E&M Reporting based on Medical Decisions

??????????????E&M Reporting based on Medical Decisions

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In the modern healthcare industry, providers document every single information about their patients and create an appropriate medical record listing all subjective an objective details of the patient. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's medical history), performed an examination, and reviewed any test results, they have already formulated a working diagnosis and understand the associated risks of treatment or failure to treat that the patient will face.?

In this process, the provider is sorting through subjective and objective data to determine not only the diagnosis, or whether there is even enough information to do so without additional testing, but also the level of severity associated with it. Questions providers may be asking include:

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• Can the patient wait for additional testing and results before receiving treatment?
• What kind of treatment is required?
• Are more conservative measures appropriate (e.g., rest, over-the-counter medications), or do they require a prescription medication to recover??
• If a prescription is required, what are the risks associated with it, and is it contraindicated with any other prescription medications or supplements the patient is already taking to treat another condition??
• What are the other conditions (chronic or co-morbid) the patient has and how might the recommended treatment for the current problem exacerbate them??
• Will the patient require a minor, major, or emergency surgical procedure and if so, what risks, if any, are associated with the recommended procedure?
• Is there a risk to an organ system, bodily function, or even the patient's life if they go without treatment (e.g., DNR, palliative care) or if they choose to complete the treatment?

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A provider who is adept at documenting the required criteria to support medical decisions and medical necessity and to support the level of E/M service reported is a coveted asset. We have all seen providers who can quickly evaluate, assess, diagnose, and determine treatment for a patient with a problem of moderate complexity, even at times a high complexity problem. So why would you report based on the time when medical decision making may be a better outcome? Although the time when documented correctly, can easily support a level of service, improper or incomplete documentation can result in attempted recoupment of reimbursement. Payers may be looking at issues such as:

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• Whether the provider documented in a Start/Stop or Total Time fashion (and whether that method meets the payer's rules)
• Whether documented time is supported with a detailed enough description of "qualifying activities"
• Whether the time is specific to only the physician/QHP or if clinical staff time is also included?
• Whether any lab or imaging results the provider discussed with the patient were correctly excluded when the provider was billing for those services separately

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Changes in the office based E&M codes those affected time based reporting and prolonged services

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The overhaul of the office-based evaluation and management (E/M) services that takes effect on Jan. 1 includes changes related to time-based reporting, including prolonged services. The changes affect Current Procedural Terminology (CPT) codes 99202-99215.

Summary of changes

• Time will be based on the total time spent on the date of the face-to-face encounter, including both face-to-face?and non-face-to-face?time.
• There no longer are “typical times” but defined ranges.
• Time is not limited to time spent in counseling or care coordination.
• Time is not used in selecting?99211.
• There is a new prolonged services add-on code.
• Prolonged services are added “per 15 minutes” of extended time.

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Services included under “Time”

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests or procedures
• Communicating with other health care professionals (not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

Time may?not?include clinical staff time or time spent the previous day or next day.

Time should be documented clearly in the notes throughout the day. To aid in an audit, an entry should indicate the total time spent on the day and can refer to notes earlier in the day so the auditor knows how time was spent. You should not be required to re-document earlier services, only refer back. At this time, neither CPT nor the Centers for Medicare & Medicaid Services has specific rules on this.

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