Coding and Documentation in Practice
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1 Coding and Documentation in Practice Great Exam Documentation By: Kathy Mills Chang Kathy Mills Chang is a Certified Medical Compliance Expert, Reimbursement Consultant, Medicare Specialist, and a Documentation Authority celebrating 28 years of service to the chiropractic profession. Evaluation and Management: Detailed, comprehensive, and qualitative documentation of patient examination and management services provides a means for accurate coding and identification of billable services provided. 7 Components of EM: History Examination Clinical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time (least important) Pages: 1 of 9
2 3Factors of EM Codes: Place of Service (hospital, office, etc.) Type of Service (consultation, typical office visit, preventative) Patient Status (new or existing patient) Bad Habits: Habitually over or under coding Reporting for reimbursement rather than medical necessity Consistently billing the same level of service Patterns and repetition in documentation Consistent non-compliance is a serious act and ignorance is not a valid excuse. Stay Compliant: Learn the E/M documentation guidelines. Understand the 3 key components that are used in selecting the level of service. (History, Examination, Clinical Decision Making) Specialty Examination Guidelines: Allows for 10 single system evaluations There are 1995 (whole body) and 1997 Medicare guidelines. Chiropractors can use whatever set of guidelines is more beneficial to their practice. Pages: 2 of 9
3 The 1997 Medicare Guidelines are more beneficial for chiropractors to follow because they allow for musculoskeletal standards that are the primary form of treatment in the typical chiropractic office. Be sure the insurance carrier is aware of the guidelines your office is following. Scoring Your Examination: The guidelines are bullet oriented You must identify each bullet you plan to count in your examination record Skin and Musculoskeletal documentation allow multiple bullets per section 1) Head and Neck 2) Spine, Ribs and Pelvis or Trunk 3-6) are the extremities each counted separately Body Areas Recognized by CMS: Constitutional (e.g. vital signs, general appearance) Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/ Lymphatic/ Immunologic Guideline Tidbits: Pages: 3 of 9
4 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. Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. Follow Your Guide. Cardiovascular Examination: Examination of peripheral vascular system by observation (e.g. swelling, vericosities) and palpation (e.g. pulses, temperature, edema, tenderness) Lymphatic Examination: Palpation of lymph nodes in the neck, axillae, groin, and/or other location. Notation of any abnormalities or when within normal limits. Extremity Examination: Extremities are covered as part of the Musculoskeletal examination. Extremities are not required, but may apply on a patient by patient basis. Skin Examination: Inspection and/or palpation of skin and subcutaneous tissue (e.g. scars, rashes, lesions, café-au-lait spots, ulcers) in four of the following 6 areas. Pages: 4 of 9
5 Include dermatome inspection. Head and Neck Trunk Right upper extremity Left upper extremity Right lower extremity Left lower extremity Pages: 5 of 9
6 Neurological Examination: Test Coordination- (e.g. finger/ nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor control and coordination in young people) Examination of Deep Tendon Reflexes and/or Nerve Stretch Test with notation of Pathological Reflexes- (e.g. Babinski) Examination of Sensation- (e.g. touch, pin, vibration, proprioception) Orientation to Time, Place, and Person Mood and Affect- (e.g. depression, anxiety, agitation) Mood, Affect, and Appearance: Appearance - How does the patient look? (Neat, Groomed, Attention to Detail) Level of Alertness - Conscious? If not, can they be aroused? Can they focus? (Attention Span) Speech - Normal tone, Volume, and Quantity? Behavior - Pleasant, Cooperative, Agitated? Orientation - Awareness of environment? (Who, What, Where, When) Mood - (Happy, Sad, Depressed, Angry) Is it appropriate for the situation? Affect - How do they appear to you? (Your observations, are they appropriate?) Constitutional Exam Measurement of any three of the following seven vital signs: Pages: 6 of 9
7 sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff) General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming) Musculoskeletal Examination: This is the primary and most significant portion of the exam you will most typically perform. Although you may always do these things, they might not be documented in a particular manner. Historical clues when evaluating any joint related complaint: (Functional impairments, not pain, dictates Medical Necessity) What is the functional limitation? Symptoms within a single region or affecting multiple joints? Acute or slowly progressive? Mechanism of injury? Prior history of problems in this area? Systemic symptoms? Bullet Points: Pages: 7 of 9
8 Examination of gait and station- (identify gross abnormalities of gait indicating a neurological disorder, speed, balance, heel to toe walking, pain limitations, Romberg Test for the vestibular system) General Musculoskeletal- Examination of joints, bones, and muscles/tendons of 4 of the following 6 areas. o Head and Neck o Trunk o Right upper extremity o Left upper extremity o Right lower extremity o Left lower extremity PART Documentation: Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or diffusions. (P and A) Assessment of range of motion with notation of any pain (e.g. straight leg raising), crepitation or contracture. (R) Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements. (T) Scoring the Examination: Problem Focused = 1-5 bullet points Expanded = 6-11 bullet points Detailed = 12 or more bullet points (Typical chiropractic new patient exam) Comprehensive = Every bullet point Pages: 8 of 9
9 Code Selection: 3 of 3 must meet of exceed Code History Examination CDM (decision making) Problem Focused Problem Focused Straight Forward Expanded Expanded Straight Forward Detailed Detailed Low Comprehensive Comprehensive Moderate Comprehensive Comprehensive High Pages: 9 of 9
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