Briefing Evaluation and Management “Hot Spots”：介绍评价和管理的“热点”

1、Briefing: Evaluation and Management “Hot Spots”Date: 23 March 2010Time: 1110 12001ObjectivesDiscuss questions on:History ElementsChief Complaint (cc)History of Present Illness (HPI)Review of Systems (ROS)Past, Family and/or Social History (PFSH)Medical Decision MakingConsultations and ReferralsPreve

2、ntive MedicineTimeQuestions2History ElementsChief complaintThe reason for the encounter usually stated in the patients own wordsEvery encounter must have one1997 Documentation Guidelines for Evaluation and Management ServicesDG: the medical record should clearly reflect the chief complaint*1997 Docu

3、mentation Guidelines for Evaluation and Management Services3History ElementsHistory of present illnessChronological description of the development of the patients illnessLocation (headache, elbow, chest pain)Quality (dull, throbbing, aching)Severity (severe, mild, 7 on a scale of 1-10)Duration (for

4、the last week, since yesterday)Timing (constant, at night, off & on)Context (when I stand, after I fell, after eating) Modifying factors (relief after taking Tylenol, better when I stand)Associated signs and symptoms (n&v, swelling)4History ElementsHistory of present illnessTwo levels of HPIBrief 1-

5、3 elementsDG: The medical record should describe one to three elements of the present illness*Extended 4 or more elements or the status of at least three chronic or inactive conditionsDG: The medical record should describe at least four elements of the present illness, or the status of at least thre

6、e chronic or inactive conditions*1997 Documentation Guidelines for Evaluation and Management Services5History ElementsHistory of present illnessQuestion: If there are more than four elements of the HPI and no ROS, can you “borrow” from the HPI to get ROS?Answer: Yes you can for “bullet counting” pur

7、poses. The HPI and ROS are often co-mingled in the note.6History ElementsReview of systemsInventory of body systemsSystems recognized: Constitutional symptoms (e.g., fever, weight loss)EyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalIntegumentary (sk

8、in) and/or breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/Immunologic7History ElementsReview of systemsThree levels of ROSProblem pertinentDG: the patients positive responses and pertinent negatives for the system related to the to the problem should be documented*ExtendedDG: t

9、he patients positive responses and pertinent negatives for two to nine systems should be documented * 1997 Documentation Guidelines for Evaluation and Management Services8History ElementsReview of systemsThree levels of ROScontCompleteDG: at least ten organ systems must be reviewed. Those systems wi

10、th positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented* 1997 Documentation Guidelines for Eval

11、uation and Management Services9History ElementsReview of systems other documentation guidelinesDG: The ROS and/or PFSH may be recorded by ancillary staff or on a for completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirmin

12、g the information recorded by others.*Question: When there is an expanded problem focused history, what is the minimum ROS required?Answer: At the very least one “problem pertinent” ROS, regardless of a positive or negative response.*1997 Documentation Guidelines for Evaluation and Management Servic

13、es10History ElementsPast, Family and/or Social History (PFSH)PFSH consists of a review of three areas:Past history (the patients past experiences with illnesses, operations, injuries and treatments);Family history (a review of medical events in the patients family, including diseases which may be he

14、reditary or place the patient at risk); andSocial history (an age appropriate review of past and current activities).11History ElementsPast, Family and/or Social History documentation guidelinesDG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH

15、*DG: At least one specific item from two 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, established patient; emergency department; domiciliary care, established patient; and home care, established p

16、atient* 1997 Documentation Guidelines for Evaluation and Management Services12History ElementsPast, Family and/or Social History documentation guidelinesDG: 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 serv

17、ices: 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* 1997 Documentation Guidelines for Evaluation and Man

18、agement Services13History ElementsQuestion: Do all encounters require a PFSH?Answer: For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultation

19、s and subsequent nursing facility care.14History ElementsHistory - other documentation guidelinesDG: 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

20、 encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and u

21、pdate may be documented by:describing any new ROS and/or PFSH information or noting there has been no change in the information; andnoting the date and location of the earlier ROS and/or PFSH* 1997 Documentation Guidelines for Evaluation and Management Services15Medical Decision MakingDocumentation

22、of the complexity of Medical Decision Making (MDM)The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a man

23、agement option as measured by:The number of possible diagnoses and/or the number of management options that must be considered;The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; andThe risk of significant complica

24、tions, morbidity and/or mortality, as well as co morbidities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options.16Medical Decision MakingNumber of diagnosesor managementoptionsAmount and/or complexity of data to be reviewedRisk of

25、complications and/or morbidity or mortalityType of decision makingMinimalMinimal or NoneMinimalStraightforwardLimitedLimitedLowLow ComplexityMultipleModerateModerateModerate ComplexityExtensiveExtensiveHighHigh Complexity17Medical Decision MakingThe number of possible diagnoses and/or the number of

26、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.Question: An auditing worksheet I use, stated that the diagnoses/management o

27、ptions are referencing “to the patient”. Is this correct?Answer: The 1997 Documentation Guidelines are quoted above: “by the physician”- the provider is determining diagnoses, not the patientQuestion: Is MDM required to be one of the key components when determining an E/M level for established patie

28、nts?Answer: As of 2009 the MHS Coding Guidelines do require MDM to be one of the two required key components for established patients (rule 3.1.6.2). However, CMS states that Medical Necessity is the overarching criterion for patient encounters to be “paid”18Medical Decision MakingAmount and/or comp

29、lexity of data to be reviewedIncludes:Diagnostic service (test or procedure) is ordered, planned, scheduled, or performedReview of lab, radiology and/or other diagnostic tests should be documentedRelevant findings from the review of old recordsDirect visualization and independent interpretation of a

30、n image, tracing or specimenKey documentation must support19Medical Decision MakingThe risk of significant complications, morbidity, and/or mortality Based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management optionsFamiliarize yourself w/C

31、MS Table of Risk*The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.* 1997 Documentation Guidelines for Evaluation and Management Services20Consultations & ReferralsConsultation request for advice or opini

32、on on conditionReferral transfer care for treatment of condition to another providerQuestion: We understand that the phrase “evaluate and treat” is a required documentation statement in order to receive payment for any referral/consultation. Is this true?Answer: Not to my knowledge. It doesnt make s

33、ense as the statement written like that basically turns every “real” consult into a referral. Just because both use the “consult” module, doesnt automatically make it a consultation either.21Evaluation and ManagementNew E/M Guidelines regarding consultationand concurrent care and transfer of care Co

34、ncurrent care is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required. Transfer of care is the process where a physician who is managing some or all of a patients p

35、roblems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. 22Evaluation and ManagementThe physician transferring care is then no longer providing care for these problem

36、s though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be m

37、ade until after the initial consultation evaluation, regardless of the site of service.23Evaluation and ManagementConsultations New DefinitionA consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either reco

38、mmend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patients entire care or for the care of a specific condition or problem.A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent v

39、isit.24Evaluation and ManagementA “consultation” initiated by a patient and/or family, and not requested by a physician or other appropriate source (eg, physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psycholog

40、ist, social worker, lawyer, or insurance company), is not reported using the consultation codes but may be reported using the office visit, home service, or domiciliary/rest home care codes as appropriate. 25Evaluation and ManagementThe written or verbal request for consult may be made by a physicia

41、n or other appropriate source and documented in the patients medical records by either the consulting or requesting physician or other appropriate source the consultants opinion and any services that were ordered or performed must also be documented in the patients medical record and communicated by

42、 written report to the requesting physician or other appropriate source.26Evaluation and ManagementTo report services provided to a patient who is admitted to a hospital or nursing facility in the course of an encounter in the office or other ambulatory facility, see the notes for Initial Hospital I

43、npatient Care (pg 16 AMA) or Initial Nursing Facility Care (pg 24 AMA).Remember! Read the specific guidelines for “Office or Other Outpatient Consultations” and “Inpatient Consultations” in those subsections.27Preventive MedicineThe “comprehensive” nature of the Preventive Medicine Services codes re

44、flects an age and gender appropriate history/exam and is NOT synonymous with the “comprehensive” examination required in Evaluation and Management codesPreventive Medicine codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination28Preventive MedicineCounseling risk factor reduction and behavior change interventionRisk factor reduction different from preventive counselingFor the purpose of promoting health and preventing illness or injuryNot to b