How Many Points of Review of System Needed for Level 5 Encounter

The style medical charts are coded and billed is unnecessarily convoluted, and you accept the Centers for Medicare & Medicaid (CMS) to give thanks for that.  They are the ones who created the coding system that is used to assign an Evaluation & Management (E/Thousand) level to our charts. Each chart is billed using a Current Procedure Terminology (CPT) code based on E/M levels i-5.

Billing and coding is an extraordinarily tedious topic.  I'm actually impressed that you've read this far. Just I recall it's worth taking a little fourth dimension to sympathise the basics in order to chart as efficiently as possible.  A level 5 chart does non necessarily require that you write a novel to meet the coding criteria. It is likewise possible to write a very long, thorough chart and still merely get credit for a level three or 4 nautical chart.  Unless you know the elements of the chart that count towards that level of coding, y'all may terminate up doing a lot of unnecessary work.

Rather than review the criteria for every component of each of the 5 CPT codes, which would exist time-consuming and painful for you lot to read, I thought information technology would be most benign to go through a sample level five (CPT code 99285) ED visit, pointing out the potential pitfalls where your chart could possibly exist down-coded to a level 4.

There are only 3 components that determine the East/M level:

1. HISTORY

two. PHYSICAL EXAM

3. MEDICAL DECISION MAKING

As I become through this sample case I will demonstrate the minimum amount of documentation needed for the nautical chart to be coded as a level v chart.  I'm certainly not telling you to just document the minimum simply to hit the level 5 criteria, as you should thoroughly chart  everything that is necessary for each patient. This is merely an practise to illustrate the minimum documentation that would be needed solely for coding purposes.  Next to each of these 3 components, I volition list in parentheses the minimum criteria required for that item component. Go along in listen that the lowest scoring of the iii components will determine the East/Grand level for the entire chart.

HISTORY (HPI: Chief Complaint, 4+ elements, ROS: ten+ elements, PFSH: 2 of iii elements)

The history component consists of four elements: primary complaint (CC), History of nowadays affliction (HPI), Review of systems (ROS), and By medical, family unit and social history (PFSH).  A level 5 chart is designated "comprehensive" and includes iv+ HPI elements, 10+ ROS elements, and 2 of the 3 PFSH elements. What do yous do if the patient is unable to provide a history because they are altered or intubated?  Or what if the patient refuses to give a history? Add a qualifier describing the reason for the limitation, such as "patient is unable to provide history secondary to…". This volition employ to all elements of the history component.

• CC – This is a mandatory element for all charts, regardless of CPT level.

• HPI – A level v chart requires a minimum of 4 HPI elements*.  You tin include more, but you need at least 4.  The HPI elements include
  • Location
  • Duration
  • Timing
  • Severity
  • Quality
  • Context
  • Modifying Factors
  • Associated Signs/Symptoms

*In lieu of the HPI elements you could likewise document the status of three chronic or inactive conditions.

• ROS – There are xiv organ systems recognized by CMS
  • Ramble
  • Eyes
  • Ears, Olfactory organ, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic

A level v chart must document at least 10 organ systems.  Your EMR may have a push y'all can click that states something to the result "all other systems reviewed and are negative."  Clicking this button will technically satisfy the 10+ organ system ROS criteria, but doing so attests that you actually reviewed every organ system with the patient.  A word of caution: don't document something that you didn't do!

• PFSH – This consists of 3 singled-out components:
  • Past Medical History (PMH) – Includes experiences with illnesses, operations, injuries, and treatments.
  • Family History (FH) – Review of medical events, diseases, and hereditary conditions that may place the patient at risk.
  • Social History (SH) – Includes sexual history, booze/drug employ, employment, and education.

A level 5 chart must include at least one item each from 2 of the iii components.  These are often documented past another staff member, such equally the triage nurse.  If these are documented past another staff member they withal counts toward your coding equally long as you adjure that their notes were "reviewed and verified by me."

Let'southward get to the sample example:

John Doe is a 60yo male person with a history of hypertension and diabetes who presents to the emergency department complaining of chest pain .  He describes the hurting every bit a "pressure" sensation in his left chest that began at 4pm today while walking .   He notes that his father died of an MI at age 65 .

This cursory paragraph includes the master complaint (chest pain), four HPI elements: quality ("pressure level"), location (left breast), duration (began at 4pm), and context (while walking);  by medical history (history of hypertension and diabetes) and family history (father died of an MI at age 65). Every bit long every bit you include your 10 ROS elements, you've met the minimum level 5 criteria for the HISTORY component of the chart!  If this were a real patient yous would clearly want to include more details regarding his presentation, just over again, I'g using this example but to illustrate that you lot don't need to write a novel for your chart to exist coded at a level 5.

Pitfall – Keep in heed that the PFSH consists of 3 distinct components: PMH, FH and SH.  You could list x medical conditions that the patient is suffering from only these all simply count for 1 of these elements, the PMH.  If the entire chart meets criteria for a level five chart but simply 1 of these three elements is documented, such as failing to document that the patient is a smoker or has a significant FH of center illness, the HISTORY component of the chart will be downcoded to a level 4, which means the entire chart is downcoded to a level 4.

Physical EXAM (nine systems, with 2 bullets per system)

A level 5 chart requires a "comprehensive" physical exam, which consists of nine systems, with 2 bullets per system.  CMS recognizes the post-obit 14 systems as part of the physical exam:

• Constitutional
• Eyes
• Ears, Nose, Rima oris and Throat
• Cervix
• Respiratory
• Cardiovascular
• Chest (Breasts)
• Gastrointestinal
• Genitourinary
• Lymphatic
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric

If y'all'd similar to meet the bullets that are within each of these systems, they can be found at the CMS website here.  I've found that the most efficient mode to ensure that your chart meets level v coding criteria is to create a "normal" templated exam that includes the minimum 9 systems with ii bullets per system and modifying it as needed.  Yet, if yous choose to do this, be cautious! You need to know exactly what is in your templated examination and yous must review information technology for each patient to ensure that you have not documented something that you did not actually do.  Over again, don't document something that y'all didn't do.

MEDICAL DECISION MAKING(High)

The MDM section of your note is the most nebulous of the 3 components when it comes to understanding how it is coded.  There are 3 elements that are considered hither, with the concluding code being based upon the highest 2 of the iii post-obit elements:

• The number of possible diagnoses and/or the number of management options that must be considered (I will refer to this as DIAGNOSES )
• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed (I will refer to this as Information )
• The run a risk of significant complications, morbidity and/or mortality, as well every bit comorbidities, associated with the patient'south presenting problem(s), the diagnostic procedure(s) and/or the possible management options (I volition refer to this as RISK )

DIAGNOSES – The highest score for this category is "extensive," which is needed to bill as a level five chart.  If you lot are seeing a patient who is presenting with a trouble that is new to you, the provider, and you lot are pursuing a workup of the presenting problem, this fulfills the "extensive" criteria.  If you are seeing the aforementioned patient, but not pursuing whatever workup, this component would be categorized as "multiple" rather than "extensive" and coded as a level iv rather than a level 5.  As an emergency provider, nearly every patient you care for volition exist presenting with a problem that is new to you. A rare exception to this may be someone who is returning for a scheduled re-bank check.

DATA – Again, the highest score for this category is "all-encompassing," which corresponds to a level 5 chart.  This section is calculated using a scoring system, with a score of 4 or greater needed to be considered "extensive."  Here is the breakdown of the scoring :

• Review and/or lodge of clinical lab tests – ( i signal )
• Review and/or society of radiology tests (excluding cardiac cath and echo) – ( 1 betoken )
• Review and/or order of medical tests (PFTs, colonoscopy, cath, echo) – ( 1 point )
• Discuss tests with performing physician (due east.g., You lot discussed a colonoscopy result with the gastroenterologist.  Y'all must document this give-and-take in your note.) – ( 1 signal )
• Independent review of image, tracing, specimen* – ( 2 points )
• Reviewed and summarized old records or history from a person other than the patient (e.thou., If you lot spoke with a consultant, even informally, this counts!  Merely exist certain to document the conversation in your note.) – ( 2 points )

*If documenting an ECG, your estimation must include at least 3 of the 6 elements: rate/rhythm, axis, intervals, ST-segment changes, comparing to prior, summary of the patient's clinical condition

Adventure – Level of risk is scored from "minimal" to "loftier," with a score of "high" needed to bill as a level five chart.  The risk score is calculated using a run a risk table, which is unwieldy and probably non worth your time to study. For our purposes, to understand what qualifies as a level 5 chart in the ED, suffice it to say that a patient who is sick and requires urgent intervention typically qualifies equally a "high" level of run a risk.  Weather that autumn under this category include astute MI, pulmonary embolism, severe COPD exacerbation, multiple trauma, seizure, CVA, and psychiatric patients who are a threat to themselves or others.  Also note that any patient who receives a parenteral-controlled substance qualifies equally "loftier" risk .

Let'due south revisit our patient who is presenting to the ED with breast pain.  His chief complaint is a trouble that is new to us.  If we determine to pursue a workup for his chest hurting (e.yard., labs, ekg, cxr, etc.), the DIAGNOSES component of the MDM would come across the "extensive" criteria.  At present, in social club for the MEDICAL Determination MAKING element of the chart to qualify for level 5 billing, we merely need either the Data or RISK component to also come across the threshold for a level five chart.  Remember, you need 2 of the 3 components of the MDM ( DIAGNOSES, Information and RISK ) to satisfy the highest level of billing in order for the MDM element to exist billed as a level 5 chart.

Call up, the Data component of the MDM is calculated based on points derived from various elements of the workup.  We demand at least 4 points to satisfy the "extensive" level of billing required for a level 5 chart.  For this patient, if nosotros order labs (1 point), a chest x-ray (1 point), and then document our interpretation of the chest x-ray (two points) we take a total of 4 points, which is sufficient to achieve the "extensive" level of billing for the DATA component.

At this point the MDM element of the chart satisfies the billing criteria for a level 5 E/M code because 2 of the 3 elements of the MDM, the DIAGNOSES and Information components, meet the maximum level of billing.  The RISK component of the MDM does not even need to be considered because the MDM tin be billed as a level 5 chart without it.  However, if you had treated your patient'south breast pain with morphine during the encounter, this would have automatically bumped the Run a risk component to the maximum level, "loftier."  If this were the instance, all iii of the MDM elements would satisfy the criteria for a level 5 nautical chart, though simply 2 of these 3 are needed.

SUMMARY

To recap, a level 5 E/1000 chart requires that all 3 components of the chart, the HISTORY, PHYSICAL Exam, and MDM, meet their respective maximum coding criteria.  Here are the 3 components with their respective level v billing criteria and the items from the nautical chart that fulfill them:

Critical Intendance Fourth dimension

Critical care documentation is a special snowflake that warrants its own section.  CMS defines critical care as a medical condition that "impairs one or more vital organ systems" and is i in which "there is a high probability of imminent or life-threatening deterioration in the patient's condition."  They further note that the physician should provide "frequent personal assessment and manipulation" of the patient's status.

Here is a list of diagnoses that advise critical care billing may exist appropriate:

• Active seizures
• Acute altered mental status
• Astute GI bleed
• Astute psychosis with agitation
• Acute stroke
• Cardiac arrest
• Delirium tremens
• DKA
• Ectopic pregnancy
• Hyperkalemia requiring handling
• Hypovolemic stupor
• Intracerebral hemorrhage
• Moderate to astringent asthma
• Moderate to severe CHF
• Overdose requiring antidotes or reversal agents
• Pneumothorax
• Pulmonary embolus
• Rapid atrial fibrillation
• Respiratory distress requiring non-invasive positive pressure level ventilation
• Respiratory distress requiring intubation
• Sepsis
• Severe anemia requiring blood transfusion
• STEMI
• Suicidal ideation immediate threat
• SVT
• Unstable angina

In addition to the patient having a disquisitional condition, in society to bill for disquisitional care time, you lot need to have spent thirty minutes or more on patient care.  This includes fourth dimension spent on straight patient care, besides every bit fourth dimension spent on indirect patient care.  Indirect patient care may include documentation, reviewing prior records, and speaking with consultants, paramedics, and family members.  It is important to annotation that critical care time does not include fourth dimension spent on procedures that are billed separately, such every bit intubations and cardinal lines.

Some critically-ill patients may not qualify for disquisitional care billing.  If a patient with a STEMI is brought in by ambulance and so whisked off to the cath lab within ten minutes of arrival, they would typically not qualify for critical intendance billing, regardless of how unstable they were.  At least xxx minutes of time must be spent on patient care to bill for disquisitional intendance.

If you care for a patient who meets the criteria for disquisitional care billing and document information technology as such, these CPT codes ( 99291 for the first xxx-74 minutes, 99292 for each additional 30 minutes beyond the first 74 minutes) supercede all of the elements discussed above for coding a E/M level 5 chart.  Meaning, if you didn't document a social history and your ROS merely includes viii organ systems instead of the ten required for a level 5 chart, information technology volition all the same be billed equally a critical care nautical chart.

Keep in mind that some patients may appear clinically stable but still qualify for disquisitional care billing.  The hyperkalemic patient who requires treatment, monitoring and frequent reassessments may authorize. As may the asthmatic who requires BiPAP and frequent reassessments.

Congrats on making it to the terminate!  I hope this has been helpful. If you have any feedback for me regarding this commodity please contact me at theefficientmd@gmail.com.

Efficient MD

Disclaimer: This article was written for informational purposes only.  I cannot guarantee the accurateness of the information provided. Payment policies can vary from payer to payer.  I assume no responsibleness for, and expressly disclaim liability for, damages of any kind arising out of, or relating to, the apply, non-utilise, interpretation of, or reliance on information contained here.  Specific coding or payment related bug should be directed to the payer.

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