East Bay Nephrology Medical Group
E&M Education
These
codes are used to bill for subsequent hospital care services known to all
physicians as hospital progress notes. There are three levels of
care for this type of encounter which all require qualifying documentation
of two out
of three key
components. Most physicians over-document and under-code
for these services. You can break this pattern by reviewing below.
Level
3 Hospital Progress Note (99233) 1)
a chief
complaint, 2)
an extended
HPI §
four HPI
elements
OR the status
of three chronic or inactive problems - if using the 1997 E/M
guidelines), §
and two
to nine elements of ROS.
3)
You
don't have to include any PFSH. 1997 Detailed Exam requires at least 12 bullets from any organ systems. At
least 12 bullets from any organ
systems Example Vitals:
120/80, 88, 98.6 (1
bullet for three vital signs) High Complexity Medical
Decision-Making
truly is complex. Either the patient is quite
ill or the physician must review a significant amount of primary
data. This level of MDM is required for a level 3 hospital progress
note (99233).
The patient would need to have a severe exacerbation of a chronic problem
or an acute illness which threatens life or bodily function to qualify for
this level of risk. The data reviewed would have to be quite
extensive to reach the threshold for high complexity MDM. High
MDM Requires two out
of three
of the following: 1) Four
problem points based on problem point table below The
“nature and number of clinical problems” are quantified into Problem
Points by referring to the following table:
The
above table is fairly self explanatory. An “established problem”
refers to a diagnosis which is already known to the examiner, such as
hypertension, or diabetes. An example of a “new problem with no
additional work-up planned” may be a new diagnosis of essential
hypertension. Examples of “new problem, with additional work-up
planned” may include any new clinical issue which requires further
investigation such as proteinuria, anemia, shortness of breath, etc Data Points: The “amount and complexity of the data
points reviewed” are quantified by referring to the following table:
The
physician should be aware that no
“double dipping” is allowed. For example, if you review
lab results and order labs during the same visit, you only get one point
(not one point for ordering and one point for reviewing). This same
rules applies to imaging studies or other medicine tests such as EKGs
or Echos. Commonly overlooked points are those garnered for
obtaining or reviewing old records. If you do review old records,
you must summarize your findings in the chart. It is not
acceptable to just say, “Old records were reviewed.” High
Risk:
This is the highest level of risk. This level of risk is required
for a level 3 hospital progress note (99233).
Diagnostic
Procedure(s)
Management
Options Selected
Clinical Example 1 A patient with worsening acute renal
failure following CABG
Plan
The
clinical example qualifies as a Detailed History.
Usually this level of history must include one element of PFSH,
but this requirement is waived
for hospital progress notes . Therefore in this case a
Detailed History requires only a chief complaint, an extended HPI
consisting of four HPI elements (or
the status of three chronic problems--if using the 1997 guidelines) and an
extended ROS (review of
two to nine systems). In the example, the status of three problems (ARF,
CAD and hypertension) are used to satisfy the HPI requirements using the
1997 E/M rules. A review of the constitutional,
cardiovascular, and GU
systems satisfy the requirement for two to nine ROS. All the
elements of history included are probative and clinically relevant in
keeping with the intrinsic medical necessity of the encounter.
Notice that even though no PFSH is required for this particular Detailed
History, a review of the patient’s medications would technically count
as one element of PFSH . Coding
Tip : The 99233 should probably be used more often by
all physicians. In the above example, High Risk is obvious and is
used as a qualifying component of High Complexity Medical Decision-Making,
but it is not necessary that every patient assigned this code be High
Risk. Often, the Data Points can add up quickly in the hospital
(especially if you personally review an image or tracing). In these
cases the Data Points can be added to the Problem Points to qualify for
High Complexity Medical Decision-Making. Physicians are urged to
systematically calculate the Medical Decision-Making for every encounter
in order to recognize and take credit for their cognitive labor.
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