Scribd
Upload
18 views

Charting and Coding

Charting and Coding

Uploaded by

Mohamed Attia Ragab
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
18 views

Charting and Coding

Charting and Coding

Uploaded by

Mohamed Attia Ragab
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Emergency Department Charting:

Evaluation & Management (E/M) Levels


Burkhardt J, Watsjold B, Fan T, Dyer S

*Categorical Label (Cumulative Points) - Points based on Marshfield Clinical Scoring Tool & Data
Points Scoring – see tables below

Dx/Tx: Diagnosis and Treatment; PFSH = Past Medical, Family, & Social History; (E)PF = (Expanded)
Problem Focused; Comp = Comprehensive; SF = Straightforward; Min = Minimum; Mod = Moderate,
Lim = Limited, Mult = Multiple, Ext = Extensive

THE BASICS
• 3 essential elements: History, Physical Exam, Medical Decision Making
• Billed as E/M levels 1-5, increasing respectively in complexity and
reimbursement. Most ED visits are level 3-5.

HISTORY
• CC: Clearly presented Chief Complaint required for all levels (often in patient’s
own words)
• HPI: Location, quality, severity, duration, timing, context, modifying factors,
associated signs and symptoms
• ROS: Constitutional, Eye, ENT, CV, Respiratory, GI, GU, Musculoskeletal,
Integument, Neuro, Psych, Endo, Heme/Lymph, Allergy/Immunology
• PFSH: Past Medical, Family, and Social History scored as a group
• Lowest scoring element (HPI, ROS, PFSH) determines E/M level. Under-
documentation can limit E/M level.

PHYSICAL EXAM
• 1995 and 1997 E/M Documentation Guidelines – may use either, based on
department or provider preference
• General Multi-System Exam or Complete Exam of Single Organ System

Updated 8/5/16
MEDICAL DECISION MAKING (MDM)
• Highest scoring 2 of 3 elements (Dx/Tx, Data, Risk) determines E/M level
• Dx/Tx: Cumulative total of points for each active problem and chronic problems
complicating diagnosis

Diagnosis/Treatment (Dx/Tx) Points


-- Add all problem points for cumulative total --
[Marshfield Clinical Scoring Tool]
1 Self-limited / minor problem (max 2 problems)
1 Established problem: Stable
2 Established problem: Worsening
3 New problem & no added workup (max 1 prob)
4 New problem & added workup required

• Data: Cumulative points for data collection & interpretation

Data Points
1 each Order/review: Labs, XR/Imaging, ECG,
echocardiogram
2 each Independently interpret: Image, ECG tracing,
specimen
1 Old records – Obtain
2 Old records – Review and summarize

• Risk: Assessed based on highest level in one of these categories: Problem,


Diagnostics, Management

CRITICAL CARE (CC) TIME


• Current Procedural Terminology (CPT) codes
o 99291: First 30-74 minutes
o 99292: Each additional 30 minutes beyond the first 74 minutes
• CMS definition: A condition which “impairs one or more vital organ systems, that
there is a high probability of imminent or life-threatening deterioration in the
patient’s condition”.
• Cumulative time w/ required minimum of 30 minutes. Calculated separately from
the point system of E/M
• Included in CC Time: Cardiac output measurements, ECG & CXR interpretation,
ABGs & arterial puncture, pulse oximetry, NG tube placement, transcutaneous
pacing, ventilator management, peripheral vascular access
• Excluded from CC Time: Procedure that are billed separately, e.g. intubation
and central line placement.
o CC Time requires direct attending involvement (resident time is excluded).

RESOURCES:
• CMS: Evaluation & Management Services Guide (August 2015)
• CMS: 1995 E/M Documentation Guidelines & 1997 E/M Documentation Guidelines
• E/M University: Problem Points & Data Points
• ACEP: Medical Decision Making & the Marshfield Clinical Scoring Tool FAQ

Updated 8/5/16

You might also like