Single Organ System Exam Respiratory Created by The Lung Doctor Single Organ System Exam Respiratory Comprehensive Level Perform and document ALL elements in the following organ systems Perform and document at least 1 element in each of the following Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic Musculoskeletal Extremities Skin Neurologic Created by The Lung Doctor Single Organ System Exam Respiratory Constitutional Document at least 3 vital signs as follows Blood Pressure – Sitting OR Standing Blood Pressure – Lying Pulse – Rate AND Regularity Temperature Height Weight Note: May be measured and recorded by ancillary staff Created by The Lung Doctor Single Organ System Exam Respiratory Ears, Nose, Mouth, Throat Inspection of nasal mucosa, septum, turbinates Inspection of teeth and gums Examination of oropharynx Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx Created by The Lung Doctor Single Organ System Exam Respiratory Neck Examination of neck Masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid Enlargement, tenderness, mass Examination of jugular veins Distension, a, v or cannon a waves Created by The Lung Doctor Single Organ System Exam Respiratory Respiratory Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort Intercostal retractions, accessory muscle use, and diaphragmatic movement Percussion of chest Dullness, flatness, hyperresonance Palpation of chest Tactile fremitus Auscultation of lungs Breath sounds, adventitious sounds, rubs Created by The Lung Doctor Single Organ System Exam Respiratory Cardiovascular Auscultation of heart sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation and palpation Swelling and varicosities Pulses, temperature, edema, tenderness Created by The Lung Doctor Single Organ System Exam Respiratory Gastrointestinal (Abdominal) Examination of abdomen with notation of presence or absence of masses or tenderness Examination of liver and spleen Created by The Lung Doctor Single Organ System Exam Respiratory Lymphatic Palpation of lymph nodes Neck Groin Axilla Other location Note: Exam of at least 2 locations must be documented Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Musculoskeletal Assessment of muscle strength and tone with notation of any atrophy and abnormal movements Flaccid, cogwheel, spastic Examination of gait and station Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Extremities Inspection and palpation of digits and nails Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Skin Inspection and/or palpation of skin and subcutaneous tissue Rashes, lesions, ulcers Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Neurological/Psychiatric Brief assessment of mental status Include orientation to person, time and place Include mood and affect – Anxiety, depression, agitation Created by The Lung Doctor
A concise summary of the medical documentation requirements for the respiratory single organ system exam. The documentation requirements for the history and medical decision making components are similar in all exam types, and can be reviewed in the Demystifying Medical Documentation presentation.
Documentation of Level of Service of Medical Encounters Created by The Lung Doctor for e-Medtools Inpatient Encounters Initial Hospital Encounter Or Observation Requires 3 components within shaded area Subsequent Inpatient Or Follow up Requires 2 components History Examination Complexity of medical decision LEVEL Init Hosp Care Observation D or C D or C SF/L I 99221 99218 C C M II 99222 99219 C C H III 99223 99220 PF PF SF/L I 99231 99261 EPF EPF M II 99232 99262 D D H III 99233 99263 C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Outpatient, Consults (Outpatient, Inpatient) and ER New Office / Consult / ER Requires 3 components within shaded area Established Office Requires 2 components History PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C SF ER: SF SF ER: L L ER: M M ER: M H ER: H Minimal problem that may not require presence of physician PF PF SF II -212 EPF EPF L III -213 D D M IV -214 C C H V -215 I 99-201 99-241 99-251 99-281 II -202 -242 -252 --282 III -203 -243 -253 -283 IV -204 -244 -254 -284 V -205 -245 -255 -285 I 99211 Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting □Yes □No □Yes □No □Yes □No Does documentation describe the content of counseling or coordinating care Does documentation reveal that more than half the time was counseling or coordinating care? Documentation of Time requires that ALL of the answers to the above questions are YES Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools
A concise summary of the medical documentation required to determine the overall level of service for medical encounters based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.
Documentation of Medical Decision Making Created by The Lung Doctor for e-Medtools Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Complexity of Medical Decision Making Number of Diagnoses Or Management Options Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 1 Body Area or System □ Up to 7 Body Areas or Systems □ Up to 7 Body Areas or Systems □ 8 or more Body Areas or Systems Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Number of Diagnoses or Treatment Options Complexity of Medical Decision Making A Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT Review and/or order of tests from medicine section of CPT Discussion of test results with performing physician Decision to obtain history from source other than patient Review and summarization of history obtained from source other than patient Independent visualization of image, tracing or specimen (NOT reviewing report) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies -Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives Moderate -Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury -Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture High -Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status -Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis The highest level in ANY category determines the overall risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools
A concise summary of the medical documentation requirements for medical decision making based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.
Documentation of the Medical Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related area Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Most levels require a minimum of a Detailed Exam Most levels require a minimum of a Detailed Exam Created by The Lung Doctor for e-Medtools Multi-organ System Exam Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight ≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems Comprehensive ≥2 elements* in at least 9 organ systems or body areas *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements Comprehensive Document ALL elements* *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth and gums Exam of oropharynx Chest (Breasts) Inspection Palpation Gastrointestinal Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect Musculoskeletal Gait and station Inspection, palpation digits and nails Exam of bones, joints, muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and tone Genitourinary Male Scrotal contents Penis Digital rectal exam of prostate gland Female External genitalia Urethra Bladder exam Cervix Uterus Adnexa/parametria 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools
A concise summary of the medical documentation requirements for the medical exam based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.
The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words Elements of HPI Location Brief Quality Contains 1-3 elements listed Severity Extended Duration Contains ≥ 4 elements Timing OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Documents responses to the system directly related to the presenting problem Extended Documents positive and negative responses to 2-9 systems related to the problem Complete Documents all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total) Created by The Lung Doctor for e-Medtools Past, Family and Social History Past Medical History Illnesses, Operations, Injuries and Treatments Family Medical History Include heritable diseases and those that place the patient at increased risk Social History An age appropriate review of past and current activities Pertinent Document at least 1 item from ANY of the 3 areas It must be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools
A concise summary of the medical documentation requirements for the medical history based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.
This version uses a different color theme, making it easier to view and use the worksheet in a printed format. This form is also available as a fillable PDF.
Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Status of 1-2 Chronic Conditions OR MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions OR Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Brief 1-3 Elements Brief 1-3 Elements Pertinent to Problem Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned MDM = Medical Decision Making (Number x Number Max = 2 Max = 1 Check corresponding box below on Line A Final Result for Complexity of MDM Points Points 1 1 2 3 4 Total = Result) Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Check corresponding box below on Line B of Final Result for Complexity of MDM MDM = Medical Decision Making TOTAL C. Risk of Complications, Morbidity and/or Mortality Risk Min Choose highest risk level and select corresponding risk level on line B in Final Result for Complexity Presenting problems Dx procedures ordered Management options 1 minor or self-limited Venipuncture, CXR, EKG, EEG Rest, elastic bandages 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac 1 chron prob Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Mod Elective major surgery 2 stable chron prob Prescription drug therapy Acute illness + systemic Sx Therapeutic nuclear medicine Acute complicated injury IV fluids + additives Elective maj surg + risk factors High Sev exac, 1 chron prob Emergency major surgery Acute or chronic illness Parenteral controlled sub posing threat to life/limb Rx requiring intense monitoring Abrupt change neuro status DNR or de-escalation of care Check corresponding box below on Line C of Final Result for Complexity of MDM Low Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options See TOTAL above in Box A Amount of Data See TOTAL above in Box B Highest Risk See Box C Above 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High Decision Making Level SF Low Moderate High 2 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? □Yes □No □Yes □No □Yes □No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates
Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Pertinent to Problem MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total OR Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned Number Number Max = 2 x Max = 1 Circle corresponding answer on Line A of Final Result for Complexity Points = Points 1 1 2 3 4 Total Result Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Circle corresponding answer Line B of Final Result for Complexity TOTAL C. Risk of Complications, Morbidity and/or Mortality Choose highest risk level and select corresponding risk level on line C in Final Result for Complexity Risk Min Low Mod Presenting problems 1 minor or self-limited 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac 1 chron prob Dx procedures ordered Venipuncture, CXR, EKG, EEG Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography Management options Rest, elastic bandages OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Elective major surgery Prescription drug therapy Therapeutic nuclear medicine IV fluids + additives Elective maj surg + risk factors Emergency major surgery Parenteral controlled sub Rx requiring intense monitoring DNR or de-escalation of care 2 stable chron prob Acute illness + systemic Sx Acute complicated injury High Sev exac, 1 chron prob Acute or chronic illness posing threat to life/limb Abrupt change neuro status Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options Amount of Data Highest Risk Decision Making Level 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High SF 2 Low Moderate High FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? Yes Yes Yes No No No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates
Medical Templates Demystifying Medical Documentation Created by The Lung Doctor for e-Medtools A Quick Review of Medical Documentation Requirements Created by The Lung Doctor for e-Medtools Patient Encounters The Centers for Medicare and Medicaid Services (CMS) has published definitions and documentation guidelines for the key components of a medical encounter note, using CPT codes. Created by The Lung Doctor for e-Medtools Key Components of Documentation History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time Created by The Lung Doctor for e-Medtools Key components in selecting the level of E/M services 1997 Guidelines for Evaluation & Management Services 1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words Elements of HPI Location Brief Brief Quality Contains 1-3 elements listed Contains 1-3 elements listed Severity Extended Duration Extended Contains ≥ 4 elements Timing Contains ≥ 4 elements OR discusses 3 chronic or inactive conditions OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Problem Pertinent Documents responses to the system Documents responses to the system directly related to the presenting directly related to the presenting problem problem Extended Extended Documents positive and negative Documents positive and negative responses to 2-9 systems related to responses to 2-9 systems related to the problem the problem Complete Complete Documents all positive and negative Documents all positive and negative responses to systems related to the responses to systems related to the presenting problem AND all other presenting problem AND all other systems (10 or more total) systems (10 or more total) Created by The Lung Doctor for e-Medtools Past, Family and Social History Past Medical History Illnesses, Operations, Injuries and Treatments Family Medical History Include heritable diseases and those that place the patient at increased risk Social History An age appropriate review of past and current activities Pertinent Pertinent Document at least item from ANY of the areas Document at least 11item from ANY of the 33areas must be directly related to the problems identified in the HPI ItItmust be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools The Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related area Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Most levels require a minimum of a Detailed Exam Most levels require a minimum of a Detailed Exam Created by The Lung Doctor for e-Medtools Multi-organ System Exam Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight ≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems Comprehensive ≥2 elements* in at least 9 organ systems or body areas *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements Comprehensive Document ALL elements* *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth and gums Exam of oropharynx Chest (Breasts) Inspection Palpation Gastrointestinal Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect Musculoskeletal Gait and station Inspection, palpation digits and nails Exam of bones, joints, muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and tone Genitourinary Male Scrotal contents Penis Digital rectal exam of prostate gland Female External genitalia Urethra Bladder exam Cervix Uterus Adnexa/parametria 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools Medical Decision Making Created by The Lung Doctor for e-Medtools Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Complexity of Medical Decision Making Number of Diagnoses Or Management Options Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 1 Body Area or System □ Up to 7 Body Areas or Systems □ Up to 7 Body Areas or Systems □ 8 or more Body Areas or Systems Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Number of Diagnoses or Treatment Options Complexity of Medical Decision Making A Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT Review and/or order of tests from medicine section of CPT Discussion of test results with performing physician Decision to obtain history from source other than patient Review and summarization of history obtained from source other than patient Independent visualization of image, tracing or specimen (NOT reviewing report) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies -Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives Moderate -Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury -Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture High -Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status -Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis The highest level in ANY category determines the overall risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Determining Overall Service Levels Created by The Lung Doctor for e-Medtools Inpatient Encounters Initial Hospital Encounter Or Observation Requires 3 components within shaded area Subsequent Inpatient Or Follow up Requires 2 components History Examination Complexity of medical decision LEVEL Init Hosp Care Observation D or C D or C SF/L I 99221 99218 C C M II 99222 99219 C C H III 99223 99220 PF PF SF/L I 99231 99261 EPF EPF M II 99232 99262 D D H III 99233 99263 C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Outpatient, Consults (Outpatient, Inpatient) and ER New Office / Consult / ER Requires 3 components within shaded area Established Office Requires 2 components History PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C SF ER: SF SF ER: L L ER: M M ER: M H ER: H Minimal problem that may not require presence of physician PF PF SF II -212 EPF EPF L III -213 D D M IV -214 C C H V -215 I 99-201 99-241 99-251 99-281 II -202 -242 -252 --282 III -203 -243 -253 -283 IV -204 -244 -254 -284 V -205 -245 -255 -285 I 99211 Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting □Yes □No □Yes □No □Yes □No Does documentation describe the content of counseling or coordinating care Does documentation reveal that more than half the time was counseling or coordinating care? Documentation of Time requires that ALL of the answers to the above questions are YES Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Summary Examples Documentation Requirements Created by The Lung Doctor for e-Medtools Initial Hospital Care Must meet ALL criteria 99223 Comprehensive History and Exam High complexity Medical decision making 99222 Comprehensive History and Exam Moderate complexity Medical decision making 99221 Detailed OR Comprehensive History and Exam Straightforward or Low Complexity Medical decision making Created by The Lung Doctor for e-Medtools Initial Inpatient Consultation Must meet ALL criteria 99255 Comprehensive History AND Exam High complexity medical decision making 99254 Comprehensive History AND Exam Moderate complexity medical decision making 99253 Detailed History AND Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools New Outpatient Encounter Not a Consult Must meet ALL criteria 99205 Comprehensive History and Exam High complexity medical decision making 99204 Comprehensive History and Exam Moderate complexity medical decision making 99203 Detailed History and Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools New Outpatient Consult Must meet all criteria 99245 Comprehensive History Comprehensive Exam High complexity medical decision making 99244 Comprehensive History Comprehensive Exam Moderate complexity medical decision making 99243 Detailed History Detailed Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools Established Outpatient Encounter Must meet 2 out of 3 criteria 99215 Comprehensive History Comprehensive Exam High complexity medical decision making 99214 Detailed History Detailed Exam Moderate complexity medical decision making 99213 Expanded Problem Focused History Expanded Problem Focused Exam Low complexity medical decision making Created by The Lung Doctor for e-Medtools We hope you found this presentation helpful! Remember to thank all the patient and knowledgeable billing and coding specialists who make themselves available to answer your questions in more detail! Created by The Lung Doctor for e-Medtools
Hypersensitivity Pneumonitis Extrinsic Allergic Alveolitis Martha Burk MD, MS Definition “…a group of immunologically mediated lung diseases in which the repeated inhalation of certain finely dispersed antigens of a wide variety, mainly including organic particles or low molecular weight chemicals, provokes a hypersensitivity reaction with granulomatous inflammation in the distal bronchioles and alveoli of susceptible subjects” Bourke et al Eur Respir J 2001 Epidemiology First recognized in grain workers in 1713 Prevalence difficult to assess Not caused by a single etiologic agent A complex syndrome varying in Intensity Clinical presentation Lack of agreement on diagnostic criteria Causative Antigens The Simple List Bacteria Fungi Animal proteins Insect proteins Amoebae Chemicals Medications Soybean hulls Causative Agent Source Thermophilic actinomycetes Aspergillus Aureobasidium sp Alternaria sp Candida albicans Mixed ameba, fungi, bacteria Moldy hay, plant materials, compost Animal bedding Ubiquitous Contaminated water Wood, wood pulp Saxophone mouthpiece Cold mist and other humidifiers, air conditioners Metal working fluids Paints, plastics Plastics Disease Farmer’s Lung Dog house disease Sauna-taker’s disease Wood worker’s lung Sax lung Nylon plant Office worker’s Air conditioner’s lung Ventilation pneumonitis Machine operator’s lung Paint refinisher’s lung Chemical worker’s lung Plastic worker’s lung Epoxy worker’s lung Hard metal lung disease Berylliosis Patel et al J Allergy Clin Immunol 2001 Bacteria, fungi Isocyanates Anhydrides Cobalt Berylliosis Worksite-related Agents Organic Antigens Farmer’s lung Antigen Micropolyspora faeni Aspergillus species Streptomyces albus Sacharopolyspora rectivirgula Malt worker’s lung Wood worker’s lung Aspergillus species Penicillium chrysogenum Alternaria species Merulius lacrymans Saccharomonospora viridis Cryptostroma corticale Aureobasidium pullulans Wood dust Cheese worker’s lung Sugar cane worker’s lung (Bagassosis) Detergent worker’s lung Cork worker’s lung Coffee worker’s lung Cotton worker’s lung (Bysinnosis) Wheat worker’s lung Metal worker’s lung Penicillium casei Thermoactinomyces vulgaris Bacillus subtilis Penicillium frequentens Coffee bean dust Bract of cotton flower Wheat weevil Rapid growing mycobacteria www.lungcancerfrontiers.com Inorganic Antigens Associated with HP Paints, resins, plastics Insulation, polyurethane Vineyard sprayer’s lung (fungicide) Pesticide/insecticide Non-microbial Diisocyanates Trimellitic anhydride Copper sulfate Pyrethrum Home or Work-related Agents Humidifier lung Organic Antigens Microbial Acanthamoebae castellani Acanthamoebae polyphaga Naegleria gruberi Thermoactinomyces candidus Bird breeder’s lung (budgies, pigeons) Rodent handler’s lung Hot tub/spa lung Bird droppings Urinary antigens, serum, pelts Mycobacterium avium complex Inorganic Antigens Associated with HP Polyurethane foam insulation Non-microbial Diisocyanates How much antigen are we talking about? Airborne Fungi In Industrial Environments Study of six industrial facilities Poultry house Swinery Feed preparing and storing house at swinery Grain Mill Wooden panel factory Organic waste recycling facility Samples collected by multiple methods Lugauskas et al Ann Agric Environ Med 2004 Grain Mill 49 species of 20 fungal genera isolated Penicillium, Aspergillus, Mucor, Alternaria, Cladosporium, Rhizopus and others Poultry House 31 species of 13 fungal genera Aspergillus, Penicillium, Rhizopus, Trichophyton Swinery 33 species from 15 fungal genera Aspergillus, Penicillium, Cladosporium, Zygomycetes Food processing and storing house 35 fungal species from 18 genera Aspergillus, Zygomycetes, Staphylotrichum Wood panel factory 21 fungal species from 10 genera Paecilomyces, Rhizopus* Organic waste recycling facility 40 fungal species from 21 genera Penicillium, Aspergillus, Cladosporium, Geotrichum Rhizopus cause of ODTS among wood trimmers Inciting antigens are ubiquitous! So why doesn’t everyone exposed to these environments develop hypersensitivity pneumonitis? Antigen Qualities Size 1-5 microns, usually <3 microns Inhaled into distal bronchial tree and alveoli Induce an IgG response IgE sometimes formed as well Many are capable of stimulating the complementary cascade Delayed cellular response Environmental Factors Antigen concentration Duration of exposure Frequency/intermittency of exposure Particle size Antigen solubility Use of airway protection Variability in work practice Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Genetic Susceptibility Approximately 5-15% of exposed individuals develop disease ~4% budgerigar’s fanciers ~8% pigeon breeders ~4% farmers Males affected > females Familial forms of HP documented No confirmed genetic factors May represent undetected common exposures Ethnicity may matter Pigeon fancier’s disease worse in Mexican Americans compared with Caucasian Americans Higher prevalence of HLA-DR7 in Mexican Americans HLA-DPB1 associated with more severe disease in beryllium exposure Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Additional Factors Occurs more frequently in nonsmokers Onset may be triggered by Non-specific Infections lung inflammation Mycoplasma – Case studies of HP development after Mycoplasma infection Influenza A common in lower airways of patients presenting with acute HP Inhibitory Effect of Nicotine Fewer inflammatory diseases in smokers Sarcoidosis Ulcerative colitis Radiation pneumonitis In vivo and in vitro experimental HP in rats Nicotine associated with dose-dependent decreases in Macrophage, lymphocytes and neutrophils IFN gamma, TNF Smokers develop fewer antibodies when exposed to antigens Yet, if they do develop HP More insidious More chronic Worse prognosis Blanchet et al Am J Resp Crit Care Med 2004 Occupational Respiratory Disease Surveillance Sex Yr No. of Deaths Under-lying Cause (%) M 31 28 14 31 28 24 35 25 31 36 283 F 10 8 4 15 8 13 16 13 7 21 115 W 38 34 17 44 36 32 49 38 37 56 381 Race B 1 1 1 5 2 1 1 12 O 2 2 1 5 1524 2 2 2534 1 1 1 1 3 3 10 3544 1 1 2 1 3 1 2 11 Age Group (yrs) 4554 3 2 2 4 2 6 5 2 2 9 37 5564 8 4 2 7 5 4 7 6 3 5 51 6574 11 11 3 14 8 7 11 8 10 11 94 7584 15 11 7 14 12 14 16 14 17 19 139 85 + 2 5 1 5 9 5 6 7 6 8 54 Median Age (yrs) 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 TOTAL 41 36 18 46 36 37 51 38 38 57 398 63.4 72.2 77.8 52.2 75.0 62.2 76.5 71.1 63.2 64.9 67.1 73.0 73.5 72.5 71.5 76.5 75.0 73.0 76.0 78.5 74.0 74.0 Table 8-1. Hypersensitivity pneumonitis: Number of deaths by sex, race, and age, and median age at death, U.S. residents age 15 and over, 1990-1999 CDC National Instititute for Occupational Safety and Health Hypersensitivity pneumonitis: Number of deaths, crude and age-adjusted mortality rates, U.S. residents age 15 and over, 1979-1999 CDC National Instititute for Occupational Safety and Health Immunopathogenesis Acute phase Inhaled Ag binds IgG Ab Macrophage activated and release IL-8, IL-6 Chemotactic for monocytes/macrophage Differentiation of CD4+ TH0 cells to TH1 cells Differentiation of B cells to plasma cells (IL-6) Maturation of CD8+ cells into cytotoxic cells TH1 cells secrete TNF alpha -> fever Subacute phase Macrophage develop into epithelioid cells and multinucleated giant cells Lymphoid follicles with plasma cells develop in lesions Chronic phase Macrophage express TGF beta Fibrosis Angiogenesis Patel et al J Allergy Clin Immunol 2001 Ag Memory cells Stimulates T cell Activates Cytotoxic cells Lymphocyte Stimulates Helper cells Chemokines Lymphokines Ab formation Over-expressed In rat models of HP IFN gamma key to granuloma formation in mouse models Opal and DePalo Chest 2000 Gudmundsson et al J Immunology 1998 Patel et J Allergy Clin Immunol 2001 Key Players In Fibrosis Angiotensin II TGF-β Macrophage TNF-α IL-1 Neutrophils TGF-β TNF−α Alveolar Epithelial Cell Fibroblast IFN-γ Angiotensin II TGF-β Lymphocyte Fibroblast Proliferation Extracellular Matrix Formation Clinical Features Classification Systems Classical Acute Boyd Acute progressive Cormier Active Selman Active Nonprogressive and intermittent Subacute Acute intermittent nonprogressive Nonacute Residual Active Progressive and intermittent Chronic Chronic Progressive Nonprogressive J Allergy Clin Immunol 1989;89:839 Clin Allergy 1982;12(suppl):53 Clin Pulm Med 1996;3:72 Interstitial Lung Disease Schwarz, MI, King, TE Jr, (Eds) 4th Ed, Hamilton, BC Decker 2003 UpToDate Acute Abrupt onset Clinical Diffuse rales Tachypnea Central cyanosis Cough Dyspnea Chest tightness Fevers Chills Malaise Myalgias Anorexia Nausea/vomiting Labs Leukocytosis Restrictive pattern on PFTs Positive serum precipitins Sx 4-8 hrs after high level Radiographs exposure Sx subside over hours -days Prognosis good complete recovery in 7-10 days Kupeli, et al Postgrad Med 2003 1-5mm bilateral pulmonary nodules Bilateral consolidation Ground glass infiltrates Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Acute HP London Southbank University@myweb.lsbu.ac.uk www.emedicine.com Differential Diagnosis Acute stage Acute tracheobronchitis, bronchiolitis, pneumonia Acute endotoxin exposure Organic dust toxic syndrome Allergic bronchopulmonary aspergillosis Reactive airways dysfunction syndrome Acute Respiratory Distress Syndrome Aspiration pneumonitis Bronchiolitis obliterans organizing pneumonia Diffuse alveolar damage Patel et al J Allergy Clin Immunol 2001 Subacute More insidious onset Dyspnea Cough Occurs after weeks to Exam Diffuse rales Hypoxia Labs Restrictive defect Hypoxemia months of exposure Prognosis good Radiographs Air trapping Micronodules Kupeli, et al Postgrad Med 2003 Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Differential Diagnosis Subacute stage Recurrent pneumonia ABPA Granulomatous lung diseases Infection – mycobacteria, fungi Pneumoconiosis Langerhans’ cell histiocytosis Churg-Strauss syndrome Wegener’s granulomatosis Sarcoidosis Patel et al J Allergy Clin Immunol Chronic Sx occur over 4-12 Labs months Dyspnea Fatigue Cough Same as for prior stages Pathology Fibrosis Patchy alveolar infiltrate Prognosis is poor Inciting antigen Mononuclear cells Bronchocentric pattern unlikely to be isolated Non-necrotizing granulomas Bronchiolitis obliterans Organizing pneumonia Radiographs Honeycombing Kupeli, et al Postgrad Med 2003 Non-neoplastic Disorders of the Lower Respiratory Tract 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Chronic HP www.emedicine.com Hayakawa et al Respirology 2002 Differential Diagnosis Chronic stage Idiopathic pulmonary fibrosis Chronic obstructive pulmonary disease with pulmonary fibrosis Bronchiectasis/bronchiolectasis Mycobacterium avium complex Patel et al J Allergy Clin Immunol 2001 Clinical Course Acute illness resolves in weeks if recognized early and patient exposure to antigen is eliminated Subacute or chronic illness More insidious symptoms Increased risk of emphysema, fibrosis, asthma Avian sensitivity associated with poor prognosis similar to interstitial lung disease 5 year mortality 50% Clubbing on exam portends a worse prognosis Diagnostic Criteria Major History of symptoms compatible with HP Appear or worsen within hours after antigen exposure History, Environmental investigation, Serum Ab or BAL Ab Evidence of exposure to antigen BAL lymphocytosis Histologic findings compatible with HP Compatible radiographic findings Basilar crackles Decreased diffusion capacity Decreased O2 saturation with rest or activity Synopsis of Diseases of the Chest 3rd ed Minor 1. Known exposure to offending antigen A.History of appropriate exposure B. Environmental tests confirm Ag presence C. Positive serum IgG to Ag 2. Compatible clinical, radiologic, physiologic findings Definite A. Respiratory (+/- constitutional) Si/Sx B. Compatible CXR/CT findings C. Altered PFTs, gas exchange 3. BAL with lymphocytosis A.Low CD4/CD8 B. Positive specific imm response to Ag A. Reexposure to environment B. Lab exposure to suspected Ag Probable Subclinical Sensitization 1,2,3 1,2,4A 1,2A,3,5 1,2A,3 1,3A 1 4. Positive inhalation challenge test 5. Compatible histopathology A. Poorly formed, noncaseating granulomas B. Mononuclear infiltrate Atlas of Nontumor Pathology Travis, et al 2002 American Registry of Pathology and the Armed Forces Institute of Pathology Diagnostic Value to History/Exam Multicenter trial studying consecutive patients presenting with a pulmonary syndrome for which HP was considered in the differential diagnosis Objective: Identify diagnostic criteria and develop clinical prediction rule History of exposure to Ag Presence of precipitating Ab Recurrent episodes of Sx Inspiratory crackles on exam Sx occurring 4-8 hrs after exposure Weight loss 400 patients in derivation cohort 261 patients in validation cohort HRCT and BAL defined presence or absence of HP Lacasse et al Am J Respir Crit Care Med 2003 Significant Predictors of HP Variables Exposure Precipitating Abs present Recurrent episodes Inspiratory rales Sx 4-8 hrs after exposure Weight loss Sensitivity 86% OR 38.8 5.3 3.3 4.5 7.2 2.0 Specificity 86% CI 11.6-129.6 2.7-10.4 1.5-7.5 1.8-11.7 1.8-28.6 1.0-3.9 Rules do not apply to subacute or chronic forms HP Lacasse et al Am J Respir Crit Care Med 2003 Pulmonary Function Classically, a restrictive pattern Decreased FEV1 and FVC Decreased total lung capacity Decreased diffusion capacity Concomitant bronchiolitis may result in obstructive defect Hypoxemia Bronchial hyperreactivity Chest Radiography CXR Acute Fine micronodular pattern Diffuse ground-glass opacity Normal CT Acute Profuse centrilobular micronodules Ground-glass opacities Evidence of air trapping Chronic Chronic Honeycombing Poorly defined nodules Fibrosis Lobar volume loss Interstitial fibrosis Imaging of Diseases of the Chest 3rd ed Armstrong et al Mosby London 2000 Ground Glass Opacities www.emedicine.com Bronchoalveolar Lavage Immediate (within 48 hours) Neutrophils Days later T lymphocyte predominant alveolitis CD8+ predominant CD4/CD8 usually < 1.0 Few disease processes > 50% 20-70% lymphocytes Increased mast cells, usually > 1% Problem Lymphocytic response seen in asymptomatic patients with antigen exposure, and patients with organic dust toxic syndrome Atlas of Nontumor Pathology Non-Neoplastic Disorders of the Lower Respiratory Tract Hypersensitivity pneumonitis: current concepts Eur Respir J 2001 18:81s-92s Histopathology Cellular bronchiolitis Interstitial lymphocytic infiltrate Usually bronchocentric Scattered, small, poorly formed non-necrotizing granulomas Large histiocytes with foamy cytoplasm Fibrosis Indistinguishable from other causes in advanced disease Approximately 80% of subacute and chronic cases have this triad Differential Diagnosis Table Modified from Atlas of Nontumor Pathology Histologic Hypersensitivity Sarcoidosis feature Pneumonitis Granulomas Frequency Morphology Distribution Intraluminal fibrosis Lymphocyte infiltrates Dense fibrosis BAL lymphocytosis 2/3 open biopsies 100% of cases LIP 5-10% cases; Well formed or poorly formed Random Poorly formed Mostly random, some peribronchiolar 2/3 open biopsies Mild-moderate Peribronchiolar Advanced cases CD8>CD4 (CD4/CD8 < 1.0) Well formed Lymphangitic, peribronchiolar, perivascular Very rare Absent or minimal Advanced cases CD4>CD8 (> 3.5 has a PPV 75%) Unusual Extensive, diffuse Unusual Usually B cells Non-neoplastic Disorders of the Lower Respiratory Tract Predictive Value of BAL Cell Differentials in the Diagnosis of Interstitial Lung Disease (ILD) Retrospective evaluation 3,975 BALF samples from 3,118 pts Collected January 1997 – November 2003 Determine pre-test and post-test probabilities Relative frequencies of diagnoses based on available information (prior to BAL) were used as pre-test probabilities Post-test probabilities determined using Bayes’ rule based on cell differentials and the CD4/CD8 ratio Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of CD4/CD8 in suspected ILD n CD4/CD8 Sarcoidosis UIP EAA 239 112 66 33.7 15.8 9.3 Pre-test 9.1 * 13.6 27.3 * Post-test <0.5 0.5-3.5 40.3 12.2 17.2 * >3.5 69.1 *** 5.2 * 12.5 p<0.05; *** p<0.001 Versus the respective a priori value Likelihood of EAA rose 3x with a CD4/CD8 <0.5 Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of lymphocytes and CD4/CD8 in suspected ILD when the percentage of granulocytes was low (eosinophils <2% and neutrophils <4%) Post-test Lymph % and CD4/CD8 Sarcoidosis UIP EAA n 182 25 35 Pretest 45.2 6.2 8.7 <30 Low High 30-50 Low High Low >50 High 28.6 86.1 56.1 *** *** 9.4 1.4 *** 5.6 0.0 3.5 17.5 * 86.5 *** 0.0 2.7 33.3 3.0 39.4 *** 55.6 0.0 29.6 *** Likelihood of EAA rose nearly 4x independently of CD4/CD8 when lymphocytes were very high and granulocytes were low •p<0.05; *** p<0.001 •Low CD4/CD8 <3.5 Eur Respir J 2004; 24: 1000-1006 Probability of ILD as a function of lymphocytes and CD4/CD8 in suspected ILD when the percentage of granulocytes was high (eosinophils >1% and neutrophils >3%) Lymph % and CD4/CD8 Sarcoidosis UIP Pretest 18.6 28.3 Post-test <30 Low High 30-50 Low High >50 Low High n 57 87 13.9 44.4 23.1 * 34.2 22.2 11.5 50.0 * 6.3 21.4 0.0* 0.0 0.0 EAA 31 10.1 3.0* 5.6 34.6 *** 37.5 *** 50.0 *** 50.0 Likelihood of EAA rose nearly 5x independently of CD4/CD8 when lymphocytes were very high and granulocytes were high p<0.05; *** p<0.001 Low CD4/CD8 <3.5 Eur Respir J 2004; 24: 1000-1006 Who Gets HP? Farmers Farmers moving hay into a barn, [between 1895 and 1910] Bartle Brothers Glass plate negative Reference Code: C 2-10232-1729 Thermophilic actinomycetes Hay, grain, compost, manure Pigeon, duck, turkey, quail Contaminated air conditioning systems Contaminated air conditioning systems Avian proteins Amoebae (Naegleria, Acanthamoeba) Thermophilic actinomycetes Bird Fanciers www.ryancordell.com Bird Fanciers Avian proteins Case study 67 yo 150+ pack-yr smoker www.ladygouldianfinch.com Raised budgerigars 1980-88 Diagnosed as IPF 1988 1994 diagnosed with Bird Fancier’s Lung Lymphocytic alveolitis and organizing pneumonia by TBBx Serum precipitins positive for bird antigens Developed low grade fever and increased dyspnea Bronchocentric alveolitis on CT/chest Patient acquired feather duvet Inase et al Internal Medicine 2004 Disease stable until 2000 Nursing Home Aviary Factory Workers Metalworking fluid aerosols Pseudomonas fluorescans Mycobacterium avium complex Cheese mold www.groupnch.com www.defra.gov.uk Penicillium Plastics and resins Anhydrides Paint catalysts, adhesives, and foam Diisocyanates Contaminated ventilation systems Naegleria, Acanthamoebae Patients With H/O Medication Use Amiodarone Gold Procarbazine Minocycline Chlorambucil Sulfasalazine Beta blockers HMG co-A Reductase inhibitors Others Wood workers Alternaria species Malt workers Aspergillus Bathtub refinishers Domestic engineers Ventilation systems, compost, chemicals, greenhouses Office employees and Paint refinishers Diisocyanates Ventilation systems Lab workers Rat urinary proteins Anybody! Household mold Air conditioning Saunas, Hot tubs Birds Goose down Diagnostic Approach Detailed history and physical exam Patient may not associate symptoms with antigen exposure Symptoms may be delayed for hours Temporal relationship weaker with chronic forms Positive precipitating antibodies Once thought to be hallmark Demonstrates immune response Lack sensitivity and specificity for HP Serve as markers for antigen exposure Poorly standardized antigens Improper quality controls More sensitive, but less specific Enzyme-linked immunosorbent assay Bronchoscopy Lung biopsy No single clinical or laboratory feature is diagnostic Occupational History Current and previous occupations Description of job processes Chemical exposure Symptom improvement away from work? Similar symptoms in coworkers? Use of respiratory protection at work Environmental History Pets (especially birds) Hobbies and recreational activities Presence of humidifiers, swamp coolers, indoor vented dryers Use of hot tubs, saunas Visible fungal growth in household/workplace History of flooding or water damage to walls and carpets History of recent renovation/remodeling Similar symptoms in home occupants Feather pillows, comforters, bedding, jackets Use of air fresheners, spray cleaners www.brickleyenv.com www.indoorairpro.com Treatment Antigen avoidance Responsible antigen may be difficult to isolate Multiple antigens may be involved Half-lives of animal dander, proteins measured in years Exposure may be unavoidable Disease may progress in spite of antigen avoidance Corticosteroids 0.5 mg/kg/d for severe, acute episodes Subacute episodes may benefit from 1 mg/kg/day 2-4 weeks Improved short term effect No difference in long term effects (5 years) Role of inhaled steroids and beta agonists unclear May provide symptomatic relief UpToDate Monkare Eur J Respir Dis 1983 Kokkarinen et al Am Rev Respir Dis 1992 Patel et al J Allergy Clin Immunol 2001 Value of steroids Monkare Eur J Respir Dis 1983 93 pts with Farmer’s lung studied prospectively No impact on lung function or work capacity Minor improvements in radiographic changes Kokkarinen et al Am Rev Respir Dis 1992 36 pts in double blind, placebo control 20 received prednisolone x 8 wks 16 received placebo 1 month follow up Steroids improved DLCO No statistical significance between groups Symptoms recurred – 6 pts receiving steroids – 1 pt in placebo group 5 year follow up Summary of HP Antigen exposure is necessary but insufficient Important exposures occur at home Pet birds, feathers, humidifiers, indoor molds and bacteria Challenging to diagnose Nonspecific symptoms Variable clinical presentation Variable radiographic findings Lack of a “gold standard” diagnostic test Immunopathogenesis remains unclear Can be improved with antigen avoidance, and steroids in severe, acute cases Unrecognized/untreated it may lead to development of asthma, emphysema or interstitial fibrosis
