New Provider Coding andDocumentation EducationEvaluation and Management (E/M) Servicesand Teaching Physician GuidelinesBilling ComplianceCorporate Compliance Office2021

ObjectivesNew Providers will understand:I.Overview of Billing ComplianceII. Inpatient, Observation, and ED Coding and DocumentationIII. Outpatient Coding and Documentation and 2021 ChangesIV. Teaching Physician GuidelinesV. Other Coding and Documentation TopicsVI. The Process for Auditing New Provider DocumentationBMC Billing Compliance2

I.Overview of Billing ComplianceBMC Billing Compliance3

Importance of Compliant BillingAccuracy and integrity in all billing practices is an essential part of“Exceptional Care” at BMC. Boston Medical Center recognizes the importance of maintaining anenvironment of integrity, honesty and respect. We submit claims for services/items that are: Reasonable and medically necessary Properly documented and Support the level of serviceBMC Billing Compliance4

Oversight of Healthcare BillingPartial List of Government AgenciesOffice of InspectorGeneralCenters for Medicareand Medicaid ationsState DPHJointCommissionFDAState MedicaidMedicare IntegrityProgramContractorsMedicare RegionalContractor(NGS Medicare) We hold the Public’s trust as a recipient of government funds.BMC Billing Compliance5

Accurate DocumentationYou can only bill for what your documentationsupports.Medical necessity of a service is the overarching criterion for paymentin addition to the individual requirements of a CPT code.It would not be medically necessary or appropriate to bill a higher levelof evaluation and management service when a lower level of serviceis warranted.Documentation should support the level of service reported, rather thanthe volume of documentation as the primary influence.Excerpt from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04,Chapter 12, Section 30.6.1BMC Billing Compliance6

II. Inpatient, Observation, and ED Coding and DocumentationBMC Billing Compliance7

Inpatient Evaluation and Management ServicesKey Components History elements:—Chief Complaint and History of Presenting Problem—Review of Systems—Past, Family and Social History Exam:—95 or 97 CMS guidelines Medical Decision Making elements:—Diagnosis—Data—RiskOR Time (when counseling and/or coordination of care are greater than 50% of the patient-relatedunit/floor time)—Floor/unit time occurs when the physician is physically present on the patient’s hospital floor or unitdelivering bedside services to the patient.—Includes both time spent with the patient and time spent working on the patient’s chart or discussinghis or her care with nurses and others.—Applies to hospital observation services, inpatient hospital care, initial and subsequent hospitalconsultations, and nursing facility services.BMC Billing Compliance8

History of Present Illness (HPI)History of Present Illness: Description of the patient’s illness from firstsign or symptom to the presentExample HPI: Over the past t6.Timing7.Modifying Factors8.Associated Signs & Symptomsweeks, the patient has experiencedsharp lower back pain intermittentlyDuration – Past few weeksQuality - SharpLocation – Lower BackTiming – IntermittentlyFour elements of the HPI have beendocumented in this statement whichrepresents a comprehensive HPI.BMC Billing Compliance9

Review of Systems (ROS)The review of systems is an inventory of body systems obtained through a series of questionsseeking to investigate the presenting problemCMS recognizes the following 14 systems: Constitutional, Eyes,Ears/Nose/Mouth/Throat, Cardiovascular, Respiratory, Gastrointestinal,Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine,Hematologic/Lymphatic, Allergic/Immunologic Document all positive finding(s) and pertinent negatives as relevant to thepresenting problem. Ancillary staff may obtain the ROS and you as theprovider document your review of this information. 4 individually documented ROS elements of the positive findings would support adetailed history (which is between 2-9 elements) Documentation of 10 or more systems is a comprehensive ROS. If the provider reviews and documents 10 systems and the remaining systemsare negative the provider can add a summary statement such as follows: “Allother remaining systems have been reviewed and are negative.” It’s insufficientto say “Otherwise negative”BMC Billing Compliance10

Past Patient, Family & Social History (PFSH)Past Currentmedications Allergies Prior: Illnesses Injuries Operations Hospital stays Age appropriate: Vaccine status Dietary statusFamily Specific diseases offamily related toproblems identifiedand documented Diseases that arehereditary or placethe patient at risk Age of parents andsiblings (if alive) andtheir current healthstatus, or their ageand cause of death ifthey are deceased*(“non-contributory”wording alone is notgiven credit)BMC Billing ComplianceSocial Marital status&/or livingarrangements Level ofeducation Sexual history Occupationalhistory Use of drugs,alcohol andtobacco Other relevantsocial factors11

Key Component: ExamThe CMS 1995 Multi-system Exam Guidelines7. Genitourinary1. Constitutional8. Musculoskeletal2. Eyes3. Ears/Nose/Mouth/Throat9. Integumentary4. Cardiovascular10. Neurological11. Psychiatric5. Respiratory12. Hematologic/Lymphatic/Immunologic6. Gastrointestinal Problem focused exam of one body area / organ system Problem focusedLimited exam of 2 – 7 body areas/organ systems Expanded problem focusedExtended exam of 2 – 7 body areas/organ systems DetailedA general multi-system exam of 8 organ systems ComprehensiveThe CMS 1997 Exam Guidelines includes single system exam for certain specialties such asPsychiatry, Dermatology, Ophthalmology and Neurology.BMC Billing Compliance12

Key Component: Medical Decision Making (MDM)Diagnoses/Problem(s)Problem Complexity and Number/ Management Options ConsideredProblem CategorySelf-limited or Minor (stable,improved or worsening)Estab. Prob. (stable, improved)Estab. Problem (worsening)New Problem (no add. work-upplanned,New Prob. (Additional work-upplanned )NumberMax # 2XMax #1Points1 XXX123 X4 TOTALScoreTally the score for the final diagnosis/problem complexity:S Straightforward ( 1) L Low (2) M Moderate (3) H High (4)Examples: A new problem (to the patient) with work-up planned is considered high complexity (4pts).Two worsening problems is also high complexity (2 x 2pts 4pts).One worsening problem (2pts) one improved problem (1pt) is considered moderatecomplexity (3pts).BMC Billing Compliance13

Key Component: MDM - Data The data complexity is weighted according to the tests reviewed/ordered,discussions with other specialties/ disciplines, and review/summarization of otherdata/records. For the first three bullets, only one point is assigned regardless of the number oftests in that category (Labs, Radiology, Medicine). Note that there are three ways to be given the same two points in the last item. Tally the score for the final data complexity:S Straightforward ( 1)L Low (2)M Moderate (3)BMC Billing ComplianceH High (4)14

MDM: Table of Risk: The highest level of risk in any one category represented by a bullet on theTable of Risk determines the overall riskLevelMINIMALLOWManagement Option(s) Selected One self-limited or minor problem Laboratory tests with venipunctureChest x-raysEKG/EEGUltrasound RestGarglesElastic bandagesSuperficial dressings Two self-limited or minor problemsOne stable chronic illness (e.g. wellcontrolled hypertension, non-insulindependent diabetes, cataract, BPH)Acute uncomplicated illness or injury (e.g.cystitis, allergic rhinitis, simple sprain) Physiologic tests not under stress (e.g.PFTs)Non-CV imaging with contrast (e.g. bariumenema)Laboratory tests with arterial punctureSkin biopsies Minor surgery with no identified risk factorsOver-the- counter drugsPT/OTIV fluids without additivesPhysiologic tests under stress (e.g.cardiac stress test, fetal contraction stresstest)Diagnostic endoscopies with no identifiedrisk factorsDeep needle or incisional biopsyCV study with contrast and no identifiedrisk factors (e.g. cardiac cath.)Obtain fluid from body cavity (e.g. lumbarpuncture, thoracentesis, culdocentesis) Minor surgery with identified risk factorsElective major surgery with no identified riskfactorsClosed reduction of fracturePrescription drug managementTherapeutic nuclear medicineIV fluids with additives MODERATEDiagnostic Procedure(s) OrderedPresenting Problem(s) HIGH One or more chronic illnesses with mild (ormoderate) side effect, exacerbation, orprogressionTwo or more stable chronic illnessesUndiagnosed new problem with uncertainprognosis (e.g. lump in breast)Acute illness w/ systemic symptoms (e.g.pyelonephritis, colitis)Acute complicated injury (e.g. head injurywith brief loss of consciousness)Illnesses with severe side effects,exacerbation or progressionAcute or chronic illnesses or injuries thatposes a threat to life or bodily function, (e.g.multiple trauma, acute MI, pulmonaryembolus, severe respiratory distress,progressive severe rheumatoid arthritis,psychiatric illness with potential threat to selfor others, peritonitis, acute renal failure.)Abrupt change in neurologic status (e.g.seizure, TIA, weakness, and sensory loss) CV study with contrast and identified riskfactorsDiagnostic endoscopy with identified riskfactorsCardiac electrophysiological testsDiscography BMC Billing ComplianceElective major surgery with identified riskfactors (e.g. open percutaneous/endoscopicwith identified risk factor)Drug therapy requiring intensive monitoringfor toxicityDecision not to resuscitate or to de-escalatecare because of poor prognosisParenteral controlled substances16

Putting it all Together-MDM ComplexityExample 1:Example mplexity)SLM*HData (Test/Discussions)SLMH**Data (Test/Discussions)SL**MHRiskSLM***HRiskSLM***HMDM Level (2 out of 3)SLMH(High)MDM Level (2 out of 3)SLMH(moderate)*A new problem with work-up planned (4pts- H)* 1 worsening problem (2pts) 1 stable problem (1pt.) (3pts- M)** Order Labs (1pt) and Rad (1pt) review andsummarization of old records (2pts) (4pts- H)** Review labs (1pt) Rad (1pt) (2pts- L)*** Mild /moderate progression M*** Undiagnosed new problem MMDM complexity MODERATE (2 out of 3)MDM complexity HIGH (2 out of 3)Example 3:Problem(number/complexity)SLMH*Data (Test/Discussions)SL**MH** Ordering/Review of labs (1pt) and radiology(1pt) (2pts L)RiskSLM***H***Prescription drug management ( 3pts M)MDM Level (2 out of 3)SLMHMDM complexity MODERATE(moderate)*2 worsening problems (4pts- H)In this case it’s the middle level.BMC Billing Compliance16

Observation Services We have Care Managers and a Physician Advisor who manage this process and advise on Inpatient vsObservation level of care. The Physician Advisor will review cases referred by Care Management when it appears thedocumentation does not support the level of care. We are required to have an order for status i.e. Inpatient orObservation. When the provider has an expectation of the hospital stay requiring 2 midnights, or a procedure is onthe “inpatient-only” list, an order for Inpatient stay is indicated. When the provider has an expectation that the hospital stay will require less than 2 midnights, an orderfor Observation is indicated. For elective surgical procedures the choices are SDC, Bedded Outpatient or Inpatient If the patient goes home earlier unexpectedly, the physician should document the reason in the medicalrecord.99218 Initial observation care99224 Subsequent observation care99219 Initial observation care99225 Subsequent observation care99220 Initial observation care99226 Subsequent observation care99217 Observation Discharge DayBMC Billing Compliance17

Time as the (Alternate) Key Componentfor Inpatient Visits Only when counseling and/or coordination of care dominate the visit (more than 50% of thepatient related unit/floor time), then time may be considered the key or controlling factor. The code isselected based on the physician’s patient-related unit/floor time for inpatient visits. This cannot includetime off the unit even if it is patient related. The duration of the counseling and/or coordination of care may be estimated but that estimate, along withthe total duration of the visit must be recorded. Providers must document the specific counseling and/orcoordination of care that was provided. There is an approved attestation in Epic to facilitate time documentation: Counseling and/or Coordination of Care 50% of the Inpatient Patient Related Unit/Floor Time: Iwas physically present on the unit for *** minutes providing services for this patient; *** minutes werespent on counseling and/or coordination of care. I discussed with the patient/family and/or otherproviders the following topics ***.AMA Definition Counseling is a discussion with a patient and /or family concerning one or more of the followingareas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risksand benefitsand management (treatment) options; instructions for management (treatment) and /or follow-up;importance of compliance with chosen management (treatment) options; risk factor reduction; andpatient and family education. Coordination of Care may involve discussions with family, other care-givers, agencies. Only the attending/teaching physician time can be reported for time-based codes.BMC Billing Compliance18

Initial Inpatient Care(All 3 Components Needed)3 out of 3 Key Components or use*Time only when counseling and/orcoordination of care is 50% of patientrelated unit/floor time.Initial Inpatient InitialObservationSame Day Admit/ DischargeInpatient Consults99221 - 30 Min99218 – 30 Min99234 – 40 Min99253 – 55 Min99222 - 50 min99219 – 50 Min99235 – 50 Min99254 – 80 Min99223 - 70 min99220 – 70 Min99236 – 55 Min99255 – 110 MinHistory*Exam*Medical DecisionMaking Complexity*DetailedChief Complaint(CC)HPI: 4ROS: 2-9PFSH: 1DetailedExtended Exam ofaffected area and otherOrgan Systems/ BodyAreas (2 - 7 )Straightforward/Low2 out of 3 Problem/ Data/ Riskare Low ComplexityComprehensiveChief ComplaintHPI: 4ROS: 10PFSH: All 3Comprehensive8 Organ SystemsModerate2 out of 3 Problem/ Data/Riskare Moderate ComplexityComprehensiveChief ComplaintHPI: 4ROS: 10PFSH: All 3Comprehensive8 Organ SystemsHigh2 out of 3 Problem/ Data/ Riskare High Complexity 99251 – 20 Min – Prob Focused Hx/ Prob Focused Exam/ Straightforward MDM (crosswalks to a 99231) 99252 – 40 Min – Exp Prob Focused Hx/ Exp Prob Focused Exam/ Straightforward MDM (crosswalks to a 99231) 99234-99236 Same Day Admit/ D/C (Initial inpt / Obs) Pt stay 8hrs 24 hrs. Attending provides admit and d/c svc. on same day (two F2Fvisits) Modifier AI: The attending/principal physician of record shall append modifier - “AI” in addition to the initial visit code. (99222- AI)BMC Billing Compliance19

Subsequent Inpatient Care(2 out of 3 Components Needed)2 out of 3 Key Components oruse *Time only when counselingand/or coordination of care is 50% of patient related unit/floortime.History*Exam*Subsequent InpatientMedical Decision Making*ComplexitySubsequent Observation99231 - 15 min99224 - 1599232 - 25 min99225 - 2599233 - 35 min99226 - 35Problem FocusedChief ComplaintHPI: 1-3ROS (N/A)PFSH (N/A)Problem Focused1 Organ Systems/ BodyAreasStraightforward/Low2 out of 3Problem/ Data/ Risk areLow ComplexityUsually the patient is stable, recoveringor improving.Expanded Prob.FocusedChief ComplaintHPI: 1-3ROS: 1PFSH: (N/A)Expanded ProblemFocusedLimited Exam of affectedarea and Organ Systems/Body Areas (2 – 7)Moderate2 out of 3 Problem/ Data/ Risk areModerate ComplexityUsually the patient is respondinginadequately to treatment or has minorcomplications.DetailedChief ComplaintHPI: 4ROS: 2- 9PFSH: 1DetailedExtended Exam of affectedarea and Organ Systems/Body Areas (2 – 7)High2 out of 3 Problem/ Data/ Risk areHigh ComplexityUsually patient is unstable or hasdeveloped significant complication ornew problem.BMC Billing Compliance20

ED Visits(All 3 Components Needed, Used For Consults to the ED)3 out of 3 KeyHistory*Exam*Components RequiredMedical DecisionMaking* ComplexityProblem Focused1 Organ System/Body AreaStraightforward99281Problem FocusedChief Complaint HPI:1-3ROS (N/A)PFSH (N/A)99282Exp. Prob. FocusedChief Complaint HPI: 13ROS: 1 PFSH(N/A)Expanded Prob FocusedLimited Exam of affected area and otherOrgan Systems/ Body Areas (2 – 7)Low2 out of 3 Problem/ Data /Riskare Low ComplexityExp. Prob. FocusedChief Complaint HPI: 13ROS: 1 PFSH(N/A)Expanded Prob FocusedLimited Exam of affected area and otherOrgan Systems/ Body Areas (2 – 7)Moderate2 out of 3 Problem/ Data/Riskare Moderate Complexity99284DetailedChief ComplaintHPI: 4ROS: 2-9PFSH: 1DetailedExtended Exam of affected area andOrgan Systems/ Body Areas (2 – 7)Moderate2 out of 3 Problem/ Data/Riskare Moderate Complexity99285ComprehensiveChief ComplaintHPI: 4ROS: 10PFSH: All 3Comprehensive8 Organ SystemsHigh2 out of 3 Problem/ Data /Riskare High Complexity99283BMC Billing Compliance21

Hospital Day Discharge ServicesThe Discharge Day codes:CPT CodeDescription99238Hospital discharge day management; 30 minutes or less99239Hospital discharge day management; more than 30 minutes99217Hospital observation care discharge servicesDocumentation of time: Documentation of time is required when code 99239, more than 30 minutes is billed whenapplicable. Time does not have to be continuous. The time statement can say; “I spent 45minutes for the discharge day management of this patient including exam, discussion andinstructions asnoted below”, for example, in addition to the teaching physician attestation, ifapplicable Only the attending provider time counts towards determining the appropriate level of service. There is no requirement to document time for code 99238, 30 minutes or less.Content of documentation should include the following as appropriate: Final exam Discussion of hospital stay Instructions for continuing care to all relevant caregivers and preparation of discharge records,prescriptions, and referral formsBMC Billing Compliance22

Prolonged Services: Inpatient Prolonged services can be added at any level. Code 99356, Prolonged Services, first hour in the inpatient setting with direct face-toface patient contact or on the unit/floor which require one hour beyond the usual service,when billed on the same day by the same physician/APP as the companion evaluation andmanagement codes. Minimum 30 minutes Code 99357, each additional 30 minute unit, can be reported at 15 minutes. Code 99358 Prolonged Services before and/or after direct patient care, off the unit/floor ordifferent day. Code 99359, each additional 30 minute unit, can be report at 15 minutes. There are two approved attestations in EPIC for prolonged services:Prolonged Services AttestationI provided 30 minutes or more face-to-face prolonged services above and beyond the E/M code services. The total visit timewas *** minutes, and began at *** and stopped at *** . The nature of the prolonged services was due to ***.Prolonged Services (when 50% of the base E/M service is for counseling and/or coordination of care )I provided 30 minutes or more face-to-face prolonged services above and beyond the E/M code services. The total visittime was *** minutes, and began at *** and stopped at *** . The nature of the prolonged services was due to ***. The E/Mvisit was more than 50% counseling and /or coordination of care for which the total time was *** minutes and thecounseling and/or coordination of care time was *** minutes. The nature of the counseling and/or coordination of care was***.BMC Billing Compliance23

Critical Care: Definition A critical illness or injury acutely impairs one or more vital organ systems such thatthere is a high probability of imminent or life threatening deterioration in the patient’scondition at the time of the physician’s service to the patient. Critical care involves high complexity decision making to assess, manipulate, andsupport vital system functions(s) to treat single or multiple vital organ system failureand/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include, but are not limited to: central nervoussystem failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratoryfailure. Although critical care typically requires interpretation of multiple physiologicparameters and/or application of advanced technology(s), critical care may be providedin life threatening situations when these elements are not present. Providing medical care to a critically ill, injured, or post-operative patient qualifies as acritical care service only if both the illness/injury and the treatment you provide meetthis level of care. The ICU setting alone is not enough to warrant critical care billing without the criticalcare severity of the illness and the intensity of service.BMC Billing Compliance24

Critical Care: Time Reporting Attending physician’s time spent evaluating, providing care and managing the critically ill orinjured patient's care. Attending time at the bedside or on the unit and the physician is immediately available to thepatient. Time off the unit is not included even if patient-related since the physician is notavailable to the patient. Time spent reviewing laboratory test results or discussing the critically ill patient's care withother medical staff on the unit/floor, if this time represents the physician’s full attention to themanagement of the critically ill/injured patient. The physician cannot provide services to any other patient during the same period of time. Discussions with family members or other surrogate decision makers, to obtain a history or todiscuss treatment options may be counted toward critical care time since they affect themanagement of the patient. Routine updates are not counted in time billed. Critical care services provided on the same date by physicians representing different medicalspecialties that are not duplicative services are permitted. Concurrent critical care services provided by each physician must be medically necessaryand not provided during the same instance of time.BMC Billing Compliance25

Critical Care: Attestation There is an approved attestation in EPIC for critical care:I saw and evaluated the patient. I reviewed the findings and assessment with theresident and I agree with the plan as documented in the resident's note; with nochanges (or) except as outlined below. The patient is critically ill with ***. I spent*** minutes providing critical care services including ***. The teaching physician may refer to the resident’s documentation for history, examand assessment. The teaching physician’s required documentation (which this attestation facilitates)is the following :1. The time the teaching physician spent providing critical care;2.That the patient was critically ill during the time the teaching physician saw thepatient, and what made the patient critically ill; and3.The nature of the treatment and management provided by the teachingphysician.BMC Billing Compliance26

Critical Care: Code Selection99291: Critical Care, evaluation and management of the critically ill or criticallyinjured patient; first 30-74 minutes. 99292: Each additional 30 minutes (List separately in addition to code forprimary service.)Total Duration of Critical Care UnitsLess than 30 minutes30 -74 minutes(30 minutes – 1 hour 14 minutes)75 - 104 minutes(1 hour 15 minutes – 1 hour 44 minutes)Appropriate E/M codeCode - 99291105 - 134 minutes(1 hour 45 minutes – 2 hours 14 minutes)Code - 9929199292 x 2135 - 164 minutes(2 hours 15 minutes – 2 hours 44 minutes)Code - 9929199293 x 3165 – 194 minutes(2 hours 45 minutes – 3 hours 14 minutes)Code – 9929199292 x 4Code - 9929199292BMC Billing Compliance27

III. Outpatient Coding and Documentation and 2021 ChangesBMC Billing Compliance28

E/M Changes for 2021 Outpatient Visits(99202 – 99205; 99212 – 99215) The 2021 changes for the outpatient E/M codes are primarily a continuation of theprovisions that Medicare has allowed for telehealth billing during the public healthemergency (PHE). Providers will select new and established outpatient visits (99202 - 99215)based on total time or medical decision making (MDM). History and Exam will no longer factor into code selection. Counseling and/or coordination of care will no longer need to dominate theservice for time-based coding. There is a new prolonged service code for the outpatient setting for 2021. All other E/M services (Inpatient / Observation / ED) will continue to use thecurrent E/M Guidelines for E/M level selection.BMC Billing Compliance29

General Reminders for Outpatient Visits Continue to include the chief complaint to explain the medical necessity for thevisit with the reason, such as, patient here for follow-up for shoulder pain (ratherthan just “ here for follow-up”). Continue to document history and exam as clinically appropriate for the visit. Continue to select new versus established outpatient code according to the CPTdefinitions.New Patiento Patient who has not received any face-to-face professional services from thephysician/APP or another physician of the same specialty who belongs tothe same group practice, within the past 3 years, in any setting or location.Established Patiento Patient who has received face-to-face professional services from thephysician/APP or another physician of the same specialty who belongs tothe same group practice, within the past 3 years, in any setting or location.BMC Billing Compliance30

Level Selection for Outpatient E/M Visitsby Medical Decision-Making (MDM) (2 out of 3)2 out of 39920215 - 29Min9921210-19 MinProblemDataRiskMinimal1 self limited or minor problem or injuryMinimal or NoneMinimal risk9920330 - 44Min9921320 - 29MinLow2 or more self limited or minor problems or1 stable chronic illness or1 acute, uncomplicated illness or injuryLimited - Category 1: Tests and documentsAny 2 of the following categories or 2 within a category:Review of prior external note(s) from each uniquesourceReview of the result(s) of each uniquetestOrdering of each unique testOR – Category 2:Assessment requiring an independent historian(s)Low riskof morbidity from additional diagnostic testing or treatmentOver the counter drugs management.Minor surgery with no risk factorsPT/OTIV fluids without additives9920445 – 59Min9921430 –39Moderate1or more chronic illnesses withexacerbation, progression, or side effectsof treatment;OR2 or more stable chronic illnessesOR1 undiagnosed new problemwithuncertain prognosis; (e.g., lump inbreast)OR1 acute illness with systemicsymptoms; (e.g., pyelonephritis,pneumonitis, colitis)OR1 acute complicated injury (e.g., head injury withbrief loss of consciousness)Moderate – Category 1: Tests, documents, orindependent historian(s)Any 3 of the following categories or 3 within a category:Review of prior external note(s) from each uniqueReview of the result of each unique testOrdering of each unique testAssessment requiring independent historian(s)OR – Category 2: Independent interpretation of tests Independentinterpretation of a test preformed by another physician/QHCP (notseparately reported);OR – Category 3: Discussion of management or test interpretationDiscussion of management or test interpretationwith external physician/otherQHCP*/appropriate source (not separately reported)Moderate riskof morbidity from additional diagnostic testing or treatmentExamples only: Prescription Drug management Decision regarding minor surgery without identifiedpatient or procedurerisk factors Diagnosis of treatment significantly limited by socialdeterminants of health9920560 – 74Min9921540 - 54MinHigh1 or more chronic illnesses withsevereexacerbation, progression, or side effects oftreatment;OR1 acute or chronic illnessor injury that poses athreat to life or bodily function (e.g., multiple trauma,Extensive(Must meet the requirements of at least 2 out of 3 Categoriesimmediately above)High risk - of morbidity from additionaldiagnostic testing ortreatment* Decision regarding elective major surgerywith identifiedpatient or procedure riskfactors Decision re: emergency major surgery Decision regarding hospitalization DNR Decision or de-escalate of care dueto poorprognosis Drug therapy requiring intensive monitoringfor toxicity.acute MI, pulmonary embolus, severe respiratorydistress, progressive severe rheumatoid arthritis,psychiatric illness with potential threat to self orothers, peritonitis, acute renal failure)*Qualified Health Care ProfessionalAn abrupt change in neurologic status (e.g.,seizure, TIA, weakness, sensory loss)BMC Billing Compliance31

Medical Decision-Making Key DefinitionsExternal:External records, communications and/or test results from an external physician, other qualified health careprofessional or facilityIndependent historian(s):An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a historyprovided by the patient who is unable to provide a complete or reliable history (e.g., due to developmentalstage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case wherethere may be conflict or poor communication between multiple historian(s) requirement is met.Independent Interpretation:The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This doesnot apply when the physician or o

sharp lower back . pain . intermittently. BMC Billing Compliance. 9. Duration – Past few weeks Quality - Sharp Location – Lower Back Timing – Intermittently Four elements of the HPI have been documente