Introduction and History

SOAPware, Inc. is proud to introduce its Evaluation and Management Coder Module. HCFA and the AMA have developed very detailed requirements that physicians must meet in order to bill for certain levels of service during patient encounters. SOAPware users can now automatically determine the level of service for their encounter note documentation. Using the optional E&M coder, a wizard continually reports the complexity of history, exam and decision making. This will greatly simplify the process of determining the adequacy of documentation and relieve provider anxiety.

Evaluation and Management codes, as designed by HCFA and the AMA, have 5 levels of service (or level of complexity) for each type of patient encounter (new patient, established patient, consultations, initial hospital visit, subsequent hospital visit, ER encounter, etc.).

The level of service (or evaluation and management code, E&M code) for encounters is determined by 3 categories: I. History; II. Exam; III; Decision Making. Each of these three main categories is separated into subcategories:

I. History = 1. HPI*; 2. Review of Systems; 3. PFSH*

II. Exam = 15 main categories and 54 specific items

III. Decision Making = 1. Diagnosis complexity; 2. Data/studies complexity; 3. Risk

*HPI = History of present illness.

*PFSH = Past, Family, and Social History.

Note - All encounters levels must contain both a specified Chief Complaint and a Diagnosis.

In order to document a level of service for an encounter, you must determine the following 8 scores, and must always include a chief complaint and have at least one diagnosis specified. Below is an outline as to how to go about determining the scores related to determining the E&M code:

Chief Complaint: Yes/No
Diagnosis: Yes/No

I. HISTORY:
Total HPI Score: _____
Total ROS Score: _____
Total PFSH Score: _____
Total History Score: _____

II. EXAM:
Total Exam Score: _____

III. DECISION MAKING:
Total Number of Problems/Diagnoses Score ____
Total Data Score ____
Total Risk Score ___

Total Decision Making Score: _____

SOAPware will automatically determine the level of service if you utilize the following methods or structure when creating your documentation. Not only is this a great potential time saver, but this eliminates the need to have to count up individual scores, etc which is very difficult for busy physicians. The remainder of this exercise will attempt to explain the structure and logic SOAPware uses to calculate the E&M codes as defined by HCFA and the AMA.

Most of the History components are placed in the Subjective field of SOAPware. Go to a SOAPware chart and create a new or empty encounter. For the E&M coder to work properly, it is necessary to place a group of headings into the subjective field. This outline can be inserted via a menu item or by use of code expanders. For this demonstration, start the encounter by selecting "Insert Documentation Template" from the Subjective menu. It appears as this:

CHIEF COMPLAINT: __.

HPI:

ONSET/TIMING: __.

DURATION: __.

QUALITY/COURSE: __.

LOCATION: __.

INTENSITY/SEVERITY: __.

CONTEXT/WHEN: __.

MODIFIERS/TREATMENTS: __.

SYMPTOMS/RELATED: __.

REVIEW OF SYMPTOMS:

GEN: __.

Associated/Constitutional: __.

Endocrine: __.

Hematologic/Lymphatic: __.

Allergic/Immunologic: __.

ENT: __.

Eyes: __.

NECK: __.

LUNGS/Respiratory: __.

HEART/Cardiovascular: __.

ABD/Gastrointestinal: __.

GENT/Genitourinary: __.

BJE/Musculoskeletal: __.

SKIN/Integumentary: __.

NEURO: __.

PSYCH: __.

PAST FAMILY AND/OR SOCIAL HISTORY:

Past History:

Summary (Problems/Surg/meds/Allergies): Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

There are a number of double underscores "__" which can be left blank or changed into information. Each of the headings ( e.g. ONSET/TIMING:) preceding each double underscore is an element defined in the documentation guidelines from HCFA. Each time a double underscore is replaced by information, then a point is added to the HPI score and adds to the level of complexity of the visit. For example, the text string "ONSET/TIMING: 3 days ago. Nocturnal." in the subjective field would add one point to the history score in the HPI section. Note that in this example a "(+)" or a "(-)" after each heading in order for a point to be added.

1. ONSET/TIMING: __. (e.g. 3 days ago. Nocturnal.)
2. DURATION: __. (e.g. Continuous.)
3. QUALITY/COURSE: __. (e.g. Sharp. Worsening.)
4. LOCATION: __. (e.g. Bilateral.)
5. INTENSITY/SEVERITY: __. (e.g. Severe.)
6. CONTEXT/WHEN: __. (e.g. Activity. Stress.)
7. MODIFIERS/TREATMENTS: __. (e.g. Analgesics.)
8. SYMPTOMS/RELATED: __. (e.g. Diaphoresis with chest pain.)

A level 4 visit must contain at least 2 of the 8 elements in the HPI section. A level 3 visit only has to contain 1 HPI element.

Once the documentation is completed, any of the 8 HPI elements in the subjective field left blank can be automatically removed via the "Remove Subjective Underlines" and the "Remove Unused Documentation Items" commands under the Subjective menu.

For example, note the following subjective field text:

ONSET/TIMING: 3 days ago(+). Nocturnal(+).
DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.
QUALITY/COURSE: __. –Worsening(+). Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__.

After selecting the option "Remove Subjective Underlines" it appears as

ONSET/TIMING: 3 days ago(+). Nocturnal(+).
DURATION:
QUALITY/COURSE: Worsening(+).

Finally, after selecting "Remove Unused Documentation Items" it will appear as below:

ONSET/TIMING: 3 days ago(+). Nocturnal(+).
QUALITY/COURSE: Worsening(+).

Note- each of the 8 HPI elements can score only one point for each element, even though you may include more than one item of information. For example, "ONSET/TIMING: 3 days ago. Nocturnal." And "ONSET/TIMING: 3 days ago." Both add just one point even though the first example contains 2 items.

The " REVIEW OF SYMPTOMS: "section contains 14 sections as defined by HCFA. A level 4 visit, for example, must have at least 2 of the categories addressed as below:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

ENT:

Eyes:

Neck:

LUNGS/Respiratory: Cough(+).

HEART/Cardiovascular:

ABD/Gastrointestinal: Nausea(-).

GENT/Genitourinary:

BJE/Musculoskeletal:

SKIN/Integumentary:

NEURO:

PSYCH:

As you will recall, selecting "Insert Documentation Template" from the Subjective menu automatically placed the above outline into the Subjective field. If any text is placed after any one of these ROS items (i.e. "Cough(+)." after "LUNGS/Respiratory:" ) then one point is added to the History score within the ROS category. You do not have to include a "(+)" or a "(-)" in order for a point to be added to the ROS score. The example below will add 2 points to the ROS score:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

ENT:

Eyes:

Neck:

LUNGS/Respiratory: Cough(+). Dyspnea(-).

HEART/Cardiovascular:

ABD/Gastrointestinal: Nausea(-).

GENT/Genitourinary:

BJE/Musculoskeletal:

SKIN/Integumentary:

NEURO:

PSYCH:

The line containing "REVIEW OF SYMPTOMS:" is a special exception in that it has a unique capability in the subjective field. You can add up to 3 ROS points by way of using either a "(+)" or a "(-)"

For example:

"REVIEW OF SYMPTOMS: Cough(+). Nausea(-). Fever(-). Dyspnea(+)."

The line above in the subjective field will add 3 ROS points.

The outline for the history category "PAST FAMILY AND/OR SOCIAL HISTORY" (or PFSH) is also listed in the subjective field when you select the "Insert Documentation Template" command in the Subjective menu. Its inclusion within the Subjective field is for convenience only in that it serves as a reminder during the creation of documentation. You should place the actual PFSH information into the appropriate sections of the summary on the left side of the SOAPware screen. The PFSH headings are included in the summary field as a reminder during the encounter that these sections on the summary side need to be addressed if you plan to code for higher levels of service(i.e. greater than level 3 such as 99213).

The PFSH outline (see below) is routinely and automatically deleted as the encounter note is permanently stored or printed, or after selecting the "Remove Unused Documentation Items" items in the Subjective menu:

PAST FAMILY AND/OR SOCIAL HISTORY (Summary fields in SOAPware)

Past History:

1. Summary (Problems/Surg/Meds/Allergies): Refer to specific fields.
2. Social History: Refer to specific fields.
3. Family History: Refer to specific fields.

When automatically scoring documentation in order to determine the level of service for E&M coding,, SOAPware will check to see if any one of these 3 groups of the "PFSH" summary fields contain information. Group #1, past history, includes any information which exists within any one of the five following fields: the 1-Active Problems, 2-Inactive Problems, 3-Surgeries, 4-Medications or Allergy fields. Group 2 is the Social History field on the summary side. Lastly, group 3 consists of any information within the Family History field within the SOAPware summary. The PFSH section can add up to a total of 3 points to the history score. One point is added for each field for information in either the social history or family history fields for a total of up to 2 points. Likewise, another single point is added if any one of 5 specific past history fields of the summary contain any information (Problems-Active or Inactive, Surgeries, Medications, and Allergies).

It is very important to remember that the final encounter documentation which is either printed or stored must include information from the summary fields if you designate a level of service above level 3. The print report "Extended SOAP Note" will include summary field information in addition to the 6 fields in the SOAP encounter note when producing the final encounter documentation which is either printed or stored.

In summary, below is the complete outline that the SOAPware E&M coder utilizes for determining the history component of the level of service for E&M coding.

HISTORY:

HISTORY--(Subjective and Summary Fields in SOAPware)-----------------------------------------

CHIEF COMPLAINT __. (Subjective field in SOAPware) Chief Complaint: Yes/No

HPI:

ONSET/TIMING: __. (e.g. 3 days ago, nocturnal)

DURATION: __. (e.g. continuous, intermittent)

QUALITY/COURSE: __. (e.g. sharp, dull, worsening, improving)

LOCATION: __. (e.g. bilateral, right)

INTENSITY/SEVERITY: __. (e.g. mild, severe)

CONTEXT/WHEN: __. (e.g. activity, stress)

MODIFIERS/TREATMENTS: __. (e.g. analgesics, cough)

SYMPTOMS/RELATED: __. (e.g. diaphoresis with chest pain)

Total HPI Score: _____

REVIEW OF SYMPTOMS: (Subjective field in SOAPware)

GEN:

Associated/Constitutional: __.

Endocrine__.

Hematologic/Lymphatic__.

Allergic/Immunologic__.

ENT: __.

Eyes__.

LUNGS/Respiratory: __.

HEART/Cardiovascular: __.

ABD/Gastrointestinal: __.

GENT/Genitourinary: __.

BJE/Musculoskeletal: __.

SKIN/Integumentary: __.

NEURO: __.

PSYCH: __.

Total ROS Score: _____

PAST FAMILY AND/OR SOCIAL HISTORY (Summary fields in SOAPware)

Past History:

Problem Lists/Surg/Meds/Allergies: Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

Total PFSH Score: _____

EXAM:

The exam documentation is entered into the objective field in SOAPware. There are 14 systems listed in the published HCFA/AMA documentation guidelines.

1. Constitutional:

2. Lymphatic:

3. Ears, Nose, Mouth, & Throat:

4. Eyes:

5. Neck:

6. Respiratory:

7. Chest:

8. Cardiovascular:

9. Gastrointestinal (Abdomen):

10. Genitourinary:

11. Musculoskeletal:

12. Neurologic:

13. Psychiatric:

14. Skin:

Below are the equivalent headings within the objective field in SOAPware.

1. GEN:

2. LYMPH:

3. HEENT:

4. EYES:

5. NECK:

6. LUNGS:

7. CHEST/BREASTS:

8. HEART:

9. ABD:

10. GENT:

11. BJE:

12. NEURO:

13. PSYCH:

14. SKIN:

There are close to 50 specific (First level) items that can be addressed in a general multisystem exam. Each double underscore within the objective template placed within the objective field which is replaced with a (-) will add one point (*see below) to the total exam score. If the underscore is replaced with a (+), HCFA requires that you must define or describe the abnormal exam (or objective) finding. For example, "Oropharynx-Abn__. " can be changed simply to "Oropharynx-Abn(-). " with mouse clicks. In contrast, it can not be simply changed to "Oropharynx-Abn(+). " . You must add some definition, such as "Oropharynx-Abn(+) with swollen tonsils. " In this example, "with swollen tonsils." is the description or definition for "Oropharynx-Abn(+)".

Below is the first level items for documentation of exam findings:

GEN: Appear/General-Abn__. VS- __. LYMPH: __.

HEENT: Lips/Teeth/Gums-Abn__. Oropharynx-Abn__. EARS- Hearing-Abn__. Otoscopic-Abn__. Ear-Nose/Appear-Abn__. NOSE- Nose/Internal-Abn__. EYES: Conjunctiva/Lids-Abn__. Pupils/Irises-Abn__. Ophthalmoscopic-Abn__.

NECK: Neck-Abn__. Thyroid-Abn__.

LUNGS: Lung/Auscultation-Abn__. Respirations-Abn__. Chest/Palpation__. Lungs/Percussion-Abn__. CHEST/BREASTS: Breasts/Inspection-Abn__. Breast/Palpation-Abn__.

HEART: Heart/Palpation-Abn__. Heart/Auscultation-Abn__. Pulses/Carotid-Abn__. Pulses/Aorta__. Pulses/Femoral-Abn__. Pulses/Pedal-Abn__. Peripheral/Edema_or_Varicosities__.

ABD: Abdomen-Mass/Tenderness-Abn__. Liver/Spleen-Abn__. Hernia-Abn__.

GENT: Anus/Perineum/Rectum-Abn__. Guaiac-Positive__. MALE-__. Scrotal-Abn__. Penis-Abn__. Prostate-Abn__. FEMALE-__. Pelvic/External__. Urethra__. Bladder__. Cervix-Abn__. Uterus-Abn__. Adnexa/Parametria-Abn__.

BJE: Inspection/Palpation/Motion/Stability/Strength-Abn__ of __. Digits/Nails-Abn__. Gait/Station-Abn__.

NEURO: Cranial/Nerves-Abn__. Sensation-Abn__. DTR-Abn__. PSYCH: Insight/Judgement-Abn__. Disoriented__. Memory/Impairment__. Mood/Affect-Abn__.

SKIN: Skin/Subcutaneous-Inspection-Abn__. Skin/Subcutaneous-Palpation-Abn__.

STUDIES:

BJE: Inspection/Palpation/Motion/Stability/Strength-Abn__ of__.

*area = 1. Head/Neck; 2. Spine/Ribs/Pelvis; 3. Right Upper Ext; 4. Left Upper Ext; 5. Right Lower Ext; 6. Left Lower Ext.

Secondarily can address each of the following for one point each: Inspection-Palpation-Abn__. Range_of_Motion-Abn__. Instability-Abn__. Strength-Abn__.

VS__ = Must include 3.

LYMPH __ (Must include 2 lymph sites) Lymph/Neck-Abn__. Lymph/Axillae-Abn__. Lymph/Groin-Abn__. Lymph/Other-Abn__.

Note that the logic varies slightly in dealing with 3 items related to the exam score:

"VS- __" ,

"LYMPH- __"

"Inspection/Palpation/Motion/Stability/Strength-Abn__ of __" .

VS__ = Must include 3 of 7 vital signs.

LYMPH __ = Must include 2 of 4 lymph sites: Lymph/Neck-Abn__. Lymph/Axillae-Abn__. Lymph/Groin-Abn__. Lymph/Other-Abn__.

For example, "LYMPH- Lymph/Neck-Abn(-)." Would not add any points.

According to the E&M documentation guidelines, If you bill for a level 5 encounter, you must address no less than 18 exam items in no less than 9 different systems. In contrast, a level 4 encounter must address at least 12 exam items in at least 2 different systems.
Once the documentation is completed, any of the physical exam elements in the objective field left blank (e.g. "Otoscopic-Abn__.") can be automatically removed via the Remove Objective Underlines command in the Objective menu.

The STUDIES: listing in the Objective field heading template is present because this was where it was located in previous versions of SOAPware over many years. However, in the future, we suggest that documentation regarding studies be placed within the plan field in order to facilitate more accurate functioning of the E&M coder. The next section will explain why this is important.

Again, notice the Objective menu has several selections to facilitate E&M coding. For example, the item "Objective Template" enters the following outline:

GEN: LYMPH:

HEENT: EYES:

NECK:

LUNGS: CHEST/BREASTS:

HEART:

ABD:

GENT:

BJE:

NEURO: PSYCH:

SKIN:

STUDIES:

The Objective menu selection of "Enter All Normal" enters the following outline:

GEN: Appear/General-Abn(-). VS- __. LYMPH: __.

HEENT: Lips/Teeth/Gums-Abn(-). Oropharynx-Abn(-). EARS- Otoscopic-Abn(-). Hearing-Abn(-). Ear-Nose/Appear-Abn(-). NOSE- Nose/Internal-Abn(-). EYES: Conjunctiva/Lids-Abn(-). Pupils/Irises-Abn(-). Ophthalmoscopic-Abn(-).

NECK: Neck-Abn(-). Thyroid-Abn(-).

LUNGS: Lung/Auscultation-Abn(-). Respirations-Abn(-). Chest/Palpation(-). Lungs/Percussion-Abn(-). CHEST/BREASTS: Breasts/Inspection-Abn(-). Breast/Palpation-Abn(-).

HEART: Heart/Palpation-Abn(-). Heart/Auscultation-Abn(-). Pulses/Carotid-Abn(-). Pulses/Aorta-Abn(-). Pulses/Femoral-Abn(-). Pulses/Pedal-Abn(-). Peripheral/Edema_or_Varicosities(-).

ABD: Abdomen-Mass/Tenderness-Abn(-). Liver/Spleen-Abn(-). Hernia-Abn(-).

GENT: Anus/Perineum/Rectum-Abn(-). Guaiac-Positive(-). MALE-(-). Scrotal-Abn(-). Penis-Abn(-). Prostate-Abn(-). FEMALE-(-). Pelvic/External-Abn(-). Urethra-Abn(-). Bladder-Abn(-). Cervix-Abn(-). Uterus-Abn(-). Adnexa/Parametria-Abn(-).

BJE: Inspection/Palpation/Motion/Stability/Strength-Abn(-) of extremities. Digits/Nails-Abn(-). Gait/Station-Abn(-).

NEURO: Cranial/Nerves-Abn(-). Sensation-Abn(-). DTR-Abn(-). PSYCH: Insight/Judgement-Abn(-). Disoriented(-). Memory/Impairment(-). Mood/Affect-Abn(-).

SKIN: Skin/Subcutaneous-Inspection-Abn(-). Skin/Subcutaneous-Palpation-Abn(-).

STUDIES:

Note that each of these main items individually can only add one point each. For example, the line below within the objective field would only add one point to the exam score even though 2 elements were described.

SKIN: Skin/Subcutaneous-Inspection-Abn(+) with diffuse Urticaria. Seborrheic Keratosis(+) multiple, on trunk. Skin/Subcutaneous-Palpation-Abn__.

Again, note that the text "Oropharynx-Abn(+). " will not add any points to the exam score. You must add some definition whenever there is a (+), such as "Oropharynx-Abn(+) with swollen tonsils." which will add a point to the exam score.

Code expanders have been added to allow for quick entry of specific systems. For example, empty the objective field and enter the code "oh" to get the following objective headers:

GEN:

HEENT:

NECK:

LUNGS:

HEART:

ABD:

GENT:

BJE:

NEURO:

SKIN:

STUDIES:

In the objective field, you can place the insertion point just to the right of the colons and use the headers as code expanders. For example, place the insertion point just to the right of "ABD:" and expand it to get the following:

ABD: Abdomen-Mass/Tenderness-Abn__. Liver/Spleen-Abn__. Hernia-Abn__.

Similarly, if you add a "n" such as "ABD:n" and expand it, you get an all normal exam as below:

ABD: Abdomen-Mass/Tenderness-Abn(-). Liver/Spleen-Abn(-). Hernia-Abn(-).

The exception to this rule is the "GENT:" header. In this case you can add either a "m" or an "f" in order to get a male and female exam as below:

"GENT:m" expands into:

GENT: Anus/Perineum/Rectum-Abn(-). Guaiac-Positive(-). MALE-__. Scrotal-Abn(-). Penis-Abn(-). Prostate-Abn(-).

While "GENT:f" expands into:

GENT: Anus/Perineum/Rectum-Abn(-). Guaiac-Positive(-). FEMALE-__. Pelvic/External(-). Urethra(-). Bladder(-). Cervix-Abn(-). Uterus-Abn(-). Adnexa/Parametria-Abn(-). Pap obtained__.

Finally, adding an "e" will expand each header into an extended exam which is useful if doing an extensive exam of a particular organ system. For example, "NECK:e" expands into:

NECK: Neck-Abn__.---Neck_Appearance__. Neck_Mass__. Neck_Symmetry__. Tracheal_Deviation__. Neck_Crepitus__. Veins/Jugular-Abn__.---Jugular/Distension__. Jugular/Awave__. Jugular/Vwave__. Jugular/CannonWave__.

Thyroid-Abn__. Thyroid/Enlargement__. Thyroid/Tenderness__. Thyroid/Mass__.

You will notice that "---" serves to link qualifiers to the main objective items.

Decision Making:

The Decision Making section of the documentation guidelines is comprised of 3 subcategories:

Number of Problems/Diagnoses.

Data/Studies.

Level of Risk.

While the first 2 subcategories are a little more specific, the section dealing with level of risk is open to interpretation and not easily automated. Because the level of risk is very much subjective, there is no good way to accurately automate its value within a comuter-based medical record. As a compromise, the SOAPware coding wizard simply adds one point for each diagnosis listed in the assessment field when it is calculating the subcategory dealing with the level of risk. IT IS EXTREMELY IMPORTANT That the user review the calculated risk score before accepting any suggested level of service.

For calculating Number of Problems/Diagnoses score, the SOAPware automatic coding wizard will look at each of the lines in the assessment field. If a line containing a diagnosis also includes the encounter date (i.e. which is the mechanism that you indicate a new diagnosis), the text string "(See Plan)" and either the word "uncontrolled" or "worsening" then 4 points are added to the Decision Making score.

Uncontrolled Anxiety Syndrome (Tense or nervous) #300.00. 02/28/1998 (See Plan).

There is no maximum point total here with this rule, so if 3 lines meet this criteria, then 12 points are added to the point total.

For example, if the following is placed into the objective field then 12 points are added to the score:

Uncontrolled Anxiety Syndrome (Tense or nervous) #300.00. 02/28/1998 (See Plan).

Worsening Upper respiratory infection (cold virus) #465.9. 02/28/1998 (See Plan).

Worsening Sprain, ankle #845.00. 02/28/1998 (See Plan).

If a line containing a diagnosis includes only the encounter date (i.e. indicates a new diagnosis), then 3 points are added. There is a maximum here in that this rule will only allow 3 points to be added to the total. Whether there is one line or 3 lines containing the encounter date as the only qualifier, only 3 points will be added. For example, the following text in the Assessment field will add 3 points to the total:

Anxiety Syndrome (Tense or nervous) #300.00. 02/28/1998

If a line containing a diagnosis includes only the word "uncontrolled" or "worsening" then 2 points are added. Therefore, if there are 3 diagnosis which are uncontrolled or worsening, then 6 points are added to the point total. For example, the following would add 6 points to the total:

Uncontrolled Anxiety Syndrome (Tense or nervous) #300.00.

Worsening Upper respiratory infection (cold virus) #465.9.

Worsening Sprain, ankle #845.00.

Finally, for the remaining diagnoses, 1 point is added for each diagnosis which stands alone (i.e. no additional descriptors as described above). There is a maximum here in that this rule will only allow 2 points to be added to the point total. For example, the following would add 2 points to the total:

Anxiety Syndrome (Tense or nervous) #300.00.

Upper respiratory infection (cold virus) #465.9.

Likewise, the following will only add 2 points even though there are 3 lines or diagnoses:

Anxiety Syndrome (Tense or nervous) #300.00.

Upper respiratory infection (cold virus) #465.9.

Sprain, ankle #845.00.

For convenience, code expanders for these modifier/descriptors have been included in SOAPware:

"U" expands into "Uncontrolled" and "W" expands into "worsening."

Control-D automatically enters the encounter date.

"D" in the assessment field expands into "(See Plan)."

In Summary, for calculating the Number of Problems/Diagnoses portion of the Decision Making score, the automatic coding wizard will look at the Decision Making rules as described in the outline below:

DECISION MAKING--Has 3 parts - Number, Data, Risk)--(Assessment/Plan fields in SOAPware)

Number of Problems/Diagnoses:

Each diagnosis addressed. 1 point (Max Point Total=2) _____
Each diagnosis uncontrolled/worsening 2 points (No Maximum) _____
A new diagnosis (not minor/self-limited) 3 points (Max Point Total=3) _____
A new diagnosis (not minor/self-limited) with plan. 4 points (No Maximum) _____
Total Number of Problems/Diagnoses Score____

For calculating the Data subset of the Decision Making score, the automatic coding wizard will look into the plan field. In order for the E&M coder to function properly, you should begin the plan field documentation by entering the Plan Template which can be obtained from the Plan menu. This action will place the following outline into the Plan field:

Plans_for_new_Dx- __.
Lab/Tests- __.
X-rays- __.
Studies(other)- __.
Old_Records_Requested- __.
Discuss_with_physician- __.
Summary_updated- __.
Second_Interpretation- __.

The letter "p" in the plan field can also be used as a code expander to give the above outline.
Data points are added to the Decision Making score based upon the following formulas:

Plans_for_new_Dx- __.
Lab/Tests- __. 1 point _____
X-rays-__. 1 point _____
Studies(other)- __. 1 point _____
Old_Records_Requested- __. 1 point _____
Discuss_with_physician- __. 1 point _____
Summary_updated- __. 2 points _____
Second_Intrepretation- __. 2 points _____
Total Data Score____

Data points are added when text is added to one of the items in the plan template or outline. For example, if the line of text "Lab/Tests- __." Is changed to "Lab/Tests- CBC." Then 1 point is added to the Data subset of the Decision making score.

Plans_for_new_Dx- __. This would be where you would place plan items for any new diagnoses that have been placed into the Assessment field (i.e. those which have the date added and the text "(See Plan)" as below:

Assessment:

Sinusitis, acute #461.9. 03/14/1998 (See Plan).
Plan:

Plans_for_new_Dx- Moist heat to face.

Lab/Tests- __. This line is where you would place documentation for planned laboratory studies or testing. For example "Lab/Tests- CBC" would add 1 point.

X-rays- __. This line is where you would place documentation for radiographic items. For example "X-rays- Chest X-ray." would add 1 point.

Studies(other)- __. This line is where you would place documentation for other types of studies other than lab or x-rays. For example "Studies(other)- Treadmill Stress Test." would add 1 point.

Old_Records_Requested- __. This line is where you would place documentation of the fact that outside medical records are being obtained. For example "Old_Records_Requested- From Northwest Medical Center." would add 1 point.

Discuss_with_physician- __. This line is where you would place documentation of the fact that you consulted or discussed with another physician. For example "Discuss_with_physician- Neurologist, Dr. Davis regarding need for MRI of head." would add 1 point.

Summary_updated- __. This line is where you would place documentation of the fact that you have updated information within the medical history, which in SOAPware would be the fields on the Summary side. For example "Summary_updated- From information collected from patient questionnaire." would add 2 points.

Second_Interpretation- __. This line is where you would place documentation of the fact that you have rendered a second opinion. For example "Second_Interpretation- Regarding need for hysterectomy discussed with patient." would add 2 points.

These 8 elements which are listed in the plan template determine the score for the "Data" portion of the Decision Making section. Any elements left blank are automatically removed when you select the Remove Plan Underlines menu item of the Plan menu.

Determining the third and last category, the Risk score, is very difficult to accomplish automatically. Of all the elements of E&M coding, it is the least defined. The guidelines list several examples of different patient encounters and then assigns risk levels rather than delivering any very specific rules. As a compromise, the SOAPware E&M coder simply adds one point for each of the first 4 diagnoses.

Minimal risk =1 point.
Low risk =2 points.
Moderate risk =3 points.
High risk =4 points.

Before accepting any suggested level of service, you should always check for the appropriate risk score.

Actual Use

When a patient arrives in the exam room, the nurse retrieves the chart and creates a new encounter note. We have included some helpful tools in order to speed up data entry. An alternative method for inserting the subjective outline is to use a code expander. For example, "pe" expands into the following in the subjective field:

CHIEF COMPLAINT: __.

HPI:

ONSET/TIMING: Onset __ days ago. Sudden__. Gradual__. Today__. Yesterday__. 3 days ago__. 4 days ago__. 5 days ago__. 6 days ago__. 1 week ago__. 2 weeks ago__. 3 weeks ago__. 4 weeks ago__. 5 weeks ago__. 6 weeks ago__. 1 month ago__. 2 months ago__. 3 months ago__. 4 months ago__. 5 months ago__. 6 months ago__. Recheck__. Work related__.

DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.

QUALITY/COURSE: __. --Worsening__. Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__.

LOCATION: __.--Bilateral__. Right__. Left__. Radiation__.

INTENSITY/SEVERITY: __.--Mild__. Moderate__. Severe__.

CONTEXT/WHEN: __.--Similar problems__. Physician visits__. Exposure_to_others_with_similar_symptoms__.

MODIFIERS/TREATMENTS: __.--None__.

SYMPTOMS/RELATED:

REVIEW OF SYMPTOMS:

rosextend__.

The nurse can then click through the outline, very quickly creating documentation satisfying HCFA requirements for HPI. Note the changes below where "__." has been changed to "(+)."

CHIEF COMPLAINT: Cough.

HPI:

ONSET/TIMING: Onset __ days ago. Sudden__. Gradual__. Today__. Yesterday__. 3 days ago(+). 4 days ago__. 5 days ago__. 6 days ago__. 1 week ago__. 2 weeks ago__. 3 weeks ago__. 4 weeks ago__. 5 weeks ago__. 6 weeks ago__. 1 month ago__. 2 months ago__. 3 months ago__. 4 months ago__. 5 months ago__. 6 months ago__. Recheck__. Work related__.

DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.

QUALITY/COURSE: __. --Worsening(+). Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__.

LOCATION: __.--Bilateral__. Right__. Left__. Radiation__.

INTENSITY/SEVERITY: __.--Mild__. Moderate(+). Severe__.

CONTEXT/WHEN: __.--Similar problems(-). Physician visits__. Exposure_to_others_with_similar_symptoms__.

MODIFIERS/TREATMENTS: __.--None__.

SYMPTOMS/RELATED:

REVIEW OF SYMPTOMS:

rosextend__.

When the nurse gets down to the "REVIEW OF SYMPTOMS:" there is a choice to be made. If 3 or less ROS items are to be noted, then these are often simply added along with a "(+)" or "(-)" as demonstrated below:

CHIEF COMPLAINT: Cough.

HPI:

DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.

QUALITY/COURSE: __. --Worsening(+). Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__.

LOCATION: __.--Bilateral__. Right__. Left__. Radiation__.

INTENSITY/SEVERITY: __.--Mild__. Moderate(+). Severe__.

CONTEXT/WHEN: __.--Similar problems(-). Physician visits__. Exposure_to_others_with_similar_symptoms__.

MODIFIERS/TREATMENTS: __.--None__.

SYMPTOMS/RELATED:

REVIEW OF SYMPTOMS: Cough(+). Dyspnea(-). Fever(+).

rosextend__.

If a more extensive review is to be performed, then the nurse can expand "" into the following outline:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional: roscon__.

Endocrine: rosend__.

Hematologic/Lymphatic: roshem__.

Allergic/Immunologic: rosall__.

ENT: rosent__.

Eyes: roseye__.

LUNGS/Respiratory: roslun__.

HEART/Cardiovascular: roshea__.

ABD/Gastrointestinal: rosabd__.

GENT/Genitourinary: rosgent__.

BJE/Musculoskeletal: rosbje__.

SKIN/Integumentary: rosski__.

NEURO: rosneu__.

PSYCH: rospsy__.

PAST FAMILY AND/OR SOCIAL HISTORY:

Past History:

Summary (Problems/Surg/meds/Allergies): Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

After each ROS header is a code which can be expanded into respective lists. For example, "rosabd__." is expanded and then "Regurgitation__." is clicked to positive as seen below:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional: roscon__.

Endocrine: rosend__.

Hematologic/Lymphatic: roshem__.

Allergic/Immunologic: rosall__.

ENT: rosent__.

Eyes: roseye__.

LUNGS/Respiratory: roslun__.

HEART/Cardiovascular: roshea__.

ABD/Gastrointestinal: Negative abdominal/gastrointestinal review__.

Abdomen Distention__. Abdomen Pain__. Belching__. Constipation__. Diarrhea__. Flank Pain__. Flatulence__. Hematemesis__. Hematochezia__. Hernia__. Melena__. Nausea__. Pyrosis__. Regurgitation(+). Steatorrhea__. Stool changes__. Suprapubic Pain__. Vomiting__.

GENT/Genitourinary: rosgent__.

BJE/Musculoskeletal: rosbje__.

SKIN/Integumentary: rosski__.

NEURO: rosneu__.

PSYCH: rospsy__.

PAST FAMILY AND/OR SOCIAL HISTORY:

Past History:

Summary (Problems/Surg/meds/Allergies): Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

The total contents of the subjective field now appears as:

CHIEF COMPLAINT: Cough.

HPI:

DURATION: __.--Continuous__. Intermittent__. Chronic__. Acute__.

QUALITY/COURSE: __. --Worsening(+). Improving__. Unchanged__. Sharp pain__. Dull pain__. Burning pain__.

LOCATION: __.--Bilateral__. Right__. Left__. Radiation__.

INTENSITY/SEVERITY: __.--Mild__. Moderate(+). Severe__.

CONTEXT/WHEN: __.--Similar problems(-). Physician visits__. Exposure_to_others_with_similar_symptoms__.

MODIFIERS/TREATMENTS: __.--None__.

SYMPTOMS/RELATED:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional: roscon__.

Endocrine: rosend__.

Hematologic/Lymphatic: roshem__.

Allergic/Immunologic: rosall__.

ENT: rosent__.

Eyes: roseye__.

LUNGS/Respiratory: roslun__.

HEART/Cardiovascular: roshea__.

ABD/Gastrointestinal: Negative abdominal/gastrointestinal review__.

GENT/Genitourinary: rosgent__.

BJE/Musculoskeletal: rosbje__.

SKIN/Integumentary: rosski__.

NEURO: rosneu__.

PSYCH: rospsy__.

PAST FAMILY AND/OR SOCIAL HISTORY:

Past History:

Summary (Problems/Surg/meds/Allergies): Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

After selecting the "Remove Subjective Underlines" command, the subjective text appears as below:

CHIEF COMPLAINT: Cough.

HPI:

ONSET/TIMING: 3 days ago(+).

DURATION:

QUALITY/COURSE: --Worsening(+).

LOCATION:

INTENSITY/SEVERITY: Moderate(+).

CONTEXT/WHEN:--Similar problems(-).

MODIFIERS/TREATMENTS:

SYMPTOMS/RELATED:

REVIEW OF SYMPTOMS:

GEN:

Associated/Constitutional:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

ENT:

Eyes:

LUNGS/Respiratory:

HEART/Cardiovascular:

ABD/Gastrointestinal: Regurgitation(+).

GENT/Genitourinary:

BJE/Musculoskeletal:

SKIN/Integumentary:

NEURO:

PSYCH:

PAST FAMILY AND/OR SOCIAL HISTORY:

Past History:

Summary (Problems/Surg/meds/Allergies): Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

After selecting the "Remove Unused Documentation Items" the subjective text appears as:

CHIEF COMPLAINT: Cough.

HPI:

ONSET/TIMING: 3 days ago(+).

QUALITY/COURSE: --Worsening(+).

INTENSITY/SEVERITY: Moderate(+).

CONTEXT/WHEN:--Similar problems(-).

REVIEW OF SYMPTOMS:

ABD/Gastrointestinal: Regurgitation(+).

Now, the clinician can come into the exam room, open up the chart review the above with the patient and make corrections either by direct keyboard entry or via dictation. At this point, the E&M coder can be pulled up to reveal a History score of 5. You will notice that this consists of 4 HPI items and 1 ROS item. The nurse or clinician is thus able to quickly document a number of items without having to type. In many practices, the nurse is encouraged to update the summary on the left side of the chart so that the clinician can quickly get a relevant overview at a glance and the history documentation will be in place to produce the extended soap notes required for levels 4 and 5 visits.

An alternative approach would be to enter a more specific or symptom based template such as one for cough. In order to do so, start with an empty encounter, go to template list and select "aanpcou" in order to enter more specific text options into the soap note fields. In each field are items which can be expanded. For example, "aacou2345" will expand into a level 5 exam, while "aacou23" expands into a level 3 exam. The other fields in the soap note also contain items for expansion.

Hopefully, this exercise has given you the start you need to efficiently create documentation.

In summary, below are the blanks which must be filled in order to determine the proper level of service for E&M coding:

Chief Complaint: Yes/No

Diagnosis: Yes/No

I. HISTORY:

Total HPI Score: _____

Total ROS Score: _____

Total PFSH Score: _____

II. EXAM:

Total Exam Score: _____

III. DECISION MAKING:

Total Number of Problems/Diagnoses Score ____

Total Data Score ____

Total Risk Score ____

Total Decision Making Score: _____

Below is a description of each level of service and the documentation requirements for each level.

	Level 1	Level 2	Level 3	Level 4	Level 5
	e.g. 99211	e.g. 99212	e.g. 99213	e.g. 99214	e.g. 99215
History	Yes	Yes	Yes	Yes	Yes
Chief Complaint	Yes	Yes	Yes	Yes	Yes
Diagnosis

Total HPI Score	N/A	1	1	4	9
Total ROS Score	N/A	N/A	1	2	10
Total PFSH Score	N/A	N/A	N/A	1	3

Exam
Total Exam Score	1	1	6	12	18

Decision Making
Total DM Score	1	1	4	9	12

In some cases, you have to met only the criteria for 2 out of 3 (History, Exam, Decision Making) for (e.g. established patients). For other groups of codes (e.g. for new patients) you must meet 3 out of 3 of the criteria defined for each category.

In conclusion, all the elements for determining the level of service are summarized below:

HISTORY--(Subjective and Summary Fields in SOAPware)

CHIEF COMPLAINT __. (Subjective field in SOAPware) Chief Complaint: Yes/No

HPI:

ONSET/TIMING: __. (e.g. 3 days ago, nocturnal)

DURATION: __. (e.g. continuous, intermittent)

QUALITY/COURSE: __. (e.g. sharp, dull, worsening, improving)

LOCATION: __. (e.g. bilateral, right)

INTENSITY/SEVERITY: __. (e.g. mild, severe)

CONTEXT/WHEN: __. (e.g. activity, stress)

MODIFIERS/TREATMENTS: __. (e.g. analgesics, cough)

SYMPTOMS/RELATED: __. (e.g. diaphoresis with chest pain)

Total HPI Score: _____

REVIEW OF SYMPTOMS: (Subjective field in SOAPware)

GEN:

Associated/Constitutional: __.

Endocrine__.

Hematologic/Lymphatic__.

Allergic/Immunologic__.

ENT: __.

Eyes__.

LUNGS/Respiratory: __.

HEART/Cardiovascular: __.

ABD/Gastrointestinal: __.

GENT/Genitourinary: __.

BJE/Musculoskeletal: __.

SKIN/Integumentary: __.

NEURO: __.

PSYCH: __.

Total ROS Score: _____

PAST FAMILY AND/OR SOCIAL HISTORY (Summary fields in SOAPware)

Past History:

Problem Lists/Surg/Meds/Allergies: Refer to specific fields.

Social History: Refer to specific fields.

Family History: Refer to specific fields.

Total PFSH Score: _____

---------------------------------------------------------EXAM (Objective field in SOAPware)

GEN: Appear/General-Abn__. VS- __. LYMPH: __.

HEENT: Lips/Teeth/Gums-Abn__. Oropharynx-Abn__. EARS- Otoscopic-Abn__. Hearing-Abn__. Ear-Nose/Appear-Abn__. NOSE- Nose/Internal-Abn__. EYES: Conjunctiva/Lids-Abn__. Pupils/Irises-Abn__. Ophthalmoscopic-Abn__.

NECK: Neck-Abn__. Thyroid-Abn__.

LUNGS: Lung/Auscultation-Abn__. Respirations-Abn__. Chest/Palpation__. Lungs/Percussion-Abn__. CHEST/BREASTS: Breasts/Inspection-Abn__. Breast/Palpation-Abn__.

HEART: Heart/Palpation-Abn__. Heart/Auscultation-Abn__. Pulses/Carotid-Abn__. Pulses/Aorta__. Pulses/Femoral-Abn__. Pulses/Pedal-Abn__. Peripheral/Edema_or_Varicosities__.

ABD: Abdomen-Mass/Tenderness-Abn__. Liver/Spleen-Abn__. Hernia-Abn__.

BJE: Inspection/Palpation/Motion/Stability/Strength-Abn of (*area) __. Digits/Nails-Abn__. Gait/Station-Abn__.

NEURO: Cranial/Nerves-Abn__. Sensation-Abn__. DTR-Abn__. PSYCH: Insight/Judgement-Abn__. Disoriented__. Memory/Impairment__. Mood/Affect-Abn__.

SKIN: Skin/Subcutaneous-Inspection-Abn__. Skin/Subcutaneous-Palpation-Abn__.

STUDIES: Total Exam Score: _____

*area = 1. Head/Neck; 2. Spine/Ribs/Pelvis; 3. Right Upper Ext; 4. Left Upper Ext; 5. Right Lower Ext; 6. Left Lower Ext. Secondarily can address each of the following for one point each: Inspection-Palpation-Abn__. Range_of_Motion-Abn__. Instability__. Strength__.

VS__ = Must include 3 of 7 vital signs.

LYMPH __ = Must include 2 of 4 lymph sites: Lymph/Neck-Abn__. Lymph/Axillae-Abn__. Lymph/Groin-Abn__. Lymph/Other-Abn__.

------------------------------------------------------------------------------------------------------------

DECISION MAKING--Has 3 parts - Number, Data, Risk)--(Assessment/Plan fields in SOAPware)

Number of Problems/Diagnoses:

Each diagnosis addressed. 1 point (Max Point Total=2) _____

Each diagnosis uncontrolled/worsening 2 points (No Maximum) _____

A new diagnosis (not minor/self-limited) 3 points (Max Point Total=3) _____

A new diagnosis (not minor/self-limited) with plan. 4 points (No Maximum) _____

Total Number of Problems/Diagnoses Score____

Data:

Plans_for_new_Dx- __. (This adds refers to the above section)

Lab/Tests- __. 1 point _____

X-rays-__. 1 point _____

Studies(other)- __. 1 point _____

Old_Records_Requested- __. 1 point _____

Discuss_with_physician- __. 1 point _____

Summary_updated- __. 2 points _____

Second_Intrepretation- __. 2 points _____

Total Data Score____

Risk:

Minimal=1 point. Low=2 points. Moderate=3 points. High=4 points. _____

Total Data Score____

Total Decision Making Score: _____

Introduction and History

Support