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Evaluation and Management (E&M) Guidelines

Evaluation and Management coding is a medical coding process in support of medical billing.  Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters. 

E/M standards and guidelines were established by Congress in 1995 and revised in 1997. It has been adopted by private health insurance companies as the standard guidelines for determining type and severity of patient conditions. This allows medical service providers to document and bill for reimbursement for services provided.

1995 Documentation Guidelines For Evaluation and Management Services

I. Introduction

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. The medical record facilitates:

  • the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time;
  • communication and continuity of care among physicians and other healthcare professionals involved in the patient's care;
  • accurate and timely claims review and payment;
  • appropriate utilization review and quality of care evaluations; and
  • collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY? Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

  • the site of service;
  • the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
  • that services provided have been accurately reported.

II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services. 1. The medical record should be complete and legible. 2. The documentation of each patient encounter should include:

  • reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
  • assessment, clinical impression, or diagnosis;
  • plan for care; and
  • date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. 4. Past and present diagnoses should be accessible to the treating and/or consulting physician. 5. Appropriate health risk 6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented. 7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

II. DOCUMENTATION OF E/M SERVICES This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components--history, examination, and medical decision making--appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol • DG. The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:

  • examination;
  • medical decision making;
  • counseling;
  • coordination of care;
  • nature of presenting problem; and

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.

For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area.

As an example, newborn records may include under history of the present illness (HPI) the details of mother’s pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.

A. DOCUMENTATION OF HISTORY The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

  • Chief complaint (CC);
  • History of present illness (HPI);
  • Review of systems (ROS); and
  • Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)

  • DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and

o noting the date and location of the earlier ROS and/or PFSH.

Definitions and specific documentation guidelines for each of the elements of history are listed below.

CHIEF COMPLAINT (CC) The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

HISTORY OF PRESENT ILLNESS (HPI) The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). A brief HPI consists of one to three elements of the HPI.

An extended HPI consists of four or more elements of the HPI.

REVIEW OF SYSTEMS (ROS) A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS , the following systems are recognized:

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH) The PFSH consists of a review of three areas:

For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

B. DOCUMENTATION OF EXAMINATION The levels of E/M services are based on four types of examination that are defined as follows:

For purposes of examination, the following body areas are recognized:

For purposes of examination, the following organ systems are recognized:

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING The levels of E/M services recognize four types of medical decision making (straight-forward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

Each of the elements of medical decision making is described on the following page.

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible,” "probable,” or "rule out” (R/O) diagnoses.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed. Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed.

RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.

The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high . Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

Table of Risk

D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

  • DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
  • DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.
  • DG: The medical record should clearly reflect the chief complaint.
  • modifying factors; and
  • associated signs and symptoms.
  • DG: The medical record should describe one to three elements of the present illness (HPI).
  • DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.
  • Constitutional symptoms (e.g., fever, weight loss)
  • Ears, Nose, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Hematologic/Lymphatic
  • Allergic/Immunologic
  • DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.
  • DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.
  • DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
  • past history (the patient's past experiences with illnesses, operations, injuries and treatments);
  • family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and
  • social history (an age appropriate review of past and current activities).
  • DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.
  • DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.
  • DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and homecare, new patient.
  • 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(s).
  • Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
  • Comprehensive -- a general multi-system examination or complete examination of a single organ system.
  • Head, including the face
  • Chest, including breasts and axillae
  • Genitalia, groin, buttocks
  • Back, including spine
  • Each extremity
  • Constitutional (e.g., vital signs, general appearance)
  • Ears, nose, mouth, and throat
  • Hematologic/lymphatic/immunologic
  • DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal” without elaboration is insufficient.
  • DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.
  • DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).
  • DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.
  • 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; and
  • the risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
  • DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
  • DG: The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
  • DG: If referrals are made, consultations requested or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.
  • DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented.
  • DG: The review of lab, radiology and/or other diagnostic tests should be documented. An entry in a progress note such as "WBC elevated" or "chest x-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results.
  • DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.
  • DG: Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed” or "additional history obtained from family” without elaboration is insufficient.
  • DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented.
  • DG: The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.
  • DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.
  • DG: If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure eg, laparoscopy, should be documented.
  • DG: If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
  • DG: The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.
  • DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

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Determining whether the visit you've just finished should be coded as a level 4 could be as simple as asking yourself three questions.

KEITH W. MILLETTE, MD, FAAFP, RPH

Fam Pract Manag. 2021;28(1):27-33

Author disclosure: no relevant financial affiliations disclosed.

e&m visits healthcare

Performing level 4 evaluation and management (E/M) outpatient visits but coding them as level 3 visits is a costly mistake for family physicians. It can result in $30,000 or more in lost revenue in a year, depending on practice volume. Some doctors choose to report a level 3 instead of a level 4 because of fear of over-coding. 1 Some do level 4 work but their documentation is lacking and doesn't support a level 4 code. But the most common reason I've seen for under-coding level 4 visits is that the coding criteria are complex and time-consuming.

“Coding is complicated and boring,” I often hear physicians say. “I have better things to do, like take care of my patients.”

New rules for coding and documenting outpatient E/M office visits should simplify things, clear up confusion, and help you code more confidently and accurately.

The rules, which took effect Jan. 1, are the most significant changes to E/M coding since 1997 (for more details, see “ Countdown to the E/M Coding Changes ” in the September/October 2020 issue of FPM ). Coding for outpatient E/M office visits is now based solely on either the level of medical decision making (MDM) required or the total time you spend on the visit on the date of service. (See “ E/M coding changes series .”) The history and exam components are no longer used for coding purposes. (Note: these changes apply only to regular office visits and not to nursing home or hospital E/M visits.)

The 2021 E/M coding changes should help ensure you're not leaving money on the table, especially when it comes to coding level 4 visits, which is not as straightforward as coding other levels.

Doing level 4 evaluation and management (E/M) work but coding it as a level 3 office visit is a common mistake that can cost a family physician thousands of dollars each year.

Rule changes that eliminated the history and exam portions from coding requirements should make it easier to identify level 4 office visits and code them for appropriate reimbursement.

Answering three basic questions can help you identify whether you've performed a level 4 visit.

E/M CODING CHANGES SERIES

September/October 2020 — Countdown to the E/M Coding Changes

November/December 2020 — The 2021 Office Visit Coding Changes: Putting the Pieces Together

January/February 2021 — Coding Level 4 Office Visits Using the New E/M Guidelines

CODING LEVEL 4 VISITS: THE BASICS

These are the basic parameters for coding a level 4 visit based on total time or MDM under the new rules.

Total time includes all time the physician or other qualified health professional (QHP) spends on that patient on the day of the encounter. This includes time spent reviewing the patient's chart before the visit, face-to-face time during the visit, and time spent after the visit documenting the encounter. It may also include discussing the patient's care with other health professionals or family members, calling the patient later in the day, or ordering medications, studies, procedures, or referrals, as long as those actions happen before midnight on the date of service. Total time does not include time spent performing separately billed procedures or time spent by your nurse or other office staff caring for the patient.

The total time needed for a level 4 visit with an established patient (CPT code 99214) is 30–39 minutes. The total time needed for a level 4 visit with a new patient (CPT 99204) is 45–59 minutes.

Many EHRs have time calculators that will show the amount of time you have had the patient's chart open. This will help you keep track of time while you're reviewing the chart before the visit, performing the exam (if you always open the chart at the beginning of the visit and close it at the end of the encounter), and making notes after the visit. It will be less helpful for physicians who open the computer only when needed during the patient visit.

Documentation of total time is fairly straightforward: just note how much time you spent on the visit that day. You aren't required to break down how much time you spent before, during, and after the visit, though that may be helpful supportive detail in the event of an audit. You may want to include a short definition of total time so that patients who read their notes don't confuse it with face-to-face time and think, “My doctor only spent 20 minutes with me, not the 40 minutes listed here.” For example, your documentation could say, “Total time: 40 minutes. This includes time spent with the patient during the visit as well as time spent before and after the visit reviewing the chart, documenting the encounter, making phone calls, reviewing studies, etc.” In addition to preventing misunderstandings, this gives patients a better idea of all the time we spend on them outside of the actual visit. Another way to accomplish it without “note bloat” is to have a pop-up message with this information that appears in the EHR whenever patients access their notes.

Medical decision making is still made up of three elements: problems, data, and risk. But the definitions have changed somewhat (see “ CPT E/M office revisions: level of medical decision making ”). The overall level of the visit is determined by the highest levels met in at least two of those three elements. That means that for an outpatient E/M office visit to be coded as a level 4 (for new or established patients), you need at least two of the three elements to reach the “moderate” category — moderate number and complexity of problems addressed; moderate amount and/or complexity of data to be reviewed and analyzed; or moderate risk of complications and/or morbidity or mortality of patient management. An important difference between coding based on MDM versus total time is that you may count MDM that occurs outside of the date of service (e.g., data reviewed or ordered the day after the patient's visit).

To make this simpler, let's substitute “level 4” for the term “moderate” as we take a look at what qualifies in each category (problems, data, and risk).

Level 4 problems include the following:

One unstable chronic illness (for coding purposes “unstable” includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal),

Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia),

One acute complicated injury (e.g., concussion),

One new problem with uncertain prognosis (e.g., breast lump).

Level 4 data includes the following:

One x-ray or electrocardiogram (ECG) interpreted by you,

Discussion of the patient's management or test results with an external physician (one from a different medical group or different specialty/subspecialty),

A total of three points, earned as follows: a) One point for each unique test ordered or reviewed (panels count as one point each; you cannot count labs you order and perform in-office yourself), b) One point for reviewing note(s) from each external source, and c) One point for using an independent historian.

Level 4 risk includes the following:

Prescription drug management, which includes ordering, changing, stopping, refilling, or deciding to continue a prescription medication (as long as the physician documents evaluation of the condition for which the medication is being managed),

The presence of social determinants of health (lack of money, food, or housing) that significantly limit a patient's diagnosis or treatment,

Decision about major elective surgery without identified risk factors for patient or procedure,

Decision about minor surgery with identified risk factors for patient or procedure.

IDENTIFYING LEVEL 4 VISITS IN THREE QUESTIONS

Here are three questions you can ask yourself to quickly determine whether you've just performed a level 4 visit:

Was your total time between 30 and 39 minutes for an established patient, or between 45 and 59 minutes for a new patient? If so, then you're done. Code it as a level 4 using total time.

Did you see the patient for a level 4 problem and either order/review level 4 data or manage level 4 risk? If so, then code it as a level 4 using MDM.

Did you order/review level 4 data and manage level 4 risk? If so, code it as a level 4 using MDM.

Another way to simplify coding level 4 visits is to recognize that ordering labs, x-rays, ECGs, and medications (prescription drug management) often signals level 4 work, while using independent historians, discussing care/studies with external physicians, and providing care limited by social determinants of health are not used as often to code level 4 visits. Therefore, questions 2 and 3 could be rephrased or shortened as follows:

2. Did you see the patient for a level 4 problem and either prescribe a medication, interpret an x-ray (or ECG), or order/review three tests?

3. Did you prescribe a medication and either interpret an x-ray (or ECG) or order/review three tests?

OFFICE VISIT EXAMPLES

Now let's look at three examples of level 4 office visits, documented with the usual SOAP (subjective, objective, assessment, and plan) note. See if you can identify why each is a level 4 before you get to the explanation.

Subjective: 44 yo female presents with 3 day hx of dysuria, frequency, urgency, L mid back pain, fever, chills, and nausea. Has prior hx of UTIs. No hx of pyelo. No hx of resistant infections. Able to keep food down .

Objective: T 100.2, P 96, R 18, BP 110/70. Pt looks ill but not toxic .

EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: Benign. NECK: Benign. No cervical adenopathy. HEART: S1 and S2 w/o murmurs. LUNGS: Clear. Breathing is nonlabored. ABDOMEN: soft, nontender, moderate L CVA tenderness. EXTREMITIES no edema .

Laboratory: UA – TNTC, WBCs – 4+ bacteria .

Assessment/Plan: Pyelonephritis N12. Discussed acute pyelo, also ways to prevent bladder infections. Handout given. Push fluids. Discussed fever and pain control. Cipro 500 mg po bid x 7 days with appropriate precautions. RTC 72 hours, RTC or ER sooner if red flags occur .

Explanation: The total time for this visit was 25 minutes (in the range of a level 3 visit), so it can't be coded as a level 4 using total time. The time also was not documented in the note, which would be required to support coding based on total time. However, here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: acute illness with systemic symptoms.

Was level 4 data ordered/reviewed? No: two lab tests reviewed (three are required).

Was level 4 risk managed? Yes: prescription drug management.

Two out of three criteria meet the requirements for a level 4, so code it as a level 4.

Subjective: 23 y/o female presents for recheck of depression, also complaining of sore throat and ankle sprain .

Counseling going well. Started on sertraline 50 mg 4 months ago. No new stressors. Pt denies depressed mood, insomnia, anorexia, loss of pleasure, suicidal ideation, poor concentration, or irritability. Anxiety is also well controlled .

Has 2 day hx of L lateral ankle pain. Tripped over dog and turned ankle in. Pt able to walk now with mild limp .

Has a 3 day hx of sore throat, fever, and fatigue. Denies other symptoms .

Objective: T 100.4, P 88, R 14, BP 125/70. Pt is NAD, affect is bright, eye contact is good. EYES: Fundi benign. PERRLA. TMs: Benign. PHARYNX: tonsils 2+ red s exudate. NECK: Benign. No cervical adenopathy. HEART: RRR. LUNGS: Clear. Bilateral ankle exam: L ant drawer is negative, inversion testing on L causes pain, focal mild tenderness and swelling just below L lat malleolus .

Laboratory: strep screen – negative, strep culture – pending .

Assessment/Plan: Depression with anxiety F41.8 well controlled. Sertraline 50 mg refilled. Continue counseling. Discussed depression .

Tonsillitis J03.90. Strep screen neg. Discussed symptomatic measures. Will call if strep culture is positive .

Sprain left ankle, initial encounter S93.492A, is mild and improving. Discussed RICE protocol and NSAIDS if needed .

RTC 2 mo to recheck depression. Call or RTC sooner if problems or concerns develop .

Total time: 35 minutes. This includes time spent with the patient, but also time spent before the visit reviewing the chart and time after the visit documenting the visit, etc .

Explanation: The total time for this visit (35 minutes) is in the range of a level 4 (30–39 minutes), so a physician could code it as a level 4 using total time. However, here's the breakdown for MDM:

Was there a level 4 problem? No: One stable chronic illness, one acute uncomplicated illness, and one acute uncomplicated injury.

Was level 4 data ordered/reviewed? No: two lab tests.

This visit only meets one out of three criteria, so it can't be coded as a level 4 based on MDM. But because the physician has documented that the visit met the criteria for a level 4 based on total time, it can be coded as a level 4.

Subjective: 47 y/o male presents for a BP recheck. His home blood pressures have been averaging 155/95. He denies chest pain, fast heart rate, headache, flushing, or nose-bleeds. Feels good. Taking losartan every day. Watches his wt and exercises .

Objective: T 97.2, P 72, R 16, BP 160/95. NAD.

EYES: Fundi nl. PERRLA. TMs: nl .

PHARYNX: nl. NECK: Benign. Thyroid is not enlarged. HEART: S1 and S2 no murmurs. LUNGS: Clear. ABDOMEN: No masses or organomegaly. EXTREMITIES: no edema .

Assessment/Plan: Essential hypertension I10. Increase losartan to 100 mg per day. Check BP 3 times a wk, avoid salt, continue to limit alcohol to 2 drinks a day or less. RTC for BP check in 3 wks, sooner if problems arise .

Explanation: Total time for this visit was 20 minutes (but not documented in note). That is in the range of a level 3 visit, not a level 4.

Here's the breakdown for coding the visit based on MDM:

Was there a level 4 problem? Yes: One chronic, uncontrolled illness.

Was level 4 data reviewed/ordered? No: No tests were ordered.

Was level 4 risk managed? Yes: Prescription drug management.

Two out of three criteria were met, so code it as a level 4.

(Templates to help code visits based on total time or MDM are available with “ Countdown to the E/M Coding Changes ,” FPM September/October 2020.)

HOW DOES YOUR LEVEL 4 CODING COMPARE?

Comparing your coding with national averages is a good way to gauge where you stand in terms of getting the reimbursements you deserve. The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare patients). 2

That's a good benchmark. But all practices are different, and some coding variation is normal. In general, doctors with more elderly patients usually have a higher percentage of level 4 visits. Doctors who address fewer problems per visit, have a high patient volume, or have a younger panel tend to have a lower percentage of level 4 visits.

Coding should be easier with the removal of the history and exam components, allowing us to focus more on treating our patients. By using the three questions presented in this article, as well as the patient examples, you should be able to more confidently code level 4 visits and make sure you're getting paid for the amount of work you're doing.

Hill E. How to get all the 99214s you deserve. Fam Pract Manag . 2003;10(9):31-36.

Marting R. 99213 or 99214? Three tips for navigating the coding conundrum. Fam Pract Manag . 2018;25(4):5-10.

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When working with medical billing for insurance companies there can be a lot of confusion about the Medical Billing Terminology used.

One term that is commonly used is E&M visit, which is short form for Evaluation and Management Encounter.

This is essentially referring to a doctor’s visit, or a consultation (a visit requested by another physician or healthcare entity).

During a patient visit (sometimes known as an encounter) a physician examines the patient, documents his or her findings, and then determines the best course of action for treatment.

The Current Procedural Terminology (CPT) codes cover evaluation and management ( E&M) services, which clinicians use in billing for office and hospital visits. E&M visits are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital.

It is important to remember that insurance companies only pay for procedures that are medically necessary to the well-being of the patient. For that reason you must link each procedure billed to a medical diagnosis that supports the medical necessity for the procedure.

Whether a physician conducts an E&M visit or a consultation, he or she will report some sort of illness or disease-related term in the patient’s record, even if the problem is something as simple as the common cold.

Then you must ensure you are using the correct codes. It is important to understand the verbiage used in the record, as well as surgical procedures, evaluation and management procedures.

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News Release

Tuesday, February 20, 2024

Women may realize health benefits of regular exercise more than men

An NIH-supported observational study finds that even when women and men get the same amount of physical activity, the risk of premature death is lower for women.

Women who exercise regularly have a significantly lower risk of an early death or fatal cardiovascular event than men who exercise regularly, even when women put in less effort, according to a National Institutes of Health-supported study. The findings, published in the Journal of the American College of Cardiology , are based on a prospective analysis of data from more than 400,000 U.S. adults ages 27-61 which showed that over two decades, women were 24% less likely than those who do not exercise to experience death from any cause, while men were 15% less likely. Women also had a 36% reduced risk for a fatal heart attack, stroke, or other cardiovascular event, while men had a 14% reduced risk.  

“We hope this study will help everyone, especially women, understand they are poised to gain tremendous benefits from exercise,” said Susan Cheng, M.D., a cardiologist and the Erika J. Glazer Chair in Women’s Cardiovascular Health and Population Science in the Smidt Heart Institute at Cedars-Sinai, Los Angeles. “It is an incredibly powerful way to live healthier and longer. Women on average tend to exercise less than men and hopefully these findings inspire more women to add extra movement to their lives.”    

The researchers found a link between women experiencing greater reduced risks for death compared to men among all types of exercise . This included moderate aerobic activity, such as brisk walking; vigorous exercise, such as taking a spinning class or jumping rope; and strength training, which could include body-weight exercises.

Scientists found that for moderate aerobic physical activity, the reduced risk for death plateaued for both men and women at 300 minutes, or five hours, per week. At this level of activity, women and men reduced their risk of premature death by 24% and 18% respectively. Similar trends were seen with 110 minutes of weekly vigorous aerobic exercise, which correlated with a 24% reduced risk of death for women and a 19% reduced risk for men.

Women also achieved the same benefits as men but in shorter amounts of time. For moderate aerobic exercise, they met the 18% reduced risk mark in half the time needed for men: 140 minutes, or under 2.5 hours, per week, compared to 300 minutes for men. With vigorous aerobic exercise, women met the 19% reduced risk mark with just 57 minutes a week, compared to 110 minutes needed by men.

This benefit applied to weekly strength training exercises, too. Women and men who participated in strength-based exercises had a 19% and 11% reduced risk for death, respectively, compared to those who did not participate in these exercises. Women who did strength training saw an even greater reduced risk of cardiovascular-related deaths – a 30% reduced risk, compared to 11% for men. 

For all the health benefits of exercise for both groups, however, only 33% of women and 43% of men in the study met the standard for weekly aerobic exercise, while 20% of women and 28% of men completed a weekly strength training session.

“Even a limited amount of regular exercise can provide a major benefit, and it turns out this is especially true for women,” said Cheng. “Taking some regular time out for exercise, even if it’s just 20-30 minutes of vigorous exercise a few times each week, can offer a lot more gain than they may realize.”

“This study emphasizes that there is no singular approach for exercise,” said Eric J. Shiroma, Sc.D., a program director in the Clinical Applications and Prevention branch at the National Heart, Lung, and Blood Institute (NHLBI). “A person’s physical activity needs and goals may change based on their age, health status, and schedule – but the value of any type of exercise is irrefutable.”

The authors said multiple factors, including variations in anatomy and physiology, may account for the differences in outcomes between the sexes. For example, men often have increased lung capacity, larger hearts, more lean-body mass, and a greater proportion of fast-twitch muscle fibers compared to women. As a result, women may use added respiratory, metabolic, and strength demands to conduct the same movement and in turn reap greater health rewards.

The Physical Activity Guidelines for Americans recommend adults get at least 2.5-5 hours of moderate-intensity exercise or 1.25-2.5 hours of vigorous exercise each week, or a combination of both, and participate in two or more days a week of strength-based activities.

The research was partially supported by NHLBI grants K23HL153888 , R21HL156132 , R01HL142983 , R01HL151828 , R01HL131532 , and R01HL143227 .

About the National Heart, Lung, and Blood Institute (NHLBI): NHLBI is the global leader in conducting and supporting research in heart, lung, and blood diseases and sleep disorders that advances scientific knowledge, improves public health, and saves lives. For more information, visit https://www.nhlbi.nih.gov . 

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

NIH…Turning Discovery Into Health ®

Ji H, Gulati M, Huang TY, et al. Sex differences in association of physical activity with all-cause and cardiovascular mortality. J Am Coll Cardiol . 2024; doi: 10.1016/j.jacc.2023.12.019.

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St. Pete Health & Wellness

Saint Petersburg Health & Wellness

Anti-Aging, Functional-Metabolic, Regenerative, Integrative & Preventative Medicine – “Live Well!”

St. Petersburg Health & Wellness

Important information regarding practice closure.

Dr. Cole, Kathie Gonzales, and the staff of St. Petersburg Health & Wellness (SPHW) and Vital Solutions IV Nutrition (VSIVN) have been honored to help care for your health and wellness and provide you a roadmap for your optimal outcomes.

For health reasons, I (Dr. Cole), must follow my own advice and make changes in my lifestyle that support my own wellness. I will be moving into semi-retirement with my focus on authoring educational materials about functional approaches to wellness.  Kathie Gonzales, ARNP, has come to a point in her career where returning to a hospital setting is what calls to her, and is her own best next step professionally.  The result of these changes means that The St Petersburg Health and Wellness office will be closing its doors on 5/28/2022 .   As of that date, Dr. Cole and Kathie Gonzales, ARNP will no longer be available as your personal medical provider. In practical terms, this means they will not be available for appointments, phone calls, or be able to authorize refills for prescriptions. We will make every effort up until that time to provide you with refills for 30-60 days, to give you ample opportunity to obtain a new provider.

If we have been your only medical provider

If we have been your only medical provider, you will need to arrange to have another health care provider take care of your medical needs.  Because our approach is specifically Functional Medicine, you can find additional Functional Medical Practitioners in the area by contacting the American Academy of Anti-Aging Medicine (A4M) at https://www.a4m.com/find-a-doctor.html or the Institute for Functional Medicine (IFM) at https://www.ifm.org/find-a-practitioner/ . Your insurance provider’s directory or local hospital’s physician referral service is another place to check.

Medical Records

Since the virtual business entity of St. Petersburg Health and Wellness itself will continue on, we will be maintaining ownership of all medical records. Legally, all requests for copies of medical records must have a signed authorization to be released. If your doctor needs your medical records, you can sign your doctor’s records request form and they will request them for you. For all other records requests, email your request to  [email protected]  and we will send you the proper medical records release form and any other information to expedite the process. Please understand that the medical record’s email is ONLY for submitting a request for medical records and does not have the ability to answer questions unrelated to the transfer of said records.

For all patients during this transition and beyond:

Continue current protocols.

Continue on your diets and pharmaceutical-grade supplement brands and dosing we have recommended to you. You will still be able to get them through the same portals – Wellevate and WholeScripts – through which you have previously obtained them. Do this in order to continue your “Live Well” lifestyle. This will ultimately keep you healthy and in less need of “sick” (medical) care in the future.

Read: “Supplements Everyone Should Take and Why”(⇐ Click Here)

Order: Specific products for your optimum health

Order: Specific products for gut health

Order: Specific dispensary products 

Gastrointestinal Protocols

If you have been on GI supplements to heal your Intestinal Permeability (Leaky Gut), GI tract, and/or Imbalanced Microbiome, continue your specified diet and all of your GI supplements for 3-6 months from the date you started. Again, you can use the same portals to reorder supplements. My rule of thumb for deciding 3 months versus 6 months is this:

  • If your symptoms clear in the 1st month of starting your GI supplements it is generally safe to stop them after 3 months of taking them.
  • If your symptoms don’t clear in the 1st month, then you generally want to stay on them for 6 months.

This guideline generally prevents the symptoms and the underlying condition from recurring.

For more information on how to maintain your health as it pertains to your underlying GI health issues, visit articles related to GI Health.

Hormonal Health

For your hormones or other medications, you will need to find another practitioner to prescribe them for you. In determining which practitioner to choose for this, remember your hormones should be optimized for you because all your hormones are intended to work together as a symphony.

Read the information concerning your hormone condition, and “Hormone health – the way to ensure you are being dosed properly”. (⇐ Click Here)

Our Continued Mission for your Health & Wellness

Your health and wellness are still my mission from a broader perspective. I will continue as a source of information to guide your healthy lifestyle and health decisions to maximize your “Live Well” Lifestyle. And so, through our website portal – stpetehw.com – I will provide important, up-to-date health education in an understandable format, as well, as access to effective, Functional Medical treatment protocols for general health and a multitude of health conditions. You will continue to have access to the same quality Pharmaceutical grade (tested for purity, quality, absorption, and effectiveness) therapeutic products. Please review our website if you haven’t done so before, be curious, and look around.

Subscribe so that you get notifications of changes as they happen, as it too will be undergoing significant growth while I transition to a virtual education and information model. You and your health are important to me. If you know me, you know that wellness is a topic I love to research, teach others, and share.

Both Kathie and I wish to thank you for trusting us with your healthcare. We are grateful that you chose us. We appreciate your loyalty and support over the years. We will miss you and wish each of you a love-filled, happy and healthy life.

Live Well, Les Cole, MD and Kathie Gonzales, ARNP

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We are committed to improving and preserving the Health & Wellness of each and every client who walks through our door. Utilizing the latest research and testing methods; we practice Functional, Anti-Aging, Preventive & Integrative Medicine. We are committed to community education on Healthy Lifestyles.

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“If you are afraid of needles, or not, and need a blood draw or health-inducing IV, fear no more. Jeremy and Jessica, at IV Solutions, are kind, conscientious, and above all very skilled. There are all sorts of wonderful IVs for everything including a hangover, nausea, immune system support, and more. Sorry if this sounds like an advertisement but I really believe in Jeremy and Jessica and the IVs they provide and have had many to improve my multiple health issues.”

Emotional Relief that I Would Finally Get Results

“5 stars is a very strong rating and I don’t give them out often. My first appointment with Dr. Cole was 5 months ago and I have never felt better! For many months, my medical practitioner prescribed medications with side effects and no results. I was even scheduled for surgery consultation to “fix” a problem I was dealing with. On my first visit with Dr. Cole, I felt so much emotional relief that I would finally get results. It is true the tests and supplements can be costly. I will say they are necessary for results. I appreciate that he never suggested supplements to try to see if they work. He knew exactly what was needed. The extensive test results showed what was needed and revealed issues no other doctor; primary, gynecologist, or rheumatologist considered. I’ve been consistent with his recommendations and they work. Any questions are promptly responded to and I feel my time is respected during my appointment. His staff, Jessica and Jeremy are just as attentive and knowledgeable. The office is clean and welcoming. Everyone goes above and beyond. I feel 100% confident to recommend to anyone”

I love my new doctor and his staff.

I love my new doctor and his staff. They are very supportive and kind. They make me feel like a VIP patient every time I call or go in for an appointment.

Dr. Cole is an Expert in his Field

“We have been going to Vital Solutions for approximately 5 years. Dr. Cole is an expert in his field and the services provided. Jessica is very thorough, professional and knowledgeable! Jeremy and Wendy are always consistent in their help and caring. We are thankful for them and their innovative strategies.”

I Feel I Received a 5-star Treatment

“First, I would like to say I am not a fan of needles. More so my veins do not cooperate. I first went to Vital Solutions for Vitamin IV as a recommendation of a friend. I was feeling run down after traveling and thought this would be a good pick me up. It was more than that! I felt 100% better the following day. The vitamin boost and hydration made me feel great. I later needed supplementation for another issue and Jessica and Jeremy were caring and attentive. I was nervous but they made me feel better about the process. The hours are convenient and the response for an appointment is quick. I feel I received 5-star treatment.”

Crossfit Competition Recovery

“This place is amazing! We have gone here before Crossfit competitions several times. The IV helps big time. Today I am here as I just arrived from a 30 hour travel time from Italy. I was feeling very run down. So I am getting an IV and already feel much improved. The staff is very helpful and always a pleasure.”

The Missing Links in my Overall Health Dilemma

“What a wonderful doctor, staff, and experience! The St. Pete Health and Wellness team is professional and always so friendly. Dr. Cole is brilliant and takes the time to listen to you and understand your unique situation. My health had been challenging me for many years and I am still a young adult. Fatigue and pain were my daily companions. When the conventional medical industry could not offer me any answers or solutions, I turned to integrated medicine and Dr. Les Cole. He literally turned my daily life around! His solutions and treatments were the missing links in my overall health dilemma that no one else has been able to solve. Now I follow his recommendations every day and reap the benefits. Renewed energy, strength, and stamina. Greater concentration and focus. I’m playing tennis again! I cannot encourage you enough to work with Dr. Cole and see the benefits manifested in your life. Thank you Dr. Cole!!”

Keenly Focused on Increasing Vitality and Anti-Aging

“After struggling to find answers on my decreasing energy with my primary care, even after cleaning up my diet and exercise routine, I followed advice to see Kathie Gonzales and wish I had done it two years ago. Kathie and the team drew my blood and tested areas my primary doctor never did. She is an expert on the thyroid and has an amazing consultative approach on the whole body. They are keenly focused on increasing vitality and anti-aging. My primary doctor waited two years while I suffered through premenopausal symptoms and never diagnosed my hypothyroid issue. Net, I am so very happy I made the switch, the entire team there is so responsive and helpful, I recommend them highly.”

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A Review of Exceptions in State Abortion Bans: Implications for the Provision of Abortion Services

Mabel Felix , Laurie Sobel , and Alina Salganicoff Published: May 18, 2023

  • Issue Brief

Key Takeaways

Abortion is currently banned in 14 states and many other states have attempted to ban or severely restrict access to abortion. Nearly all of these bans include exceptions, which generally fall into four categories: to prevent the death of the pregnant person, when there is risk to the health of the pregnant person, when the pregnancy is the result of rape or incest, and when there is a lethal fetal anomaly.

  • In practice, health and life exceptions to bans have often proven to be unworkable, except in the most extreme circumstances, and have sometimes prevented physicians from practicing evidence-based medicine.
  • Abortion bans and restrictions have led physicians to delay providing miscarriage management care. Many states allow for the removal of a dead fetus or embryo, but pregnant people who are actively miscarrying may be denied care if there is still detectable fetal cardiac activity or until the miscarriage puts the life of the pregnant person in jeopardy.
  • Mental health exceptions are rare despite the fact that 20% of pregnancy-related deaths are attributable to mental health conditions.
  • Law enforcement involvement is often required to document rape and incest, which often prevents survivors from accessing abortion care. Furthermore, survivors in states where abortion care is restricted can have difficulty finding an abortion provider.
  • In many states there is more than one abortion ban in the books, in some of those states, the exception provisions in the bans are often at odds with each other. These multiple bans and varying exceptions create confusion among patients and providers.

Introduction

Since the Supreme Court’s Dobbs decision overturning Roe v. Wade, state abortion bans and the exceptions they contain – or lack – have garnered significant attention. Conversations about these exceptions, however, often obscure the reality that many of these exceptions can be unworkable in practice. There are reports of people being unable to obtain abortions, despite the fact that their pregnancies fall into these broad exception categories. While there is no accurate estimate of the number of people seeking abortion care in circumstances that qualify for an exception in states than ban abortion, the number of people who have received abortion care post – Dobbs in states that have banned abortion is very low .  Many of the exceptions included in these bans use definitions that are vague, narrow, and non-clinical, and effectively remove the ability of health care providers to best manage the care of pregnant people, instead leaving that decision to the state or the clinician’s home institution. Further complicating matters, several states have multiple bans in effect, often with contradicting definitions, requirements, exceptions, and standards, creating ambiguity for clinicians and their patients. This brief analyzes the exceptions to abortion bans and discusses how their purported aims to provide life-saving care may not be achieved in practice.

What kinds of exceptions do abortion bans contain?

To prevent the death of the pregnant person.

All state abortion bans currently in effect contain exceptions to “prevent the death” or “preserve the life” of the pregnant person. As explained in further detail in the section below, these exceptions may create difficulties for physicians, as it is unclear how much risk of death or how close to death a pregnant patient may need to be for the exception to apply and the determination is not up to the physician treating the pregnant patient.

When there is risk to the health of the pregnant person

Most states with bans that contain a health exception permit abortion care when there is a serious risk of substantial and irreversible impairment of a major bodily function. These exceptions are limited by the lack of specific clinical definitions of the conditions qualifying for the exception. Only the Arizona ban explicitly defines the bodily functions that may be considered “major.”  The other states that use this language in their bans do not define what constitutes a “major bodily function,” nor what constitutes a “substantial impairment” to a major bodily function. This vague language puts physicians providing care to pregnant people in a difficult situation should their patients need an abortion to treat a condition jeopardizing their health and can leave the determination of whether an abortion can be legally provided to lawyers for the institution in which the clinician practices. For instance, in Ohio , where the abortion ban has a health exception, the law lists a couple of conditions that may fall under this exception, such as pre-eclampsia and premature rupture of the membranes, but with no further detail.  Using this language as guidance, it would be difficult for physicians to know if a significant health issue would fall under the exception. The difficulties presented by the simultaneous vagueness and narrowness of the exceptions are exacerbated by the lack of deference given to clinicians’ medical judgment under these bans.

In their lawsuit against the Ohio abortion ban, providers challenged the provisions of the health exception, arguing its vagueness makes it impossible to treat some patients presenting with serious health concerns. As an example, one provider detailed the case of a woman with stage III melanoma who was denied cancer treatment while pregnant and was also denied abortion care in Ohio because clinicians could not confirm whether the ban’s exceptions applied to her case. Instead, this woman left the state to terminate her pregnancy and receive cancer treatment.

However, even if these terms were defined more clearly, they would still exclude many health conditions pregnant people face. In Georgia , for example, where the health exception is slightly narrower than Ohio’s, providers challenging the ban note that the exceptions do not permit abortion care when it is needed to prevent: “(1) substantial but reversible physical impairment of a major bodily function, (2) less than ‘substantial’ but irreversible physical impairment of a major bodily function, or (3) substantial and irreversible physical impairment of a bodily function that is not ‘major.’” A medical condition may still be a significant health event, yet not qualify under the exceptions, even if their limits were more clearly defined.

In Texas ’ abortion ban, the health exception is limited to situations where there is “a life-threatening physical condition aggravated by, caused by, or arising from a pregnancy that […] poses a serious risk of substantial impairment of a major bodily function unless the abortion is performed or induced”. A condition needs to be “life-threatening” and “be aggravated by, caused by, or arising from the pregnancy” for a clinician to be able to intervene by providing abortion care. Many serious health conditions unrelated to the pregnancy may not qualify for an exception. In cases where terminating a pregnancy is necessary to begin medical treatment, it is difficult to ascertain if the pregnancy itself can be said to be aggravating the condition and therefore qualify for the exception.

MENTAL HEALTH

Mental health conditions account for over 20% of pregnancy-related deaths  in the US, yet almost all states with health exceptions limit them to conditions affecting physical health, with some going further and explicitly precluding emotional or psychological health conditions. Alabama , the only state that includes mental health concerns in its health exception, requires a psychiatrist to diagnose the pregnant person with a “serious mental illness” and document it is likely the person will engage in behavior that could result in her death or the death of the fetus that due to their mental health condition. The law does not define “serious mental illness” and does not allow physicians to determine what serious mental illnesses qualify for the exception.  In addition, abortion bans and restrictions in Georgia, Kentucky, Louisiana, Ohio, Tennessee, Idaho, Florida, Iowa, West Virginia, and Wyoming explicitly exclude mental/emotional health. Several other states (Texas, Oklahoma, Mississippi, the remaining Kentucky ban, and one of Arkansas’ total bans) limit their life and/or health exceptions to physical conditions, without explicitly calling out mental/emotional health exceptions.

ECTOPIC PREGNANCIES AND MISCARRIAGES

Some states’ abortion laws specify that care for ectopic pregnancies and pregnancy loss is not criminalized in its statutes. Most states with these provisions in their bans allow for the removal of a dead fetus or embryo, but not for miscarriage care, generally. This means that pregnant people who are actively miscarrying may be denied care if there is still detectable fetal cardiac activity. There have already been reports of such situations in Texas and Louisiana . In Louisiana, for example, a pregnant woman went to the hospital after experiencing sharp pain and bleeding. She was informed her fetus had likely stopped growing a few weeks prior, as its size did not correspond to the length of her pregnancy, and that it had very faint cardiac activity. Despite the pain and the blood loss she was experiencing, she could not receive the regimen of mifepristone and misoprostol commonly prescribed to pregnant patients who are miscarrying to ensure that the pregnancy is safely expelled from the body completely in a timely manner, thereby decreasing the risk of sepsis and infection. Instead, she had to wait for the miscarriage to progress without medical intervention, which would have expedited the process and reduced her medical risk.  In states where the abortion bans do not clarify that miscarriage care is not criminalized – even when there is still detectable cardiac activity – pregnant people may not be able to receive care to manage their pregnancy loss unless and until it becomes a medical emergency.

GREATER RISK TO THE HEALTH OF PREGNANT PEOPLE

In deciding whether or not to provide abortion care to preserve the health of a pregnant patient, physicians now face the risk of a jury or the state disagreeing with their judgment about the gravity of the health risk the pregnant person was experiencing, and as a result, face prison time, monetary fines, and loss of professional license. Prior to the Supreme Court’s decision in Dobbs , the decision to have an abortion pre-viability when facing a health risk was one the pregnant person would make in consultation with medical professionals. How much risk constituted too much risk was up to the pregnant person and their physician, taking into account the needs and overall health history of the pregnant patient.  In states with abortion bans, in deciding whether or not to provide abortion care to preserve the health of a pregnant patient, physicians now face the risk of a jury or the state disagreeing with their judgment about the gravity of the health risk the pregnant person was experiencing, and as a result, face prison time, monetary fines, and loss of professional license.

In state court challenges against the bans, providers have argued that the vagueness of the bans is unconstitutional, since it places them in a situation where it is unclear how they might follow the law. As a result, physicians may be more reluctant to provide abortion care when pregnant patients present with serious medical conditions and may deny abortion care to pregnant people with conditions that threaten their health until their condition deteriorates and the narrow exceptions inarguably apply. This delay in care, however, creates greater and avoidable risks to the health of the pregnant person. Additionally, many conditions that threaten the health of pregnant people are not included in all or most health exceptions.

The difficulties these bans and their unclear exceptions create may additionally deter physicians from practicing medicine in states that ban abortion. There have already been reports of physicians expressing reluctance or refusing to relocate to these states, as well as physicians leaving these states due to their restrictive laws. A substantial portion of these states’ residents already live in maternity deserts – areas where there are no obstetric providers or birth centers – and studies have shown that maternal mortality rates are higher in states that restrict abortion. Physicians being deterred from practicing in states with restrictive abortion laws may exacerbate these disparities in access to obstetric care and health outcomes.

  • Physician judgment should be granted deference in measuring the risk the pregnant person is facing,
  • Impairment of a “major bodily function” includes harm to fertility and the reproductive system,
  • Acute risk does not have to be already present or imminent for the exceptions to apply, and
  • Health exceptions apply in situations where treatment for a condition is unsafe during pregnancy and for fetal conditions and diagnoses that can increase the risk to a pregnant person’s health.

Plaintiffs argue the misapplication of the health exceptions violates state constitutional guarantees to fundamental and equal rights.

THE EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT (EMTALA)

The intersection of federal law requiring hospitals to provide stabilizing care and state abortion bans is another murky area hospitals and physicians must navigate. Enacted in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires Medicare enrolled hospitals to perform an appropriate medical screening examination to any patient who presents to their dedicated emergency department. If a patient is identified as having an emergency medical condition, the hospital must provide stabilizing treatment within the hospital’s capability or transfer the patient to another medical facility.

HHS, through its Office of the Inspector General (OIG) may impose a civil monetary penalty on a hospital ($119,942 for hospitals with over 100 beds, $59,973 for hospital under 100 beds/ per violation) or physician ($119,942/violation).  HHS OIG may also exclude physicians from participating in Medicare and State health care programs. This is countered by the possibility that physicians could also face monetary penalties and prison time for violating state abortion bans, even if they determine that an emergency abortion is needed to stabilize the health of the patient.

As states were starting to implement abortion bans after the Dobbs decision, in July 2022, the Department of Health and Human Services (HHS) issued guidance regarding the enforcement of EMTALA that clarifies hospitals and physicians have obligations to provide stabilizing care, including abortion in medically appropriate circumstances, when a patient presenting at an emergency department is experience an emergency medical condition.

After HHS issued this guidance, two lawsuits were filed. HHS sued the State of Idaho to block enforcement of Idaho’s abortion ban to the extent it conflicts with EMTALA and the State of Texas sued to block enforcement of the HHS guidance in Texas .

These two cases have resulted in conflicting decisions in the federal district courts. In the Idaho case, the court concluded that because the Idaho law does not include exceptions for health or life, the law conflicts with EMATLA. The Idaho law only allows physicians to assert a defense to criminal prosecution if in their good faith medical judgment performing the abortion was “necessary to prevent the death of the pregnant woman.” There is no affirmative defense (see box below) if the physician performed the abortion to prevent serious harm to the patient, rather than to save her life. The district court has blocked Idaho from enforcing the abortion ban to the extent it conflicts with EMTALA while the litigation proceeds.

The federal district court in Texas reached the opposite decision and blocked HHS from enforcing its EMTALA guidance in Texas. The court highlighted that the HHS Guidance states that abortion may be required for medical conditions that are likely to become emergent. Texas law requires that life-threatening physical conditions to already be present. The court concluded that Texas is likely to succeed on their claim that the HHS Guidance exceeds HHS’s statutory authority: “The Guidance goes well beyond EMTALA’s text, which protects both mothers and unborn children, is silent as to abortion, preempts state law only when the two directly conflict. Since the statute is silent on the question, the Guidance cannot answer how doctors should weigh risks to both a mother and her unborn child.” The Biden Administration has appealed this decision to the 5 th Circuit Court of Appeals.

Exception vs. Affirmative Defense

Some state abortion bans lack exceptions but identify situations that may be used as an affirmative defense in court – among these are Tennessee’s 6-week LMP ban, Idaho’s total ban, Kentucky’s 15-week ban (but not the state’s earlier gestational bans), and all of Missouri’s bans.  An “affirmative defense” allows someone charged with a crime to show in court that their conduct was permissible even though the action itself is illegal. An affirmative defense does not make it legal to provide abortion care in the situations delineated in the law and means that a clinician who provided abortion care is open to prosecution – regardless of the reason they provided an abortion – and would bear the burden of proof to demonstrate that they provided care according to the conditions delineated as possible affirmative defenses in the abortion ban. Bans that rely on an affirmative defense leave physicians more vulnerable to criminal prosecution and they make it even riskier for physicians to provide abortion care in situations where the life or health of the pregnant person is at risk.

Sexual Assault Exceptions

A few of the state abortion bans contain exceptions for pregnancies resulting from rape or incest, generally requiring that the sexual assault be reported to law enforcement. Some states allow for a Child Protective Services (CPS) report in lieu of a law enforcement report for minors who are survivors of sexual assault or incest.

It is well documented that survivors are often afraid to report sexual violence to the police due to fear of retaliation, shame, reporting an incident to officials who will not respond adequately, not wanting friends or family to know, fear of the justice system, or other personal reasons. It is estimated that out of every 1000 sexual assaults , only 310 are reported to the police and 50 of these reports will lead to arrest, 28 of which will lead to a felony conviction. Even for survivors who do report to law enforcement, state abortion bans do not make clear exactly what information needs to be given to a provider to make it clear that the abortion would be legal in that state. Reporting requirements place barriers in the way of survivors seeking abortion care in these states.

Among the few sexual assault exceptions, some have specific gestational limits. For instance, the total ban currently in effect in West Virginia contains an exception for cases of rape or incest, but it is limited to 8 weeks from the last menstrual period (LMP) for adults and 14 weeks LMP for minors.

Although sexual assault exceptions are intended to protect survivors, experts agree that they rarely work. There is anecdotal evidence of survivors in states with rape exceptions and who have compiled the necessary documentation, but still not being able to access abortion because they couldn’t find any abortion providers in their state.

Hyde Amendment

The Hyde Amendment is a policy that restricts the use of federal funds to cover abortion, except in cases of rape or incest, or when the life of the pregnant person is endangered (Hyde Exceptions). The policy is not a permanent law, but rather has been attached as a temporary “rider” to the Congressional appropriations bill for the Department of Health and Human Services (HHS) and has been renewed annually by Congress. In the past, federal courts have interpreted the Hyde provisions to require states to pay for abortions that fall into the Hyde Exceptions and have blocked enforcement of state statutes that prohibit coverage for these cases. However, the enforceability of these requirements has been unclear since the Supreme Court’s decision in Dobbs . Although all bans currently in effect contain exceptions to safeguard the life of the pregnant person, most states with abortion bans do not have exceptions for cases of rape or incest, and therefore, would not allow for the provision or coverage of those services to Medicaid recipients, contrary to previous court orders. To date, no court or federal agency has issued orders or guidance on states’ obligation to provide coverage for Hyde Exceptions when their bans prohibit the provision of abortion in cases of rape or incest.

Lethal Fetal Anomaly Exceptions

Bans in several states contain exceptions for lethal fetal anomalies, usually limited to those anomalies that would result in the death of the baby at birth or soon after. As with health exceptions, lethal fetal anomaly exceptions are poorly defined and limited in statute. The only state with this kind of exception that has a comprehensive list of conditions that fall under this category is Louisiana , but since the state has multiple abortion bans in effect (one of which does not include exceptions for fatal fetal anomalies), the applicability of this exception is still unclear. Other states, like Indiana , provide some general criteria, such as how long after birth the baby can be expected to live for a pregnancy to fall under the fetal anomaly. Any condition that would result in a life expectancy shorter than three months fits under the exception. The religious freedom lawsuit against the state’s ban – Anonymous Plaintiffs v. Medical Licensing Board of Indiana — specifically challenges the narrow limits of the exception, arguing that other common conditions, such as Tay-Sachs disease would result in the death very early in childhood.

What happens in states with more than one abortion ban in effect?

In many states there is more than one abortion ban in the books, and in some of those states the exception provisions in the bans are at odds with each other. In Oklahoma , four bans are currently in effect, each with different exceptions. The state’s pre-Roe, total ban contains only an exception to preserve the life of the pregnant person. The total ban with criminal penalties enacted in 2022 contains exceptions to preserve the life of the pregnant person and clarifies that treatment to remove an ectopic pregnancy does not constitute an abortion. The state’s total ban with private, civil enforcement contains exceptions to preserve the life of the pregnant person in a medical emergency (but does not define what a medical emergency is), for cases of rape, sexual assault, or incest that have been reported to law enforcement, and in situations where federal law preempts state law. This ban also clarifies that treatment to remove an ectopic pregnancy is not an abortion. The state also has a 6-week LMP ban with private, civil enforcement that contains exceptions for medical emergencies (once again, without providing a definition for what constitutes a medical emergency) and where federal law preempts state law. The conflicting exceptions in the bans result in a situation where the only real exception in the state is for cases where an abortion is necessary to prevent the death of the pregnant person. Applying any other exception in the states’ other total bans would open physicians to criminal penalties and loss of license.

Mississippi is another state with multiple bans in effect that contain contradicting exceptions. The state’s total ban only has exceptions for cases when an abortion is necessary to preserve the life of the pregnant person or when the pregnancy was caused by rape (there is no exception for incest in the state). However, the state’s 15-week LMP ban contains exceptions for fatal fetal abnormalities and serious risk of substantial and irreversible impairment of a major bodily function, along with a life exception. In situations where there is more than one ban in effect, it might seem that the easiest way to follow the law would be to adhere to the abortion ban with the strictest gestational limit. This would not suffice in Mississippi, however, since the total ban contains an exception for pregnancies caused by rape, but the state’s 15-week LMP ban does not contain such an exception. Therefore, following any one of the state’s abortion bans would not remove the legal risk of providing abortion care in the state. Instead, providers must assess how the abortion bans and their exceptions work in conjunction.

Although a lot of attention has been devoted to debates about exceptions in abortion bans, many of these exceptions are not workable in practice. Outside of testimony from providers, it is difficult to assess how many people who qualify for abortion care under the exceptions are actually able to do so, since states do not report or underreport this information. However, it is apparent these bans create barriers to accessing abortion care, even in situations where the exceptions they outline should apply. Most importantly, these bans place the health and lives of pregnant people at risk by potentially preventing physicians from providing medically appropriate care. This inability to provide evidence-based care may additionally make physicians reluctant to practice medicine in restrictive states, amplifying already-existing discrepancies in ability to access obstetric care and adverse maternal and fetal outcomes.

  • Women's Health Policy
  • Reproductive Health

news release

  • What Are the Exceptions to State Abortion Bans?

Also of Interest

  • Addressing Abortion Access through State Ballot Initiatives
  • Who Decides When a Patient Qualifies for an Abortion Ban Exception? Doctors vs. the Courts
  • The Availability and Use of Medication Abortion
  • Abortion in the United States Dashboard

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Was racism a factor in mother’s leukemia?

Dale Blackstock grew up low-income, became a physician. Her death left daughter Uché, also a doctor, with a lesson on color, class, healthcare

Excerpted from “Legacy: A Black Physician Reckons with Racism in Medicine ” by Uché Blackstock ’99, M.D. ’05, published by Viking, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC.

Our mother was a remarkably vibrant and athletic woman. She regularly ran 20 miles a week, a habit she had first picked up in medical school to calm her frazzled nerves. After my twin sister, Oni, and I were born, she began squeezing her daily run into the very early mornings before we got up for school and she had to go to work. 

In her younger years, she had run marathons, and even once won as the first woman to cross the finish line. And although after having twins, she gave up running very long distances, she’d still regularly compete in 5K and 10K races in Prospect Park and in Manhattan’s Central Park. She had experienced her own share of racism and sexism while running, with white male runners spitting at her and trash-talking to try unsuccessfully to psych her out. Despite these unpleasant experiences, she encouraged Oni and me to join her in her passion, and I ran my first race with her when I was only six years old. It was a family race in Prospect Park. She ran alongside me the whole way, cheering me on. A picture of us running together was even published in one of the local Brooklyn papers.

As Oni and I got older and entered our preteens, we joined the New York Road Runners club and began competing with her. Even when we were teenagers and she was in her forties, our mother always crossed the line before us — she was unstoppable. Then she would wait for us there, cheering us on.

By the time Oni and I left home to go to Harvard University, where my mother went to medical school, to study premed, we just assumed that our mother was invincible. 

Cover of "Legacy."

The first time I remember noticing any change was during a 10K race. It was the summer of 1996, between our freshman and sophomore years. Oni and I had signed up to race with our mother in Central Park. Usually, we would expect her to be ahead of us, but this particular day, I remember looking over my shoulder and thinking, “Where is she?” When she came in a good few minutes after we crossed the finish line, I asked her if she was okay.

“I don’t know what happened,” she replied between deep breaths. She was bent over with her hands on her hips and head down. “I just feel really tired.”

Uché Blackstock.

On the way home, our mother confided to Oni and me that she had been feeling under the weather for a while. She had been to her physician; they had done blood work and believed she had a vitamin B 12 deficiency because her red blood cells were so big. When you don’t have enough vitamin B 12 , your bone marrow makes abnormally large red blood cells. She was getting B 12 shots, but they didn’t seem to be helping. Eventually, her doctors did a more thorough workup, including a bone marrow biopsy. This took several weeks. I remember telling her to please keep us posted about the results, and soon after that we returned for our second year at Harvard.

One day, when we were back in Boston and two months into our sophomore year, we got a call from our mother’s sister, Auntie Joanie. She lived in the Boston area and had always been like a second mother to us. We would see her often, so it wasn’t unusual for her to call and come over to visit. When I saw our aunt’s face as she walked into our dormitory that day, I knew it was bad news — her usual cheery disposition was gone, and instead she looked distraught, her eyes somehow sunken into her features. We walked out to the courtyard outside our dorm, which overlooked the Charles River. It was a slightly chill fall day, the clouds overhead casting dark shadows across the silvery water. As she told us about our mother’s diagnosis, all three of us started to cry. I realized that our mother must have sent her sister to tell us because she couldn’t bear to do it herself. I remember dropping to my knees on the ground and sobbing.

Our mother had been diagnosed with acute myelogenous leukemia (AML), a type of blood cancer. Her doctors gave her two to three months to live. The chemotherapy treatments started right away. Oni and I spent that year traveling back and forth between Boston and New York, on buses, trains, and airplanes, while our mother was in and out of the hospital. 

Despite the odds, she told us that she would beat the disease, that she would endure the harsh chemotherapy side effects, infections, and sheer pain and discomfort to do so. That she was a fighter.

There are multiple risk factors for AML, and although the official list doesn’t include racism, I can’t help but wonder about the many ways systemic racism may have contributed to my mother’s increased susceptibility to the disease. Not long after her diagnosis, she came up to Boston for a second opinion at the Dana-Farber Cancer Institute, one of the leading cancer centers in the country, if not the world. After her visit with the oncologist, she told us that the doctor who had looked at her karyotype — a picture of the chromosomes at the cellular level — said it seemed to him as if she had been exposed to high doses of radiation at some point in her life, which would have increased her risk for her type of cancer.

At the time, I didn’t think to ask how this might have been possible. I was too distraught and worried about her to think much about anything else. Since that time, I’ve come to understand that my mother may well have been exposed to radiation as a child or perhaps even in utero. Today, there are four designated “Superfund” sites in New York City, locations that the Environmental Protection Agency has marked as polluted by hazardous waste and in need of cleanup. Two of the four sites are radioactive dumping grounds: one of these is in Brooklyn and one is on the Brooklyn-Queens border, both in Black and Latinx communities where my mother lived. Multiple studies show that people who reside in predominantly low-income communities of the kind my mother grew up in have much higher exposure to toxic environmental contaminants in general, which in turn can lead to higher instances of cancer.

We also know that these high rates are compounded by the fact that Black patients often have delayed cancer diagnoses due to lack of access to health care and lack of quality, culturally responsive care. By the time my mother’s leukemia was caught, it was already extremely advanced and therefore much more difficult to treat. When her oncologists looked back at her blood work, they could see that her red blood cells had been enlarged for a while, at least one to two years. But this key indicator for her disease wasn’t picked up by her primary care physician in Brooklyn, who had told her at first, when her symptoms began, that she needed to take vitamin B 12 for a deficiency. 

Aging is another key risk factor in my mother’s disease. Although people can develop AML at all ages, the risk increases substantially as someone gets older. My mother was in the prime of her life, in her midforties, when she was struck down by AML. But what if the cells in her relatively young body had gone through an accelerated aging process due to her life experiences as a Black woman? Studies have shown that the higher levels of stress to which Black people are subjected on a day-to-day basis due to racism can, in turn, cause our cells to divide and deteriorate, accelerating the body’s aging process. This phenomenon has been dubbed “weathering” or “premature aging” by public health researcher Dr. Arline Geronimus, who first noted the effects of increased stress on the health of pregnant teenagers in Black and Latinx communities in New Jersey when compared with their white counterparts. 

Like anyone Black in the United States, our mother had experienced the excruciating pain of that stress. Growing up in poverty, she had been forced to constantly move to different schools and apartments due to housing insecurity, and she never knew if there would be enough food on the table. She was the first person in her family to go to college, the first to have a professional career, navigating a demanding medical career without mentorship or support. On top of this, there was the everyday discrimination she experienced as a matter of course. I can remember the time Oni and I watched in horror as a CVS pharmacy security guard accused our mother of stealing something from the store and demanded she open her bag. Our always firm and confident mother was suddenly flustered, embarrassed, made vulnerable by this awful stranger who somehow held power over her, and by extension us. We were furious and scared, clinging to her as she opened her purse. 

People often talk about “going to war” with cancer or “the fight” to combat the disease, but we hear less about how the “war” and “fight” a person endures before they get visibly sick may have contributed to a physical diminishment of the body. And our mother is far from an outlier. Today, the National Cancer Institute’s database shows that Black patients with AML have a 12 percent increased risk for mortality compared with white patients who have the disease, but we will need far more studies that include Black people before we truly understand why. To this day, I wonder whether our mother might have lived longer had she not been Black in America. Although we’ll never know for certain, what we do know is that the ongoing impact of racism on Black bodies continues to leave untold loss in its wake.

Copyright © 2024 by Uché Blackstock, M.D.

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Innovation in Behavioral Health (IBH) Model

On January 18, 2024, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation in Behavioral Health (IBH) Model.

IBH is focused on improving quality of care and behavioral and physical health outcomes for Medicaid and Medicare populations with moderate to severe mental health conditions and substance use disorder (SUD). Medicare and Medicaid populations experience disproportionately high rates of mental health conditions and/or substance use disorders (SUD), and as a result are more likely to experience poor health outcomes and experiences, like frequent visits to the emergency department and hospitalizations, or premature death. 

The IBH Model seeks to bridge the gap between behavioral and physical health; practice participants under the IBH Model will screen and assess patients for select health conditions, as well as mental health conditions and/or SUD, in community-based behavioral health practices. IBH is a state-based model, led by state Medicaid Agencies, with a goal of aligning payment between Medicaid and Medicare for integrated services.

CMS will release a Notice of Funding Opportunity (NOFO) in Spring 2024, and up to eight states will be selected to participate. The model will launch in Fall 2024 and run for eight years.

Model Overview

The Innovation in Behavioral Health (IBH) Model is designed to deliver person-centered, integrated care to Medicaid and Medicare populations with moderate to severe mental health conditions and/or substance use disorder (SUD). The practice participants in the IBH Model will be community-based behavioral health organizations and providers, including Community Mental Health Centers, opioid treatment programs, safety net providers, and public or private practices, where individuals can receive outpatient mental health and/or SUD services. These practice participants may include safety net providers who ensure that vulnerable populations are able to access care.

Practice participants will lead an interprofessional care team and be responsible for coordinating with other members of the care team to comprehensively address a patient’s care to include behavioral and physical health, and health-related social needs (HRSN) such as housing, food, and transportation.

The practice participants will conduct an initial screening and assessment, offer treatment or referrals to other care specialists and community-based resources, and monitor ongoing behavioral and physical health conditions and HRSNs. In this value-based care approach, the practice participants will be compensated based on the quality of care provided and improved patient outcomes.

Model Purpose

Innovation in Behavioral Health (IBH) Model: Delivering Coordinated, Whole-Person Care showing Julia’s Outcomes under the IBH Model

Medicaid populations experience disproportionately high rates of mental health conditions and/or substance use disorders (SUD) and account for nearly half of all Medicaid expenditures. Medicare populations also experience higher than average rates of mental illness and/or SUD. Consequently, both populations are more likely to experience frequent visits to the emergency department and hospitalizations, have poor health outcomes, and premature death.

Limited access to care, stigma, and untreated or poorly managed chronic conditions like diabetes and heart disease can contribute to worsening health outcomes for these populations. Behavioral health providers face significant barriers to delivering care due to a lack of resources and a fragmented health care delivery system that does not systematically integrate behavioral and physical health care. The IBH Model aims to help participating practices improve access to and promote high-quality integrated care. By supporting behavioral health practices to lead an interprofessional care team, the model will address patients’ behavioral and physical health and health-related social needs.

Model Design

IBH is a state-based model focused on community-based behavioral health practices that treat Medicaid and Medicare beneficiaries and includes both Medicaid and Medicare-aligned payment models. CMS will first issue awards to Medicaid agencies in up to eight states to implement the model. Practice participants within selected states may volunteer to participate in the Medicare payment model. The selected states will partner with their state’s agencies for mental health and/or SUD to ensure alignment in clinical policies, as well as work with at least one partnering Medicaid Managed Care Organization (MCO) or another intermediary partner, where applicable, to develop and implement the IBH Model in their state.

IBH supports behavioral health practices in delivering integrated care in outpatient settings. This person-centered approach to addressing whole-person health represents a “no wrong door” approach that prioritizes close collaboration with primary care and other physical health providers to support all aspects of a patient’s care.

Community-based behavioral health practices (“practice participants”) will be responsible for conducting screenings and assessments of behavioral and physical health and health-related social needs, offering treatment as appropriate within their scope of practice, providing “closed loop” referrals to other primary care providers, specialists, and community-based resources, and monitoring ongoing conditions. Since people with moderate to severe behavioral health conditions frequently visit behavioral health settings, this approach uses the behavioral health setting as a point of entry to identify and secure further care and facilitate close collaboration with primary and specialty care providers.

The model works to improve care through four key program pillars:

  • Care Integration: Behavioral health practice participants will screen, assess, refer, and treat patients, as needed, for the services they require.
  • Care Management: An interprofessional care team, led by the behavioral health practice participant, will identify, and as appropriate address, the multi-faceted needs of patients and provide ongoing care management.
  • Health Equity: Behavioral health practice participants will conduct screenings for HRSNs and refer patients to appropriate community-based services. Participating practices will be required to develop a health equity plan (HEP). The HEP should stipulate how the practice participant will address disparities that impact their service populations.
  • Health Information Technology: Expansion of health IT capacity through targeted investments in interoperability and tools (including electronic health records) will allow participants to improve quality reporting and data sharing.

The IBH Model is projected to run for eight years and includes a pre-implementation period (model years 1-3). During this period, states and practice participants will receive funding to develop and implement model activities and capacity building. During model year 1, states will conduct outreach and recruit behavioral health practice participants into the model. Practice participants will receive funding to support necessary upgrades to health IT and electronic health records, as well as practice transformation activities, and staffing to implement the model. Practice participants who elect to participate in the Medicare payment model may also be eligible for additional funding to support model activities.

By the start of model year 4, states will implement a Medicaid payment model that supports practice participants in implementing the care delivery framework. Practice participants in selected states who participate in the additional Medicare payment model will receive a per-beneficiary-per-month payment to support their implementation of the care delivery framework. These payments will be further supplemented with additional performance-based payments during the implementation period (model years 4-8). Additional information about eligibility to receive these payments will be provided in the NOFO.

This model is intended to prepare practices for more advanced alternative payment models and accountable care arrangements in the future.

Eligibility Criteria

CMS will award Cooperative Agreements to up to eight state Medicaid agencies (SMAs), through a Notice of Funding Opportunity (NOFO) to participate in the IBH Model.

States, including U.S. territories and the District of Columbia, have the option to apply as a whole state, or a specified sub-state region. If selected, a participating state is required to select practice participants – community-based behavioral health organizations or settings that, at the time of application, meet all the following criteria:

  • Are licensed by the state awardee to deliver behavioral services, either mental health and/or substance use disorders
  • Meet all state-specific Medicaid provider enrollment requirements
  • Are eligible for Medicaid reimbursement 
  • Serve adult Medicaid beneficiaries (age 18 or older) with moderate to severe behavioral health conditions
  • Provide mental health and/or substance use disorder services at the outpatient level of care

Medicare and Medicaid beneficiaries, including those dually eligible, who receive behavioral health care from a participating practice are eligible to receive services as part of the model. All applications will be reviewed by a panel of technical experts.

Health Equity Strategy

The IBH Model supports CMS’ broader efforts to promote health equity and ensure all populations can achieve optimal health outcomes.

People with mental health conditions and/or substance use disorder often experience health disparities. These health disparities are further exacerbated among historically marginalized racial and ethnic groups, low-income, and/or rural populations.

Practice participants are required to create a Health Equity Plan (HEP) using a needs assessment of the population they serve. The HEP should detail steps that practice participants will take to address the population needs and stipulate how the practice participant will address disparities that disproportionately impact their service populations.

Additionally, the IBH Model will require practice participants to annually screen and monitor patients for underlying and/or unmet HRSNs and make necessary referrals to other health care providers or local safety-net services, and that the required care management component will help ensure that Medicaid beneficiaries receive the services needed to address their health-related social needs.

  • February 29, 2024 2:00 - 3:30 p.m. ET

Additional Information

  • IBH Fact Sheet (PDF)
  • IBH Press Release
  • IBH Model Patient Journey Map (PDF)
  • IBH Model Frequently Asked Questions

If you are interested in receiving additional information, updates, or have questions about the Innovation in Behavioral Health Model, please see the resources below:

  • Email: [email protected]
  • Sign Up for email updates from the Innovation in Behavioral Health Model team

Where Health Care Innovation is Happening

Doctors and patients fearfully proceed with IVF after Alabama court rules embryos are children

After three miscarriages in less than a year, Gabby Goidel said she was diagnosed with unexplained genetic infertility.

For reasons that aren't clear to doctors, any fetus she carries has a higher-than-average likelihood of genetic abnormalities, she said, so there is a slim chance she'd be able to carry a pregnancy to term without in-vitro fertilization.

To avoid the possibility of additional miscarriages, Goidel and her husband, Spencer, decided last year to pursue in vitro fertilization in their home state of Alabama.

IVF allows doctors to test embryos for genetic abnormalities, then implant only the ones that are healthy.

The Goidels were on track to freeze embryos later this month, and they planned to only store the ones that were genetically normal.

But on Friday, the Alabama Supreme Court ruled that frozen embryos created through IVF are considered children under state law, meaning that people could theoretically be sued for destroying an embryo.

The Goidels began to worry whether they might be forced to store — or even use — embryos they had intended to discard.

"Most of our embryos are not going to be genetically normal," said Goidel, a 26-year-old property manager in Auburn. "My hope would be that we could let those embryos naturally pass, but now it’s, 'Do we have to save them?' I don’t necessarily want to implant a child that I know is going to miscarry."

Roughly half of first-trimester miscarriages are due to a chromosomal abnormality in the fetus. In addition to vaginal bleeding, abdominal pain and cramping, miscarriages can increase the risk of anxiety, depression, post-traumatic stress disorder and suicide.

An uncertain future for IVF patients

In the wake of the Alabama ruling, many patients and providers are unsure of how to navigate the IVF process, given that embryos are often discarded if they have genetic abnormalities or after patients decide they will not need to use them. The decision raises questions about whether those who undergo IVF will have to store all their embryos indefinitely — but experts said the answer is not yet clear.

Storing frozen embryos can cost between $350 to $1,000 per year .

The court's decision was issued in a case in which a person removed embryos from storage at a fertility clinic and dropped them on the floor accidentally.

Gail Deady, senior staff attorney at the Center for Reproductive Rights, said that because of that, the ruling "does not appear to create criminal liability for IVF providers."

Instead, she said, "what it does implicate is the Wrongful Death Act, which is civil liability and negligence," meaning people could be sued for the destruction of embryos and have to pay monetary penalties.

Nevertheless, “anyone who cares about reproductive autonomy should be terrified of this decision,” Deady added.

Dr. Mamie McLean, a reproductive endocrinologist at Alabama Fertility, said she is concerned about the survival of IVF services in Alabama. Clinics may need to raise prices if they have trouble staffing providers or have to pay more for medical malpractice insurance, she said. As a result, fewer people may be able to afford IVF and fewer insurers may be willing to cover treatments.

The cost of insurance to defend against wrongful death lawsuits “might actually prevent us from practicing, it would be so high,” said Dr. Brett Davenport, a reproductive endocrinologist at Fertility Institute of North Alabama.

Davenport, too, worries the new law could penalize doctors for helping people start families.

“I am a very pro-life reproductive endocrinologist, and yet this still seems quite absurd to me,” he said.

Legal experts worry the ruling could set the stage for harsher abortion restrictions in the future, as well, such as penalties for women who get abortions. (Right now, state law only penalizes providers who administer abortions.)

"The next step will be to say, 'Well, if an embryo is a person [outside the uterus], clearly it's a person in utero," said Priscilla Smith, director of the Program for the Study of Reproductive Justice at Yale Law School.

“I don’t want to be dramatic and say it’s totally Handmaid’s Tale, but more and more, you’re in the situation rather where the state controls your behavior," Smith said.

Where to put embryos?

After the Alabama Supreme Court decision, Meghan Cole, an attorney in Birmingham, made a plan to move her remaining embryos to another state. Cole has a rare blood disorder that prevents her from safely carrying a child, so she’s planning to use a surrogate. That embryo transfer is scheduled for next week, and she still has other embryos in storage.

“I was scared for what the future held for the embryos that we’re still going to have in storage,” she said. “My first thought was, ‘OK, I need to transfer my embryos out-of-state and have them frozen somewhere else so I don’t open myself up to liability.’”

Cole said she selected which embryo to use with Alabama’s legal landscape in mind.

“We are picking a boy to transfer because these rules and laws that are coming out that are affecting women’s health kind of scare me for a daughter,” she said.

Deady said there's no reason yet why patients in Alabama should be afraid of getting IVF — but providers are proceeding cautiously.

McLean said there are even some concerns about the ability to freeze embryos in the first place, given the ruling. An alternative to freezing or discarding embryos, she said, would be to create fewer of them. But in that case, patients would likely require more rounds of IVF to get pregnant, which is both expensive and physically demanding.

Alabama's legal landscape has made the Goidels reconsider whether they want to raise kids there.

“We’re this very traditional family that just wants to have a kid, so I didn’t realize ever that this was going to be a question of morality,” Goidel said.

“We really envisioned starting a life here and probably retiring here,” she added. “We’re very much questioning whether or not we want to leave.”

e&m visits healthcare

Aria Bendix is the breaking health reporter for NBC News Digital.

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  1. Virtual Clinic Application for Healthcare e-Visits

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  2. 2021 E/M Guidelines FAQ

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  3. Can You Bill Multiple E/M Visits in Same Day for Same Patient?

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  4. CPT Coding for E/M Visits With Wound Care

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  5. Proposed Medicare Changes to Office/Outpatient Evaluation and

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  6. Emergency Medicine, Education and Training (EMET)

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VIDEO

  1. Healthcare and Access to Medical Treatment

  2. First week in a new healthcare system

COMMENTS

  1. Evaluation & Management Visits

    09/06/2023 05:05 PM Help with File Formats and Plug-Ins This page contains guidance regarding documentation and payment under the Medicare Physician Fee Schedule for evaluation and management (E/M) visits.

  2. PDF Evaluation and Management Services Reference Guide

    E/M visit of the highest level only (99223 and 99233) and is also billed in 15-minute increments, with time thresholds to report G0316 being 90 minutes for 99223 and 65 minutes for 99233. Examples A provider spends a total time of 83 minutes with a new patient. The time limit for a new outpatient visit, E/M visit 99205, is 60-74 minutes.

  3. Outpatient E/M Coding Simplified

    Prolonged visit codes cannot be used with the shorter E/M levels, i.e., 99202-99204 and 99212-99214. (See "Prolonged services " tables.) Clinicians should consult with individual payers to ...

  4. PDF CPT® Evaluation and Management (E/M) Code and Guideline Changes

    • Revision of Hospital Inpatient and Observation Care Services E/M codes 99221-99223, 99231-99239 and guidelines ... observation care visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes.

  5. PDF Evaluation and Management (E/M) Office Visits—2021

    The CPT/RUC Workgroup on E/M is committed to changing the current coding and documentation requirements for office E/M visits to simplify the work of the health care provider and improve the health of the patient. Guiding Principles: 1. To decrease administrative burden of documentation and coding 2. To decrease the need for audits 3.

  6. Understanding the landmark E/M Office Visit changes

    On Jan. 1, 2021, the Evaluation and Management (E/M) Office Visit code changes went into effect. Incorporating these groundbreaking revisions into physician workflows, software, health plans and elsewhere is vital to realizing the benefits of this burden reduction initiative.

  7. Mastering E&M Codes: Guide to Evaluation & Management Coding

    Learn about E&M codes and the importance of E&M CPT codes in Healthcare. Read here!

  8. 2021 E/M Guidelines FAQ

    1. Can the new 2021 guidelines be used for other services (e.g., emergency department)? No. The 2021 guidelines are specific to office visits reported with 99202-99215. The American Medical Association (AMA) E/M workgroup focused on the office/other outpatient category because it is the most used, by far.

  9. Evaluation and Management (E&M) Guidelines

    Evaluation and Management coding is a medical coding process in support of medical billing. Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters. E/M standards and guidelines were established by Congress in 1995 and revised in 1997.

  10. Evaluation and Management (E/M) Code Changes 2021

    Healthcare professionals across a wide range of specialties report evaluation and management (E/M) CPT ® codes on insurance claims to request reimbursement for services performed in the office or other outpatient setting.

  11. Evaluation and Management (E/M)

    Providers billing for these services will have the choice to document office/outpatient E/M visits via medical decision making (MDM) or total time. Changes include deletion of CPT code 99201. Guideline changes are specific for office and other outpatient visits and apply only to codes 99202-99205 and 99211-99215.

  12. Coding Level 4 Office Visits Using the New E/M Guidelines

    The national average for family physicians' usage of the level 4 code (99214) is slowly increasing and is approaching 50% of established patient office visits (it's now above 50% for our Medicare ...

  13. What is an Evaluation and Management (E&M) Visit in Medical Billing?

    One term that is commonly used is E&M visit, which is short form for Evaluation and Management Encounter. This is essentially referring to a doctor's visit, or a consultation (a visit requested by another physician or healthcare entity).

  14. PDF Evaluation and Management (E/M) Policy, Professional

    health care professionals should best represent the services provided based on the American Medical Association (AMA) and CMS documentation guidelines. ... 99211-99215) changes that were effective January 1, 2021, the CPT codes section for Non-Office E/M Visits (99221-99223, 99231-99239), Consultations codes (99242-99245, 99252-99255 ...

  15. Evaluation and Management (E/M) Code Changes 2023

    The AMA revised the 2023 E/M guidelines to be consistent with the changes implemented in 2021 and to support all other E/M categories, including hospital or observation services, inpatient and outpatient consultations, emergency department services, nursing facility services, and home or residence services. Overview of E/M 2023 Category Changes

  16. American Institute of Healthcare Compliance

    December 1, 2023. American Institute of Healthcare Compliance - Evaluation and Management (E/M) Visits . Beginning January 1, 2024, the Centers for Medicare and Medicaid (CMS) is finalizing implementation of a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211.

  17. Report: Clinicians complied with Medicare telehealth requirements

    Physicians and other practitioners who provided evaluation and management (E/M) services via telehealth during the first nine months of the COVID-19 public health emergency generally complied with Medicare requirements, according to a report released recently by the Department of Health and Human Services' Office of Inspector General.. The audit covered $1.4 billion in Medicare Part B ...

  18. Women may realize health benefits of regular exercise more than men

    For more information, visit https://www.nhlbi.nih.gov. About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational ...

  19. CPT®️ E&M Codes

    Evaluation and management (E/M) coding and billing are crucial to maintaining the efficiency and productivity of a medical practice today. E&M coding involves use of CPT codes ranging from 99202 to 99499. These represent services by a physician (or other health care professional) in which the provider is either evaluating or managing a patient's health. Procedures such as diagnostic tests ...

  20. St. Pete Health & Wellness

    Dr. Cole, Kathie Gonzales, and the staff of St. Petersburg Health & Wellness (SPHW) and Vital Solutions IV Nutrition (VSIVN) have been honored to help care for your health and wellness and provide you a roadmap for your optimal outcomes. For health reasons, I (Dr. Cole), must follow my own advice and make changes in my lifestyle that support my ...

  21. St. Petersburg Hospitals & Clinics : The Official St. Petersburg Guide

    St. Petersburg hospitals and clinics are an invaluable resource for all residents who require regular healthcare. Most clinics are home to specialists that treat a specific type of disease or ailments afflicting one body part, generally found through a referral from a general practitioner. The city's many hospitals are home to not only ...

  22. Healthy St. Pete

    The mission of Healthy St. Pete is to build a culture of health in our city by making the healthy choice the easy choice through a collaborative community effort. We will work to improve health outcomes, reduce health inequities, and strive to implement policies and programs that give all citizens the opportunity to reach and enjoy optimal health.

  23. A Review of Exceptions in State Abortion Bans: Implications for the

    This issue brief examines the varying exceptions (for life, health, rape/incest, and fatal fetal anomalies) in state abortion bans and restrictions and the complications that arise when pregnant ...

  24. Evaluation and Management Coding, E/M Codes

    As the name E/M indicates, these medical codes apply to visits and services that involve evaluating and managing patient health. Examples of E/M services include office visits, hospital visits, home services, and preventive medicine services.

  25. UC Davis Health launches digital inclusion program

    (SACRAMENTO) UC Davis Health has launched a first-in-the-nation Digital Inclusion Program to bring much-needed technology, connectivity, and health care to underserved populations.. The initiative is a collaboration with Verizon Business that aims to bridge the digital gap and reduce health disparities. The goal is to provide underserved populations with free smartphones, tablets and ...

  26. Excerpt from 'Legacy' by Uché Blackstock

    Excerpted from "Legacy: A Black Physician Reckons with Racism in Medicine" by Uché Blackstock '99, M.D. '05, published by Viking, an imprint of Penguin Publishing Group, a division of Penguin Random House, LLC. Our mother was a remarkably vibrant and athletic woman. She regularly ran 20 miles a week, a habit she had first picked up in medical school to calm her frazzled nerves.

  27. Innovation in Behavioral Health (IBH) Model

    On January 18, 2024, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation in Behavioral Health (IBH) Model. IBH is focused on improving quality of care and behavioral and physical health outcomes for Medicaid and Medicare populations with moderate to severe mental health conditions and substance use disorder (SUD).

  28. IVF doctors, patients fearful after Alabama court rules embryos are

    Gail Deady, senior staff attorney at the Center for Reproductive Rights, said that because of that, the ruling "does not appear to create criminal liability for IVF providers."