E&M Coding- It s All About The Documentation

Transcription

1 E&M Coding- It s All About The Documentation Presented for Anthem Blue Cross and Blue Shield By: Penny Osmon, BA, CPC Coding & Reimbursement Educator WI Medical Society Wisconsin Medical Society, Copyright 2007 CPT codes, descriptions and material only are Copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in applicable FARS/DFARS restrictions to government use.

2 Review of Coding Basics For every patient encounter: Assess the patient s chief complaint/condition (the reason for the visit). Document the service rendered and medical necessity in the medical record. Bill the appropriate CPT/ICD-9 code that reflects the service rendered and documented. Medical necessity of the visit determines the level of service, not the volume of documentation.

3 E/M Coding Above all else, medical necessity has to be there!

4 The Progress Note Subjective Objective Assessment Plan

5 Chief Complaint Chief Compliant (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, usually stated in the patient s words. (DGs 1995 & 1997)

6 Chief Complaint The CC is NOT synonymous for the HPI. The CC must be in every note. Only problem focused visits should have a HPI. Preventive services (ie: annual exam) should not have an HPI Only billing provider can perform the HPI.

7 History Both 95 and 97 Documentation guidelines state that the History component is comprised of the following four categories: Chief Complaint (CC) History of Present Illness (HPI) or the status of 3 chronic conditions Review of Systems (ROS) Past, Family, Social History (PFSH)

8 Good Examples of the Chief Complaint The patient presents today with a 3d history of hip pain. CC: hip pain. Patient here for evaluation of hip pain. The patient is here for follow-up of her hip pain. Pt presents for her annual exam and CC: of hip pain.

9 The 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. (DGs 1995 & 1997)

10 HPI HPI Elements (8) Location; Where? Quality; Constant, Sharp? Severity; Scale of 1-10 Duration; How long? Timing; Nocturnal, Diurnal? Context; When does it occur? Modifying factor; What makes it better or worse? Associated signs/symptoms; Additional Information

11 HPI Example of a Brief HPI CC: Abdominal pain S: Patient has complaints of right sided abdominal (location) pain for one day (duration). Example of a Detailed HPI CC: Abdominal pain S: Patient has complaints of constant (quality) right sided abdominal (location) pain for one day (duration) associated with vomiting (associated signs & symptoms)

12 Review of Systems Constitutional Eyes Ears, Nose, Throat, Mouth Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin/breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic

13 Review of Systems (ROS) 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. (CPT, 2007) DG: The patient s positive responses and pertinent negatives for the system related to the problem should be documented.

14 Review of Systems It is permissible in a complete ROS for the remaining systems where there are no pertinent responses to make a notation indicating all other systems reviewed and are negative. This phrase indicates that 10 systems were reviewed and any positive or pertinent negative findings are individually documented in the note. (WPS Medicare Communiqué, November 2003)

15 ROS ~ Good Examples 1. The patient denies having a fever, chills, ear pain or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain. Her appetite has been okay. (Detailed ROS) 2. The patient denies having a fever, chills, ear pain or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain. Her appetite has been okay. She is voiding in normal amounts. All other systems were reviewed and negative. (Comprehensive ROS)

16 ROS ~ Bad Examples 1. The complete ROS was performed in detail and was negative. 2. A 12-point ROS was performed in detail with the patient and is negative. 3. Patient has a runny nose and sore throat and the remainder of the ROS is negative. 4. The patient wears glasses and is diabetic and all other systems are negative. 5. ROS per history form in chart. 6. ROS per the HPI, otherwise negative.

17 Past, Medical, Family and Social History Past medical history (PMH) - the patient s past experience with illness, injuries and treatments Family history (FH) - a review of medical events in the patient s family, including diseases which may be hereditary or place the patient at risk Social history (SH) - an age-appropriate review of past and current activities

18 Past, Medical, Family and Social History (PFSH) DG: A ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting there has been no change in the information; and Noting the date and location of the earlier ROS and/or PFSH.

19 Important Tidbits If unable to obtain history from the patient, eg. intubated, mentally challenged, then describe the patient s condition or other circumstances which precludes obtaining the history. PFSH and ROS can be obtained by ancillary staff.

20 Caution!! Non-contributory: The term non-contributory is ambiguous some providers take it to mean the system was not relevant, therefore was not reviewed while other providers take it to mean that the system was reviewed, but had no pertinent findings to be reported. Avoid using the term non-contributory.

21 95 or 97 Guidelines Examination: The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). Can use either the 1995 or 1997 DGs recognizes body areas and organ systems, but does not specify the extent of exam recognizes specific bulleted elements.

22 The Exam Examination HEENT is not an organ system, but an acronym Avoid stating HEENT negative Hepatosplenomegaly vs organomegaly Unremarkable or noncontributory Use approved abbreviations Musculoskeletal exam: no edema (edema is considered exam of cardiovascular system) Alert and oriented = Constitutional exam Alert and oriented x 3 = Psychological exam

23 The Exam DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. For chronic conditions the status of the condition should be described, eg stable, well controlled; simply stating HTN without further elaboration would not be sufficient documentation.

24 Medical Decision Making (MDM) Need to document what test and why. The guidelines state that the rationale may be easily inferred, but would suggest clearly documenting the reason for any testing. Evidence-based criterion supports medical necessity and medical necessity support billing services. Avoid practices just because we always have.

25 Examples of Good MDM Direct visualization/interpretation of image, tracing or specimen should be documented. Example: I personally obtained and interpreted the wet prep for clue cells. X-ray report shows no fracture, however, my review of the films reveals a hairline fracture

26 Billing Based on Time 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. The extent of the counseling and/or coordination of care must be documented in the medical record. (CPT, 2007)

27 Good Examples of Documenting Time I spent 40 minutes with the patient and greater than 50% of the time was spent discussing her new diagnosis of depression and counseling her about the management options. Total floor/unit time was 20 minutes and greater than 50% of that time was spent with patient and family discussing patient s prognosis and treatment plan. 30 minutes spent with patient in discussion regarding her new diagnosis of diabetes and the entire time was spent in counseling.

28 Bad Examples of Documenting Time Today s visit took over 20 minutes. I spent 15 minutes counseling the patient. Total floor/unit time was 35 minutes. Spent 20 minutes above and beyond the usual time for performing the physical exam.

29 Thank You Penny Osmon, BA, CPC Coding & Reimbursement Educator The Wisconsin Medical Society

30 Disclaimer The information presented and responses to the questions posed are not intended to serve as coding or legal advice. Many variables affect coding decisions and any response to the limited information provided in a question is intended only to provide general information that might be considered in resolving coding issues. All coding must be considered on a case-by-case basis and must be supported by appropriate documentation in the medical record. Therefore, the Wisconsin Medical Society recommends consulting directly with payers to determine specific payers guidance regarding appropriate coding and claim submission. The CPT codes that are utilized in coding claims are produced and copyrighted by the American Medical Association (AMA). Specific questions regarding the use of CPT codes may be directed to the AMA.