Provider Connection

Evaluation and Management (E/M) Revisited

GuidelinesMSF has been receiving numerous calls recently regarding denials for documentation not supporting E/M services billed.  We decided to revisit E/M guidelines.  If you disagree with a determination, you can request reconsideration from ACS by submitting the request in writing to the regular MSF address (see sidebar) or by calling ACS directly at 1-888-208-2116.

Medical Necessity is the driver for choosing a level of service.  A visit should include a “Chief Complaint” or reason for the visit.  The “Chief Complaint” is a statement that describes the symptom, problem, condition, diagnosis or the reason a patient seeks medical services.  It should be in the patient’s own words.  For Worker’s Compensation patients (or Injured Workers), medical necessity and care rendered must be directly related to the injury of record.   If a patient is seeking treatment for conditions not directly related, they should be billed separate from the Workers’ Compensation services or a separate appointment made to address those conditions.

New Patient:  A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Established Patient:  A patient who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

There are seven components of E/M services.

  • History
  • Exam
  • Medical Decision Making
  • Counseling
  • Coordination of Care
  • Nature of Presenting Problem
  • Time

The “key” components for selecting the level of service are the first three listed.

History –  There are four types of history:

  • Problem Focused – Chief complaint; brief history of present illness or problem.
  • Expanded Problem Focused – Chief complaint; brief history of present illness; problem pertinent system review.
  • Detailed – Chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family and/or social history directly related to the presenting problem.
  • Comprehensive – Chief complaint; extended history of present illness; review of systems that are directly related to the problem(s) identified in the history of the presenting illness, plus a review of all additional body systems; complete past, and family and social history.

Exam – There are four types of Exam:

  • Problem Focused – A limited examination of the affected body area or organ system.
  • Expanded Problem Focused – A limited examination of the affected body area or organ system and other symptomatic or related organ system.
  • Detailed – An extended examination of the affected body area(s) and other symptomatic or related organ system(s).
  • Comprehensive – A general multisystem examination or a complete examination of a single organ system.  Per Current Procedural Terminology (CPT) guidelines, body areas are:

    Head – including the face
    Neck
    Chest – including breasts and axilla
    Abdomen
    Genitalia – groin, buttocks
    Back
    Each extremity

Per CPT guidelines the organ systems are:

Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic

Medical Decision Making –  Per CPT guidelines there are three measurements for selecting the level of medical decision making (MDM)**:

  • The number of possible diagnoses and/or the number of management options that must be considered.
  • The amount and/or complexity of medical records, diagnostic tests, and /or other information that must be obtained, reviewed and analyzed.
  • The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities associated with the patients presenting problems(s), the diagnostic procedures(s), and/or the possible management options.

**Note:  For Workers’ Compensation purposes, the MDM must be related to the injury of record.

There are four types of Medical Decision Making:

  • Straightforward – Minimal management options; minimal or no data to review; minimal risk of complications and/or morbidity or mortality.
  • Low Complexity – Limited management options; limited data to review; low risk of complications and/or morbidity or mortality.
  • Moderate Complexity – Multiple management options; moderate data to review; moderate risk of complications and/or morbidity or mortality.
  • High Complexity – Extensive management options; extensive data to review; high risk of complications and/or morbidity or mortality.

When choosing the appropriate level of E/M the following guidelines apply:

New patient – requires all three key components for level selection;
Established patient – requires 2 of 3 of the three key components for level selection.

Time – Another component that may be used to select a level is time.  Per CPT guidelines, when counseling and/or coordination of care dominates more than 50% of the approximate time allocated to each level (See your CPT manual) of face to face time with the patient, then time may be considered the key or controlling factor for selecting a level of service.  Medical necessity must be met when using time as a key factor and the documentation must clearly support how that time was utilized.  Just documenting that “more than 50% of time was spent in counseling and coordination of care” is not sufficient.

 

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Bill Status – 1-866-274-7464

Main Phone Number 406-495-5000 or 800-332-6102

Main Fax  406-495-5020

Medical Team – 406-495-5011

Submit your Claims and/or Correspondence To
Montana State Fund
PO Box 4759
Helena, MT  59604

RMS (Bill Status)
Phone  866-274-7464
Email customer.care@risingms.com

For questions about information in this bulletin, call 800-332-6102 and ask for a member of the Medical Team.
For questions about Advanced Nurse Review contact Kym Vonada at 406-495-5389.


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Justin Kennedy
Nurse Manager
406-495-5417

Shannon Hadley
Provider Relations Specialist
406-495-5245

Kym Vonada
Medical Auditor
406-495-5389

Annalyn Stewart
Medical Payment Auditor
406-495-5367

Sheryl Semans
Pharmacy Liaison
406-495-5010

Susan Bomar
Medical Payment Auditor
406-495-5271

Cindy Gallus
Medical Customer Service Liaison
406-495-5189

Sherri Sprenger
Medical Customer Service Liaison
406-495-5420

Shannon Mergenthaler
Medical Customer Service Liaison
406-495-5185

Maggie Pentecost
Medical Customer Service Liaison
406-495-5322

Jamie Statton
Medical Customer Service Liaison
406-495-5386

Website Information

Montana State Fund montanastatefund.com

Department of LaborDepartment of Labor and Industry (DLI) website.
The website includes the Facility and Non-Facility Fee Schedule information as well as the Administrative Rules of Montana (ARM) and the instruction set for the Non-Facility Fee Schedule. Historical fee schedule information can also be found on this website.

If you have questions regarding the fee schedules call 406-444-6530 and someone will direct you to a DLI representative. For NPI information click here National Plan and Provider Enumeration System (NPPES)