Physician buy in for E/M services

From the Documentation Guideline for E/M Services (Centers for Medicare and Medicaid Services):

To determine the appropriate level of service for a patient’s visit, it is necessary to first determine whether the patient is new or established. The Physician must then uses the presenting illness as a guiding factor to determine the extent of key elements of service to be performed. The key elements are:

• History
• Examination
• Medical decision making

History:  The physician must determine the type of history. Is it Problem focused, Expanded focus, Detailed, or Comprehensive.

Exam: The examination may involve several organ systems or a single organ system. The extent of the exam performed is based upon clinical judgment, patient history and the nature of the presenting problem. The type of exam must be determined to be:

• Problem focused
• Expanded focus
• Detailed
• Comprehensive

Medical Decision Making: Medical Decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. A number of options must be considered.

• The number of possible diagnosis and or management options
• The amount and /or complexity of medical records, diagnostic tests and /or other information that must be reviewed and analyzed.
• -The risk of significant complications, morbidity, and/or mortality as well as co morbidities associated with the patient’s presenting problem, the diagnostic procedures and /or the management options.

The level of decision making must be determined to be:

• Straightforward
• Low Complexity
• Moderate Complexity
• High Complexity

Some important points that should be kept in mind when documenting level of risk are:

• Comorbidities/Underlying disease
• Surgical or invasive diagnostic procedures ordered, planned or scheduled.
• Surgical or invasive diagnostic procedure performed.
• The referral for or decision to perform a surgical or invasive diagnostic procedure.

When counseling and/or coordination of care dominates the patient encounter (more than 50%), time is considered the key or controlling factor for a particular E/M service. Presenting problems that affect level of risk include:

1. Minimal: Minor problems such as colds, insect bites, etc.
2. Low:  Two or more self limiting problems such as well controlled hypertension, dontrolled diabetes, cystitis, allergic rhinitis, or simple sprain.
3. Moderate: One or more chronic illness with mild exacerbation or progression, or two or more stable chronic illnesses. An undiagnosed new problem such as a lump in the breast counts as a moderate problem. Also the presence of an acute illness with systemic symptoms such as pylonephritis, pneumonia, colitis, or brief loss of consciousness is also a moderate problem.
4. High: One or more chronic illness with severe exacerbation, progression or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily function, such as multiple trauma, acute MI, pulmonary emboli, severe respiratory distress, acute renal failure, seizures, TIA, CVA, or sensory loss.

The gem in the E/M billing system is that in order to bill for the appropriate level of service, the physician must document appropriately. Physicians cannot be billing for a higher presenting problem with 60 minutes of counseling time when the diagnoses is urosepsis with diabetes, and chest pain. The codes will simply not substantiate the higher billing! Make your physicians aware of the rules.