Title: Coding Documentation for IHS Affiliated Physician Practices

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1 Affiliated Physician Practices Effective Date: 11/03; Rev. 4/06, 7/08, 7/10 POLICY: IHS affiliated physician practices will code diagnoses utilizing the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and/or other classification systems that may be required (such as DSM-IV for classification of psychiatric patients). Professional services and procedures will be coded utilizing the Current Procedural Terminology (CPT) and the HCPCS coding system as appropriate. IHS affiliated physician practices will follow the CPT coding and documentation guidelines published by the American Medical Association and the Centers for Medicare and Medicaid Services (CMS). SCOPE: IHS system wide. All IHS and affiliated physician practices providing professional physician services. BACKGROUND: The purpose of this policy is to assure the accuracy, integrity and quality of coding practices, ensure minimal variation in coding practices, and ensure code assignments are supported by documentation and are within generally recognized guidelines. PROCEDURE: 1. Definitions CMS Documentation Guidelines. The 1995 and 1997 versions (as revised) of Evaluation and Management Documentation Guidelines currently in use by CMS as standard for professional services. Cooperating Parties. The Cooperating Parties consist of the Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), American Health Information Management Association (AHIMA) and National Center for Health Statistics (NCHS). CPT. Current Procedural Terminology, published by the American Medical Association (AMA), used for reporting physician services in a numeric format. Encounter Form. An internal charge capture form used to record professional services provided for each patient (e.g., charge ticket, fee ticket). Page 1 of 6 07/10

2 1.5 Evaluation and Management Codes. Evaluation and Management services, published in the CPT manual by the AMA, used to report professional services in several settings HCPCS. CMS s Healthcare Common Procedure Coding System is a national coding system that consists of a single alpha letter followed by four numeric digits. This coding system was developed to report medical services and supplies not found in the CPT to Medicare and Medicaid patients. Health Care Provider. For the purpose of this policy includes physicians and all non-physician practitioners. ICD-9-CM. International Classification of Disease, Ninth Revision, Clinical Modification, used for reporting diagnoses, symptoms, status or other reason for a health care encounter in a numeric and/or alpha numeric format. Medical Record. A compilation of pertinent facts of a patient's life and health history, including past and present illness(es) and treatment(s), entered by the health professionals contributing to that patient's care. The Medical Record must be compiled in a timely manner and contain sufficient data to identify the patient, support the diagnosis or reason for health care encounter, justify the treatment, and accurately document the results. Health Information Management, Huffman, 10th Edition. Modifiers. CPT and HCPCS modifiers are two characters (either alpha or numeric) used to identify circumstances that alter or enhance the description of a service or supply. 2. General Coding Standards. 2.1 All individuals involved in the coding and claims submission of professional services and procedures shall adhere to all official coding guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS and NCHS). 2.2 Coding of diagnoses and services provided shall be completed using documentation in the Medical Record or on the Encounter Form completed by the Health Care Provider at the point of service. 2.3 Only services actually rendered will be coded and billed. 2.4 Multiple services should be combined under an aggregate code whenever possible rather than separating the services into separate billing codes (unbundling) unless a payor has provided specific guidance directing services to be billed separately. Page 2 of 6 07/10

3 2.5 Coding and documentation of Evaluation and Management services will be consistent with the definitions and standards published in the current CPT manuals and CMS Documentation Guidelines. 2.6 IHS affiliated practices should refer to Policy 1.BR.21, Coding and Billing References and Tools for Physician Practices, for a list of required and recommended coding and billing resources. 2.7 Diagnoses will be coded based on documentation using codes from the current version of the ICD-9-CM Coding Manual and the ICD-9-CM Official Guidelines available at 3. Professional Services and Procedure Coding. 3.1 Professional services and procedures will be coded utilizing the current year edition of the CPT manual and the correct application of official coding rules and guidelines. 3.2 Medical services and supplies will be coded utilizing the current edition of the HCPCS codes. 3.3 Each Health Care Provider must adhere to the Documentation Guidelines for Evaluation and Management Services published by CMS and the AMA. Both the 1995 and 1997 Guidelines are acceptable. Each practice should have a copy of these Guidelines, which are available on the CMS website or from the local Medicare contractor. 4. Minimum Documentation Requirements for Coding Purposes. 4.1 All professional services and procedures must be accurately and completely documented by the provider of service or appropriate designated staff providing the service. 4.2 Accurate Medical Record documentation should comply, at a minimum, with the following principles: The Medical Record should be complete and legible to someone other than the author; The documentation of each patient encounter should include the reason for the encounter; any relevant history, physical examination findings, prior diagnostic test results, assessment, clinical impression, or diagnosis; plan of care including orders for additional services; and date and legible identity of the observer; Page 3 of 6 07/10

4 4.2.3 If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred by an independent reviewer or third party; Past and present diagnoses should be accessible to the treating and/or consulting provider; Appropriate health risk factors should be identified. The patient s progress, his or her response to, and any changes in, treatment, and any revision in diagnosis should be documented; and Errors should be identified and corrected using a standard accepted methodology For paper entries, a single line should be drawn through erroneous statements, with initials of person making the correction and date correction was made. Erasures and use of correction fluid are prohibited For electronic or paper entries, addenda may be used to show error corrections. 4.3 Documentation of services provided to patients must be authenticated by the author. The method used must be a handwritten or an electronic signature. Medicare defines a handwritten signature as a mark or sign by an individual on a document to signify knowledge, approval, acceptable, or obligation that can be compared to a signature log which clearly identifies the author associated with initials or otherwise illegible marks. Stamp signatures are not acceptable. 4.4 When a staff member assists in creating documentation for clinical services by serving as a scribe, the identity of the scribe and the identity of the Health Care Provider must be clearly noted in the Medical Record entry. The entry must also state clearly that the services were furnished by the Health Care Provider. The scribe must authenticate the entry as described in section 4.3 above. 4.5 Medical Record documentation must be retained in accordance with Policy 1.AD.03, Record Retention. 5. Quality of Physician Practice Coded Data. 5.1 Internal or external coding quality reviews must be completed pursuant to Policy 1.CE.07, Compliance Auditing and Monitoring. Page 4 of 6 07/10

5 6. Unique Payor Requirements. 6.1 It is recognized that payors in various states may utilize coding guidelines that do not comply with those issued by the Cooperating Parties. 6.2 Deviations from the coding and billing guidelines established by the Cooperating Parties are permitted as long as the deviations are approved by the payor and documented in writing (e.g., paper or on-line payor manual, payor meeting minutes, correspondence from payor, etc.). 6.3 Each physician practice should acquire and maintain or have on-line access to current copies of payor-specific coding and billing guidelines such as payor manuals. 7. Payor Coverage/Medical Necessity For Services. 7.1 Professional services and diagnoses must be accurately coded and correctly submitted to payors in accordance with the guidelines above, guidance established by the Cooperating Parties, and payor manuals. 7.2 Diagnoses and services provided should not be modified or misrepresented in any way in order to be covered and paid by third party payors. 8. Encounter Forms. 8.1 The Health Care Provider and/or staff should completely, accurately and consistently complete Encounter Forms or other charge capture documents at the time of service. 8.2 If Health Care Provider or staff is unable to accurately identify the appropriate codes for a particular encounter at the time of service, no claim should be submitted until the correct codes can be ascertained through research and/or consultation with qualified coding staff. 8.3 If staff is unable to process Encounter Forms due to incorrect or incomplete information, the Encounter Form must be returned to the provider promptly for correction and/or completion per the query process outlined below. 9. Query Process. 9.1 If there is a question about the services provided or diagnoses for an encounter that prevents the assignment of CPT and ICD-9 codes, coding and billing staff must verify the information supporting these codes. 9.2 If a review of the documentation provides the necessary information to resolve the issue, it is not necessary to consult with the Health Care Provider. Page 5 of 6 07/10

6 9.3 If a review of the existing documentation does not resolve the issue, the Health Care Provider must be queried. Documentation of the query and resolution must comply with one of the following formats: The Health Care Provider can add an addendum to the Medical Record. The addendum must be dated with the date the addendum was created and signed The Health Care Provider can correct, change or add information directly on the Encounter Form. 10. Encounter Form and Charge Capture Document Maintenance Each IHS affiliated entity should review and update Encounter Forms and other charge capture documents on at least an annual basis to ensure the accuracy and appropriateness of the codes they contain. 11. Computer System Maintenance Each IHS affiliated entity should maintain and update its computer systems on at least an annual basis to include new, revised, and/or deleted codes. /s/ William B. Leaver William B. Leaver IHS President REFERENCES: MLN Matters Number: MMM6698, Change Request #6698. Page 6 of 6 07/10

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