eight HPI elements.
- Location = arterial
- Severity = moderately severe
- Quality = labile
- Context = incidental finding on routine physical
- Timing = persistently elevated
- Duration = 10+ years
- Modifying factors = low salt diet
- Associated signs/symptoms = no pounding headaches/blurry vision
How many types of HPI are there and what are they?
There are two types of HPI:
1) Brief
2) Extended
Describe the brief HPI
Brief HPI
- Requires 1-3 HPI elements
- Applies to both 1995 and 1997 guidelines
A brief HPI is found in what two levels of history?
A brief HPI is found in
1) The Problem Focused (PF) history and
2) The Extended Problem Focused (EPF) history
Describe the EXTENDED HPI.
- Here, the 1995 and 1997 Guidelines are different.
If using the 1995 Guidelines, an Extended HPI must have at least four HPI elements.
If using the 1997 Guidelines, an Extended HPI must comment on at least three chronic or inactive problems.
What happened in Sept 10, 2013?
CMS contradicted themselves and allowed the combination of 1997 guidelines with 1995 guidelines when it is applied to Extended HPI.
Extended HPI
- Using the 1997 E/M guidelines, it’s clearly acceptable to complete an extended HPI by including four HPI elements OR by commenting on the status of 3+ chronic conditions
- Using the 1995 E/M guidelines, it is acceptable to complete an extended HPI by including four HPI elements
- Per CMS, since 9/10/2013, it’s ok to use the 97 guidelines for completing the extended HPI using chronic conditions, even when using the 1995 guidelines for the rest of the note
- Confirm with your carrier that this new approach is officially viable in your locality.
If you want to charge for a detailed or comprehensive exam, what type of HPI must you use?
a) Brief HPI
b) Extended HPI
b) You must document an Extended HPI.
- That is, using the 1995 guidelines, you need to document at least 4 elements of an HPI
- Or if using the 1997 guidelines, you need to document either 4+ HPI elements or comment on 3+ chronic or inactive issues.
What are the rules of the physical exam using 1995 E/M guidelines?
It’s safe to say that….
1) Problem focused exam requires only 1 body area or organ system
2) Comprehensive exam requires at least 8 body areas or organ systems
The gray area is in the expanded problem focused and detailed exams. Ask your Medicare carrier for clarification.
