BASIC DOCUMENTATION AND COMPLIANCE EDUCATION JANUARY UK Office of Corporate Compliance

Transcription

1 BASIC DOCUMENTATION AND COMPLIANCE EDUCATION JANUARY 2012 UK Office f Crprate Cmpliance

2 Outline What is the imprtance f crrect dcumentatin and cding? What are the dcumentatin guidelines? What are the key elements f an E/M? Cding initial and subsequent inpatient visits. Critical Care dcumentatin and cding. Using Mdifier-24 in the Pst-p Glbal Perid. Tips fr EHR dcumentatin.

3 What is the Imprtance f Crrect Dcumentatin and Cding? Dcumentatin determines the apprpriate cde and by extensin the reimbursement fr a service Mst cmmn cding mistakes include: Dwncding- undercharging fr the services rendered Upcding- vercharging fr the services rendered Bth can trigger an audit!!

4 Dcumentatin Guidelines Ntes shuld be dated, signed, and timed when apprpriate The reasn fr the visit, all tests, and prcedures rdered shuld be dcumented t supprt medical necessity Prcedure ntes shuld supprt CPT cde billed Dcumentatin and signature shuld be legible Remember, if it is nt dcumented, it did nt happen!

5 Inpatient E/M Services Initial Hspital Care, Observatins, and Cnsultatins require all 3 key cmpnents

6 Key Cmpnents f Inpatient E/M Services Histry Chief Cmplaint Histry f Present Illness (HPI) Review f Systems (ROS) Past Medical, Family, Scial Histry (PFSH) Physical Exam Medical Decisin Making Number f diagnses r management ptins Amunt and/r cmplexity f data reviewed r rdered Risk f cmplicatins and/r mrbidity r mrtality

7 Chief Cmplaint The chief cmplaint is traditinally the reasn fr the visit, usually stated in the patient s wn wrds briefly describing his/her symptm, prblem, r cnditin. The CC is required fr all E/M cdes.

8 Histry f Present Illness (HPI) The HPI is a timeline describing the patient s current illness frm the first symptm(s) t the present usually in the patient s wn wrds There are 8 elements included in the HPI

9 HPI Elements Lcatin- where prblem, pain, r symptms ccur Quality- descriptin f prblem, symptm, r pain Severity- descriptin f severity f symptm r pain Duratin- hw lng prblem, symptm, r pain has persisted Timing- when a prblem, symptm, r pain ccurs Cntext- instances that can be assciated with the prblem, symptm, r pain Mdifying Factrs- actins taken t make the prblem, symptm, r pain better r wrse Assciated Signs and Symptms- ther prblems, symptms, r facts that ccur when primary prblem, symptm, r pain ccurs

10 HPI Examples Frm : AMA Medical Recrd Auditr, 2 nd Editin By: Debrah Grider Patient s cugh is nnprductive and nnbarky and has wrsened tday. Patient als has rhinrrhea, which began yesterday Lcatin: cugh Quality: nnprductive Cntext (r) Mdifying Factrs: nnbarky and has wrsened tday Assciated Signs and Symptms: rhinrrhea 4 elements identified Extended HPI

11 Review f Systems (ROS) The ROS is generally a series f questins and answers related t the patient s cmplaints as stated in the Chief Cmplaint and Histry f Present Illness The ROS may be recrded by ancillary staff r the patient as lng as it is referenced in the chart nte by the physician

12 Review f Systems (ROS) Cnstitutinal Eyes Ears, Nse, Muth, Thrat Cardivascular Respiratry Gastrintestinal Geniturinary Musculskeletal Integumentary Neurlgical Psychiatric Endcrine Hematlgic/ Lymphatic Allergic/immunlgic

13 Review f Systems (ROS) All Hspital Observatin Services, Initial Hspital Care Services, and Inpatient Cnsultatins require a ROS. The ROS is the mst ften verlked prtin f the histry. Withut a ROS n E/M cde fr these services can be reprted. In the event that the patient is unable t give a ROS, the physician must dcument the reasn t receive a cmplete ROS fr cding purpses.

14 Past, Family, Scial Histry (PFSH) Past Histry Prir majr illnesses and injuries Prir peratins and/r hspitalizatins Current medicatins Allergies Age apprpriate immunizatins Diet

15 Past, Family, Scial Histry (PFSH) Family Histry Health status r cause f death f parents, siblings and children Specific diseases related t prblems identified in CC, HPI, and/r ROS Hereditary diseases f family members that may affect patient

16 Past, Family, Scial Histry (PFSH) Scial Histry Marital status and/r living arrangements Current emplyment Occupatinal histry Use f drugs, alchl, and tbacc Level f educatin Sexual histry Other relevant scial factrs

17 Physical Examinatin The extent f the exam is dependent n clinical judgment and the nature f the presenting prblem There are 4 levels f examinatin services Prblem Fcused Expanded Prblem Fcused Detailed Cmprehensive

18 Physical Examinatin (PE) Prblem Fcused: A limited examinatin f the bdy area r rgan system Expanded Prblem Fcused: A limited examinatin f the affected bdy area r rgan system and ther symptmatic r related bdy system Detailed: An extended examinatin f the affected bdy area(s) and ther symptmatic r related rgan system(s). Cmprehensive: A general multisystem examinatin r a cmplete examinatin n an rgan system.

19 Cmplexity f Medical Decisin Making Medical decisin making refers t the cmplexity f establishing a diagnsis and/r selecting a management ptin. Number f pssible diagnses and/r the number f management ptins Amunt and/r cmplexity f medical recrds, diagnstic tests, and/r ther infrmatin that must be btained, reviewed, and analyzed Risk f significant cmplicatins, mrbidity, and/r mrtality, as well as cmrbidities, assciated with the patient s presenting prblems, diagnstic prcedures, and/r pssible management ptins

20 Medical Decisin Making Charts Number f Diagnses/Cmplexity f Data Self-limited r minr (stable, imprved, wrsened) pints per Dx Established prblem (t examining MD); stable r imprved Established prblem (t examining MD); wrsening New prblem (t examining MD); n additinal wrkup planned New prblem (t examining MD); additinal wrkup Lab rdered/reviewed X-ray rdered/reviewed Medicine sectin ( ) rdered/reviewed Discussin f test results with perfrming MD Obtaining ld recrds/btaining Hx frm smene ther than patient Review & summary f ld recrds/discussin with ther health prvider Independent visualizatin f image, tracing, r specimen 1 pint 1 pint 2 pints 3 pints 4 pints 1 pint 1 pint 1 pint 1 pint 1 pint 2 pints 2 pints

21 Cmplexity f Medical Decisin Making Number f Diagnses r Management Optins Amunt and/r Cmplexity f Data Risk f Cmplicatins and/r Mrbidity r Mrtality Type f Decisin Making Minimal Minimal r Nne Minimal Straightfrward Limited Limited Lw Lw Cmplexity Multiple Mderate Mderate Mderate Cmplexity Extensive Extensive High High Cmplexity

22 Final Medical Decisin Making E/M Level 2/3 Straightfrward Lw Mderate High Number f diagnses/treatment ptins Amunt and/r cmplexity f data Risk f cmplicatins, mrbidity, mrtality Minimal Lw Mderate High

23 Initial Inpatient E/M Examples Hspital admissin, examinatin, and initiatin f treatment prgram fr a 67-year-ld male with uncmplicated pneumnia requiring IV antibitic therapy Initial visit fr a 61-year-ld male with a histry f previus MI, wh nw c/ chest pain Initial visit fr a 70-year-ld male with cutaneus T-cell lymphma wh has develped a fever and lymphadenpathy

24 Inpatient Hspital Care Initial Visit Requires 3/3 E/M Cde HISTORY Detailed Cmprehensive Cmprehensive CC Required Required Required HPI 4+ elements 4+ elements 4+ elements ROS 2-9 elements 10 elements 10 elements PFSH 1 PFSH 3 PFSH 3 PFSH EXAM Detailed Cmprehensive Cmprehensive 1995 Exam Detailed rgan systems 8+ rgan systems MDM Straightfrward Mderate High Prblem Lw Severity Mderate Severity High Severity

25 Subsequent Care E/M Examples Subsequent hspital care fr a 50-year-ld male with uncmplicated MI wh is clinically stable and withut chest pain Fllw-up visit fr a 67-year-ld male with CHF wh has respnded t antibitics and diuretics, and has nw develped a mnarthrpathy Subsequent visit fr a 50-year-ld diabetic, hypertensive male with nnrespnding back pain and radiating pain t left lwer extremity, wh develped chest pain, cugh, and bldy sputum

26 Inpatient Hspital Care Subsequent Care Requires 2/3 E/M Cde Histry Prblem Fcused Expanded Prblem Fcused Detailed CC Required Required Required HPI 1-3 HPI 1-3 HPI 4+HPI ROS 0 1+ elements 2-9 elements PFSH since last visit Exam Prblem Fcused Expanded Prblem Fcused 1995 Exam Limited exam prblem area Detailed Prblem area + ne ther Descriptive exam f 1 + MDM Lw Mderate High Prblem Stable, Imprving Minr Cmp, nt respnding Majr Cmp, Unstable

27 Critical Care Services Critical care is delivered directly by an MD t a patient wh has a high prbability f imminent r life threatening deteriratin, which invlves high cmplexity decisin making t assess, manipulate, and supprt vital system functins. Critical care cdes are based n time spent engaged in wrk directly related t the patient s care whether that time is spent at the bedside r n the flr r unit. Time Must Be Dcumented!!!!

28 Critical Care Inclusins Cardiac utput measurements Chest x-rays Pulse ximetry Bld gases, ECGs, bld pressures, hematlgic data Gastric intubatin Temprary transcutaneus pacing Ventilatry management Vascular access prcedures

29 Critical Care Critical care & ther E/M services may be prvided t the same patient n the same DOS by the same physician & are used t reprt the ttal duratin f time spent (same principle as Discharge billing)prviding critical care services, even if it is nt cntinuus If the patient is unrespnsive, time spent with family members discussing the patient s management may be reprted as critical care

30 Critical Care Critical care fr the E/M f the critically ill r injured patient; first minutes (30 minutes-1 hr.-14min.) Shuld nly be used nce per date, even if the time reprted des nt reflect cntinuus care f up t 74 minutes E/Ms lasting less than 30 minutes shuld be reprted with the apprpriate E/M cde

31 Critical Care Critical care E/M f the critically ill r injured patient; each additinal 30 minutes minutes (99291x1 and 99292x1) minutes (99291x1 and 99292x2) minutes (99291x1 and 99292x3) minutes (99291x1 and 99292x4)

32 Mdifier -24 Mdifier -24 is used t indicate that an unrelated evaluatin and management service was perfrmed during the pst-perative glbal perid.

33 Mdifier-24 Generally subsequent hspital visits by the surgen during the same hspitalizatin as the surgery are cnsidered t be related t the surgery and are therefre nt reimbursable; hwever, if the dcumentatin and the diagnsis cde clearly demnstrate that the service is nt part f the anticipated pst-perative care then it shuld be billed with the -24 mdifier, and paid.

34 Mdifier-24 Unrelated services include: Visits unrelated t the patient s surgical diagnsis and which the surgen is treating Treatment fr pst-perative cmplicatins requiring a return t the perating rm A mre extensive prcedure when a less extensive prcedure has failed Immunsuppressive therapy Critical care services unrelated t the surgery

35 Electrnic Medical Recrd Dcumentatin Identified Areas f Cncern with regard t EHR dcumentatin: Authrship Integrity Dcumentatin Integrity

36 Integrity Issues Authrship Integrity Authrship is the rigin f recrded infrmatin that is attributed t a specific individual EHRs allw multiple parties t enter infrmatin int a service nte, the verifying physician wh ultimately legalizes a nte is respnsible fr all dcumentatin cntained in the nte It is imprtant that services be perfrmed and dcumented in the electrnic recrd by nly thse individuals wh are licensed t perfrm such services

37 Integrity Issues Autmated insertin f clinical data: Use templates with care, aut generated negative findings can lead t an inapprpriate clinical picture and call int questin the accuracy f the entire nte Templates are designed t save time but they can cause prblems if they are nt reviewed and mnitred.

38 EHR Dcumentatin Tips Be mindful f cntradictins Only dcument what was dne n the date f service D nt dcument a histry r exam that is nt medically necessary The electrnic nte shuld be as cncise r detailed as the handwritten nte. In ther wrds, just because it is easier t add infrmatin using templates and cpy/paste des nt mean that it supprts the service