Medical Practice Management Making the Pieces Fit
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1 Medical Practice Management Making the Pieces Fit Alice Anne Andress, CCS-P, CCP Susan Parker, Corporate Compliance Officer Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN According to CMS - E & M Service Errors Other E&M s 26.9% Consul ts 28.0% 26.9% 28% Consults 22.4% 22.7% Office Visits - Est Hospi tal Vi si ts - Sub 22.4% Of f i ce Vi si ts - Est 22.7% Hospital Visits - Sub Other E&Ms
2 Risk Areas For Physician Services Superbills-code steering Employees choosing levels of E&M Lack of medical necessity New vs established patients Abd vs GI Consults-use of referring Risk Areas For Physician Services Modifier -25 Hemoccult slides 1995 Comprehensive examination Pattern billing Professional Courtesy/Waived Deductibles
3 Risk Areas For Physician Services Lack of understanding of E&M requirements Missing ROS Lack of HPI Lack of PFSH Lack of MDM False Claims Professional courtesy was supported by the AMA as an ethical requirement in the past. Now, a violation of the False Claims Act, as physicians are misrepresenting their charges when billed to federal payors (Medicare, Medicaid, Tricare)
4 False Claims Fraud Alert issued in 1991 by the OIG routine waiver of co-payments (I/O) and/or deductibles is also misrepresenting the actual charge for the service. Medicare Carriers Manual, Section 5220, calls for investigation of physician s waivers of co-payments and deductibles when they are waived routinely PRINCIPLES OF DOCUMENTATION 1) The medical record should be first and foremost a tool of clinical care and communication. 2) The medical record should be complete and legible
5 PRINCIPLES OF DOCUMENTATION 3) The documentation of each patient encounter should include: The reason for the encounter and relevant history, physical exam, findings and prior diagnostic test results PRINCIPLES OF DOCUMENTATION The physician s assessment of the patient s condition, clinical impressions or diagnoses. A plan of care (treatment plan)
6 PRINCIPLES OF DOCUMENTATION The date and legible identity of the observer (physician, nurse, etc). If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred PRINCIPLES OF DOCUMENTATION Past and present diagnoses should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified
7 PRINCIPLES OF DOCUMENTATION The patient s progress, response to treatment and changes in the treatment or diagnoses should be documented. The CPT and ICD-9-CM codes reported must be supported in medical record PRINCIPLES OF DOCUMENTATION The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law
8 Key Components History Examination Medical Decision Making *Time Key Components Time is only a factor when counseling is more than 50% of the visit
9 Components of History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PSFH) Chief complaint Reason for the visit- Usually in the patient s own words. Beware of vague language Use only standard abbreviations
10 Chief complaint Why does the patient seek care? Unbearable symptoms Anxiety about meaning of symptoms They are in a life crisis History of Present Illness (HPI) HPI is... An expansion on the chief compliant A story about the patient s problem It should contain all the information necessary to assign the proper level of HPI... Brief or extended
11 History of Present Illness (HPI) Brief: 1-3 elements Extended: 4 or more elements OR status of at least 3 chronic or inactive conditions History of Present Illness (HPI) Location: Where is the problem? Does it move or radiate?
12 History of Present Illness (HPI) Duration: How long do the symptoms last? History of Present Illness (HPI) Quality: Is it a sharp pain, dull ache, burning, itching, gnawing, etc.?
13 History of Present Illness (HPI) Severity: On a scale of 1 to 10, how bad is it? Is it interfering with daily functioning? History of Present Illness (HPI) Timing: When did you first experience the symptom/problem? Is it intermittent or continuous? Does time of day affect it?
14 History of Present Illness (HPI) Context: What were you doing when this occurred? Where were you when this began? History of Present Illness (HPI) Modifying factors: What alleviates the symptom? What makes it worse?
15 History of Present Illness (HPI) Associated signs and symptoms: What else bothers you when this occurs? Review of Systems(ROS): A definition... An inventory of body systems obtained through a series of questions
16 Brief: 1 organ system Review of Systems(ROS) Extended: 2-9 organ systems Complete: 10 or more organ systems Constitutional Ophthalmologic Otolaryngologic Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Review of Systems(ROS): Organ Systems... Integumentary Neurological Psychiatric Endocrine Hematologic/Lymph Allergic/Immuno
17 Review of Systems(ROS): Organ Systems... Eyes: Do you have any blurred vision? GI: Do you have any problems with your bowels, diarrhea, constipation? Resp: Do you have a cough, any trouble breathing, wheezing? CV: Do you have any chest pain? Shortness of breath? Past, Family, Social History (PFSH) Pertinent PFSH directly related to the problem. At least 1 item from any of the history areas Complete PFSH-depends on the category of E&M
18 Past, Family, Social History (PFSH) 3 out of 3 rule 2 out of 3 rule Complete PFSH All Three Areas Office visit new patient Hospital observation service Hospital initial inpatient service Consultations
19 Complete PFSH Two Areas Office visit established patient Emergency department service Hospital subsequent service Past History Medical Problems Hospitalizations Surgical history Trauma OB/GYN history Allergies Age appropriate immunizations Age appropriate dietary status Childhood illnesses
20 Family History Diseases that may be hereditary or place the patient at risk. Health of the parents, siblings, children or cause of death of any of these relatives Social History Alcohol use Drug use Living arrangements Job status, occupational history Marital status Sexual history Education background Current employment Any other relevant history
21 CONSTRUCTION 101 History Building Blocks Problem Focused cc- diarrhea HPI- diarrhea x2 days Key: cc, HPI- Brief
22 Expanded Problem Focused cc- diarrhea HPI - diarrhea x2 days, also complaining of abdominal pain ROS- complains of diarrhea, abdominal pain, no loss of appetite Key: cc. HPI-brief (1-3), ROS- GI cc- diarrhea Detailed HPI - diarrhea x2 days, also complaining of abdominal pain, pain described as a cramping sensation, took Pepto Bismol but it didn t help ROS- complains of diarrhea, abdominal pain, no loss of appetite denies chest pain, admits to some fatigue PFSH-HTN Key: cc. HPI-Ext: duration,s/s, quality, mod. factors ROS- Ext. (2-9):GI, CV, Constitutional PFSH-Prob.Pert:HTN
23 cc- diarrhea Comprehensive HPI - diarrhea x2 days, also complaining of abdominal pain, pain is described as a cramping sensation, took Pepto Bismol but it didn t help ROS- complains of diarrhea, abdominal pain, no loss of appetite, denies chest pain, pt admits to some fatigue, shortness of breath or cough, no muscular aches, no skin disorders, denies dizziness, cold symptoms, no problems with urination, pt is anxious about not feeling well PFSH-HTN, Non-smoker, Father- HTN, CVA Comprehensive Key: Cc- HPI-Extended duration, s/s, quality, mod factors ROS- Complete GI, CV, Resp. Musculo, Skin, Consti, Neuro, ENT, GU, Psych PFSH-Complete HTN, Non-smoker, Father- HTN, CVA
24 Examination The provider may choose whichever set of exam guidelines best suits the patient s visit or Examination Problem Focused - a limited examination of the affected body area or organ system Expanded Problem Focused - a limited examination of the affected body area or organ system and other symptomatic or related organ system(s)
25 Examination Detailed - an extended examination of the affected body area(s) or other symptomatic or related organ system(s). Comprehensive - a general multisystem examination or complete examination of a single organ system Examination ALERT A comprehensive exam consists only of organ systems!
26 Examination - Body Areas 1) Head, including the face 2) Neck 3) Chest, including breasts and axilla 4) Abdomen 5) Genitalia, groin, buttocks 6) Back, including spine 7) Each extremity Examination : Organ Systems 1) Constitutional 2) Eyes 3) ENMT 4) Cardiovascular 5) Respiratory 6) GI 7) GU 8) Musculoskeletal 9) Skin 10) Neurologic 11) Psychiatric 12) Hematologic, Lymphatic, Immunologic
27 1997 Examination Guidelines Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN EXAMINATION 1997 GUIDELINES GENERAL MULTI-SYSTEM EXAMINATION PLUS 10 SINGLE SPECIALTY EXAMS
28 Multi-system Examination LEVEL OF EXAM PERFORM AND DOCUMENT Problem Focused: One to five elements identified by a bullet. Expanded Problem Focused: At least six elements identified by a bullet. Detailed: At least two elements identified by a bullet from each of six areas/systems or at least 12 elements identified by a bullet in two or more areas/systems. Comprehensive: Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems Medical Decision Making Number of diagnoses or management options Amount and/or complexity of data reviewed Risk to patient
29 Medical Decision Making Number of dx or mgmt options Amount and/or Complexity of data Overall risk Minimal Limited Multiple Extensive Minimal/none Limited/low Moderate Extensive Minimal Low Moderate High Medical Decision Making (MDM) Level Presenting Diagnostic Management of Problems Procedures Options Selected Risk Ordered Insect bite, Cold, Tinea corpis EKG, Chest x-ray, KOH Rest, Gargle, Minimal Urinalysis Bandages Low Cystitis, sprains, controlled DM,controlled BP Pulmonary functions, BE, Skin biopsies OTC drugs,pt, OT, IV fluids, minor surgery/no risk Moderate Lump in breast, colitis, pneumonia Arteriogram, lumbar puncture, endoscopies/no risk Rx mgmt, IV fluids w/meds, closed tx of fracture,elective major surgery High Acute MI, psych illness w/threat, TIA, trauma CV imaging studies w/contrast, endoscopies w/risk Emergency major surgeries, DNRs,monitoring toxic drugs
30 Medical Necessity A government definition... A service that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member Medical Necessity Be safe and effective No experimental Be cost effective Be appropriate
31 NEW vs. ESTABLISHED PATIENTS A patient who has not received any professional services from a physician or any other physician in the group within the past three years LEVEL I New History: Problem Focused CC, Brief HPI Examination: Problem Focused Limited exam of affected body area or organ system Medical Decision Making: Straightforward Minimal, Minimal, Minimal
32 LEVEL II New History: Expanded Problem Focused CC, Brief HPI, Problem pertinent ROS Examination: Expanded Problem Focused Limited exam of affected body area or organ system and other related or symptomatic organ systems Medical Decision Making: Straightforward Minimal, Minimal, Minimal LEVEL III New History: Detailed CC, Extended HPI, Extended ROS, PFSH-1 Examination: Detailed Extended exam of the affected body area(s) or organ system(s) and other related organ systems Medical Decision Making: Low Limited, Limited, Low
33 LEVEL IV New History: Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multi-system Medical Decision Making: Moderate Multiple, Moderate, Moderate LEVEL V New History: Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: High Extensive, Extensive, High
34 LEVEL I Established Generally, no actual physician involved in care Visit of 5 minutes or less LEVEL II Established History: Problem Focused CC, Brief HPI Examination: Problem Focused Limited exam of affected body area or organ system Medical Decision Making: Straightforward Minimal, Minimal, Minimal
35 LEVEL III Established History: Expanded Problem Focused CC, Brief HPI, Prob. Pertinent ROS Examination: Expanded Problem Focused Limited exam of affected body area or organ system and other related or symptomatic organ systems Medical Decision Making: Low Limited, Limited, Low LEVEL IV Established History: Detailed CC, Extended HPI, Extended ROS, PFSH -1 Examination: Detailed Extended exam of the affected body area(s) or organ system(s) and other related organ systems Medical Decision Making: Moderate Multiple, Moderate, Moderate
36 LEVEL V Established History: Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multi-system Medical Decision Making: High Extensive, Extensive, High CONSULTATIONS A consultation is a service provided for the purpose of obtaining an opinion or advice regarding evaluation and treatment of a patient at the request of another physician
37 CONSULTATIONS Three R s of a Consult 1. Request 2. Render an opinion 3. Report CONSULTATION KEY POINTS Request must be documented in the medical records of both the requesting physician and the consultant. No designation between a new or established patient
38 TYPES OF CONSULTATIONS Office/Out-patient Initial In-patient Referred Referring
39 OFFICE CONSULTATION History: Problem Focused CC, Brief HPI Examination:Problem Focused Limited exam of affected body area or organ system Medical Decision Making: Straightforward Minimal, Minimal, Minimal OFFICE CONSULTATION History: Expanded Problem Focused CC, Brief HPI, ROS-Problem Pertinent Examination: Expanded Problem Focused Limited exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making: Straightforward Minimal, Minimal, Minimal
40 OFFICE CONSULTATION History: Detailed CC, Ext. HPI, ROS-Ext., PFSH-Pertinent Examination: Detailed Extended exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making: Low Limited, Limited, Low OFFICE CONSULTATION History: Comprehensive CC, Brief HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: Moderate Multiple, Moderate, Moderate
41 OFFICE CONSULTATION History: Comprehensive CC, Brief HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: High Extensive, Extensive, High INITIAL HOSPITAL CARE History:Detailed / Comprehensive CC, Extended HPI, Extended ROS, PFSH--1 Examination:Detailed / Comprehensive Extended exam of the affected body area(s) or organ system(s) and other related organ systems Medical Decision Making: Straightforward /Low Minimal, Minimal, Minimal
42 INITIAL HOSPITAL CARE History:Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH-3 areas Examination:Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: Moderate Multiple, Moderate, Moderate INITIAL HOSPITAL CARE History:Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH-3 areas Examination:Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: High Extensive, Extensive, High
43 SUBSEQUENT HOSPITAL CARE History:Problem Focused CC, Brief HPI Examination:Problem Focused Limited exam of affected body area or organ system Medical Decision Making: Straightforward Minimal, Minimal, Minimal SUBSEQUENT HOSPITAL CARE History: Expanded Problem Focused CC, Brief HPI, ROS-Problem Pertinent Examination: Expanded Problem Focused Limited exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making: Moderate Multiple, Multiple, Moderate
44 SUBSEQUENT HOSPITAL CARE History:Detailed CC, Extended HPI, Extended ROS, PFSH -1 Examination:Detailed Extended exam of the affected body area(s) or organ system(s) and other related organ systems Medical Decision Making: High Extensive, Extensive, High HOSPITAL DISCHARGE CODES Report the total duration of time spent by a physician for final hospital discharge of a patient
45 HOSPITAL DISCHARGE CODES Patient who is admitted as an inpatient and discharged on the same date, should not use codes and Use codes HOSPITAL DISCHARGE CODES Hospital Discharge Discharge of patient requiring 30 minutes or less Hospital Discharge Discharge of patient requiring greater than 30 minutes
46 COMPONENTS OF DISCHARGE FINAL EXAMINATION DISCUSSION OF HOSP STAY INSTRUCTIONS TO CAREGIVERS PREPARATION OF DISCHARGE RECORDS PRESCRIPTIONS REFERRALS INITIAL INPATIENT CONSULTATIONS History:Problem Focused CC, Brief HPI Examination:Problem Focused Limited exam of affected body area or organ system Medical Decision Making: Straightforward Minimal, Minimal, Minimal
47 INITIAL INPATIENT CONSULTATIONS History: Expanded Problem Focused CC, Brief HPI, ROS-Problem Pertinent Examination: Expanded Problem Focused Limited exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making: Straightforward Minimal, Minimal, Minimal INITIAL INPATIENT CONSULTATIONS History: Detailed CC, Ext. HPI, ROS-Ext., PFSH-Pertinent Examination: Detailed Extended exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making: Low Limited, Limited, Low
48 INITIAL INPATIENT CONSULTATIONS History:Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making: Moderate Multiple, Moderate, Moderate INITIAL INPATIENT CONSULTATIONS History:Comprehensive CC, Extended HPI, Complete ROS, Complete PFSH Examination: Comprehensive Complete Single Sys. Specialty/Complete Multisystem Medical Decision Making:High Extensive, Extensive, High
49 HOSPITAL OBSERVATION INPATIENT CARE SERVICES History: Detailed/Comprehensive CC, Ext. HPI, ROS-Ext., PFSH-Pertinent Examination: Detailed/Comprehensive Extended exam of affected body area or organ system and other symptomatic or related organ system (s) Medical Decision Making:Straightforward/Low Minimal, Minimal, Minimal HOSPITAL OBSERVATION INPATIENT CARE SERVICES History: Comprehensive CC, Ext. HPI, ROS-Complete, PFSH-Complete (3) Examination: Comprehensive Complete Single Sys. Specialty/Complete Multi-system Medical Decision Making: Moderate Multiple, Moderate, Moderate
50 HOSPITAL OBSERVATION INPATIENT CARE SERVICES History: Comprehensive CC, Ext. HPI, ROS-Complete, PFSH-Complete (3) Examination: Comprehensive Complete Single Sys. Specialty/Complete Multi-system Medical Decision Making: High Extensive, Extensive, High Alice Anne Andress, CCS-P, CCP Director of Physician Services Parente Randolph, LLC Susan K. Parker Corporate Compliance Officer Ephrata Community Hospital
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