E/M Documentation: Deal or No Deal? Documentation Guidelines. Documentation Elements 3/25/2013

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1 E/M Documentation: Deal or No Deal? Presented by Maggie Mac, CPC, CEMC, CHC, CMM, ICCE and Dennis Mihale, MD Documentation Guidelines 1995 vs 1997 guidelines 95 for? 97 for? General Multi-System? Specialty specific? Mix and match? HPI~ 3 chronics/status Systems vs. Areas Documentation Elements HPI Using check off boxes to validate HPI obtained by staff Reference to: Previous ROS/PFSH Changes as noted on form, unchanged Previous examination Remaining ROS All others negative PFSH non-contributory, unremarkable, negative (for what?) History unobtainable (why?) Exam rest of exam essentially negative 1

2 Documentation Elements (Cont.) Medical Decision Making No diagnosis Unclear diagnosis HA, HTN, DM No status Medical necessity for diagnostic tests (rule-outs ok but not on claim form!) No plan of care/follow-up treatment Failure to document prescriptions prescribed or sample prescription drugs given to patient Documentation Elements (Cont.) Inadequate capture of work process Failure to document ordered tests Cold reading of films or tracings Personal review Request of old records History obtained by (what was it?) Discussions with other providers Review AND SUMMARY of old records E/M Code Assignment All of my new patients are consults Preventive vs. Problem ABN? Cluster coding Fear of the F word Confusion Coders assigning levels 2

3 E/M Code Assignment (Cont.) Modifier misuse/abuse High risk modifiers No documentation to support NCCI Edits Unbundling No documentation to support Per Medicare CERT Reports Billing an add-on code without the primary surgical code Part of global surgery package (NCCI) Performing service out of scope of practice specialty Name on official red, white & blue Medicare card matches claim Invalid/missing referring provider Duplicate claims Paper Templates Circles? Slash Marks? Straight Lines? Cross-outs? Check-offs? Boxes? Abnormals no details Signature, date and LEGIBLE name of provider with credentials Signature Log? DO IT NOW! 3

4 Incident-to/Shared Visits Shared Visits Inadequate use of NPP s Not understanding the rules Incident-to Visits Inadequate plan of treatment for NPP follow-up Not understanding the rules OIG Work Plan 2012 and 2013 Time Counseling/Coordination of care total time, counseling time, details of counseling Prolonged services Prolonged discharge Critical care Other Timed Non-E/M services Physical therapy Psychotherapy Surgical complications Infusions Re-programming services Critical Care Meeting definition of critically ill patient Time for critical care services (minus separately billable services) Time with family? Teaching physician/resident physician Time documented? 4

5 Critical Definition Critically ill or critically injured patient A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition. Critical Care Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient s condition. Critical care services encompass both treatment of vital organ failure and prevention of further life threatening deterioration of the patient s condition. Critical Care Time - Family Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met: a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and The discussion is necessary for determining treatment decisions. 5

6 Documentation of Family Critical Care Discussions For family discussions, the physician should document: a. The patient is unable or incompetent to participate in giving history and/or making treatment decisions b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family", Documentation of Family Critical Care Discussions (Cont.) c. Medically necessary treatment decisions for which the discussion was needed, and d. A summary in the medical record that supports the medical necessity of the discussion All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decisionmakers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph. Critical Care Time Teaching/Resident Physicians Teaching Physicians Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time. 6

7 In-office Labs/Injections Performance but no results Urine pregnancy test Urine dipstick w/wo microscopy FOBT billed on day reviewed Hgb, HgbA1C, Blood Glucose Wet prep Mono spot Rapid Strept Injections Drug, Amount, Lot #, expiration date, site, reactions Electronic Medical Records Conflicts with ROS and patient history and/or presenting problem Name/date of individual entering information into electronic record Failure to document review of information obtained by ancillary staff (PFSH/ROS) Electronic signature? Cloned records OIG Work Plan Over-documentation not medically necessary EMR Danger to Physicians and Providers? Configured by vendors Copy and Paste Importing previous information Conflicting information Documentation of services not provided 7

8 EMR Conflicting Data Example: CC: Patient presents today c/o chest pain HPI: Pt. denies C/P, SOB. Example: HPI: Patient noticed mild pain, right calf X 1 week ROS: Pt. denies muscle or joint pain EMR Cloning Full ROS every visit Comprehensive exam every visit Same HPI every visit Example: CC by nurse Nausea and vomiting for 3 days Copied and pasted by nurse from prior visit every time More examples Carryover of ROS/PFSH every visit Provider billed just to refill an Rx Spoke to patient over the phone and billed a Patient seen in clinic for 4 visits over a period of 5 months PAP smear on every visit 8

9 Word for Word PFSH copied word for word for each patient ROS copied word for word for each patient PE copied word for word for each patient MDM Listing every diagnosis that patient has ever had on every encounter Unrelated diagnoses No longer valid diagnoses Not significant to the reason for the encounter or presenting problems Not every co-morbidity was reviewed! Finally. 9

10 Compliance Oversight No compliance buy-in or vested interest I employ a certified coder My office manager handles it We use an EMR system No plan Plan but not used Plan but not effective Plan overkill No preventive measures internal/external Compliance Oversight (Cont.) Providing resources Continuing education For staff (both clinical and administrative) Themselves Books, manuals, authoritative advice Being inflexible I m a physician not a coder This is all ridiculous This takes too much time Too confusing We agree, but not an option GET HELP! Questions? 10

11 Maggie Mac

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