Summary Guide Documentation Elements. A presentation by: Medi-Corp, Inc.
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1 Summary Guide Documentation Elements A presentation by: Medi-Corp, Inc.
2 Presentation Content Principles of Documentation Components... page 4 Four Key History Elements. page 5 Recording History Elements, A Coder s tip.. page 6 Elements of Examination: Musculoskeletal. pages 7-8 Specialty Exam pages Exam Documentation, A Coder s Tip. page 11 General Multi-System Examination. pages The Value of Medical Decision Making... page 14 Medical Decision Making, A Coder s tip.. page 15 2
3 Disclaimer Statement The material enclosed is based on information that is in effect at the time of this presentation. This presentation was prepared as a tool to assist providers and is NOT intended to grant rights or impose obligations to said providers. Medicare policies and guidelines are used as the source to dispense informational tips for easy reference. Medi-Corp, Inc. employees make no representation that this information is error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation. This is only a general summary and does not represent a legal document. Medi-Corp, Inc This document and any attached materials are the sole property of Medi-Corp, Inc. and are not to be used by you other than as an instructional guide. Improper disclosure or distribution of this material is not permitted to any unauthorized persons or third parties except by written agreement. 3
4 Principles of Documentation Components Each encounter must contain the following elements: 1. Reason for the encounter, relevant history, physical examination findings, and prior test results 2. Assessment 3. Plan for Care (POC) 4. The date and legible identity of the observer (e.g. MA, NP or MD) 5. Rationale for ordering diagnostic test 6. Health Risk Factors 7. Progress, changes in treatment, and or change in diagnosis 4
5 Four Key History Elements Chief Compliant This must be a concise statement describing: the symptom, problem, condition, diagnosis Right: Follow up visit for back pain, complaining of back pain Wrong: NP visit encounter, New Patient encounter History of Present Illness Description in chronological order, the patient s present illness; first onset of symptom to present. Note Elements: 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated signs & symptoms Review of System ROS must be relevant to the presenting illness or condition. This is an inventory of questions related to the patient s illness or condition. Past Medical, Family, and/or Social History 1. Document the past medical has the patient s experiences with illness, injuries, treatments 2. The family history is a review of medical events in the patient s family that may place the patient at risk 3. Social history should be documented as age appropriate review of past and current activities 5
6 Recording History Elements A Coder s Tip Documenting History It is not required to re-record ROS and PFSH from a previous encounter. However, you must show evidence of review and update. Ancillary staff may record ROS and/or PFSH. However, the physician must review and notate confirmation or information recorded. If you are unable to obtain history from the patient, the physician must indicate the reason and all attempts made to do so. 6
7 Musculoskeletal Elements of Examination 1997 Guidelines Key Notes Determine the number of body areas addressed within each examination Inspection, percussion and/or palpation Assessment of range of motion Assessment of stability Assessment of muscle strength and tone Examination of gait and station Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity 7
8 Musculoskeletal Elements of Examination The examination of a given area includes: A. Inspection, percussion, and/or palpation, with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions B. Assessment of range of motion with notation of any pain (e.g. straight left raising), crepitation or contracture C. Assessment of stability with notation of any dislocation (luxation), subluxation or laxity D. Assessment of muscle strength and tone with notation of any atrophy or abnormal movement Key Note: For the comprehensive level of examination (4), all four elements identified by a bullet must be performed and documentation for each anatomic area. For example, assessing range of motion in two extremities constitutes two elements. 8
9 Specialty Exam: Musculoskeletal Refer to data section (table below) in order to quantify. After reviewing the medical record documentation, identify the level of examination. Key Note: The Chest (breast); Gastrointestinal (abdomen); Genitourinary; Head/Face; Eyes; Ears, Nose, Mouth and Throat; Neck and Respiratory systems/body areas are not considered to be part of the Musculoskeletal exam. Performed and Documented One to five bullets Six to eleven bullets Twelve to more bullets All bullets Level of Exam Problem Focused Expanded Problem Focused Detailed Comprehensive 9
10 1995 Exam Guidelines Performed and Documented One body area or system related to problem Level of Exam PROBLEM FOCUSED EXAM Affected body area or organ system (up to 7 systems) EXPANDED PROBLEM FOCUSED EXAM Extended exam of affected area(s) (up to 7 systems with more depth than above) General multi-system exam or complete exam of a single organ system (8 or more system) DETAILED EXAM COMPREHENSIVE EXAM 10
11 Detailed Exam The Four 1995 Exam Documentation A Coder s Tip 4 or more items for 4 or more body areas or organ system Example: Constitutional Musculoskeletal Neurological Psychiatric Blood Pressure Pain Headaches Depression Weight Stiffness (time of day, improves/worsens) Numbness Sleep patterns Height Range of motion Weakness Anxiety Pulse Joint swelling Poor balances Work and school performance 11
12 General Multi-System Examination System/Body Area Constitutional Cardiovascular Lymphatic Musculoskeletal Measurements of any three of the following seven vital signs: 1. Sitting or standing 2. Supine BP 3. Pulse rate and regularity 4. Respiration 5. Temperature 6. Height 7. Weight General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming) Examination of peripheral vascular system by observation (e.g. swelling varicosities) and palpation, pulses, temperature, edema, tenderness) Palpation of lymph nodes in neck, axillae, groin, and/or other location Examination of gait and station Examination of joint(s), bone(s), and muscle(s)/tendon(s Four of the following six: 1. Head and Neck 2. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity 12
13 General Multi-System Examination System/Body Area Skin Neurological Psychiatry Inspection and/or palpation of skin and subcutaneous tissue (e.g. scars, rashes, lesions, spots, ulcers) in four of the following six areas: 1) head and neck, 2) trunk, 3)) right upper extremity, 4) left upper extremity, 5) right lower extremity, and 6) left lower extremity Key Note: For the comprehensive level (4), the examination of all four anatomic areas must be performed and DOCUMENTED. Test coordination Examination of deep tendon reflexes and/or nerve stretch test w/notation of pathological reflexes Examination of sensation Brief assessment of mental status to include: orientation of time, place and person Mood and affect (e.g. depression anxiety, agitation) 13
14 The Value of Medical Decision Making 1. There are three key elements that will validate the level of Medical Decision Making. The number of diagnosis and treatment options Problems addressed during the encounter Complexity of establishing a diagnosis Management decisions made by the physician 2. The amount and complexity of the data reviewed 3. The risk of complications, and/or morbidity or mortality is bases on the risk associates by: Presenting problem(s) Diagnostic procedure(s) Possible management options 14
15 Medical Decision Making A Coder s Tip Relevant impressions Document all diagnoses, both tentative and confirmed, and all treatment options chosen as they related to every problem indicated within the record and found under other key components Summarize old records or other outside information that was utilized for the decision making Diagnostic findings Remember to document clearly all diagnostic test that were ordered, reviewed, and independently visualized as part of the work of the encounter DO NOT bring forward studies previously reviewed on prior encounters unless medically necessary this will not count will the coding selection 15
16 Questions? Medi-Corp, Inc. 25 Commerce Drive Suite 250 Cranford, NJ T-(908) F-(908) Adis Whartnaby, EVP Caryn Mattia, Director of RCM Valerie Cicchetti, M.A., CPC, SCP-PM This document and any attached materials are the sole property of Medi-Corp, Inc. and are not to be used by you other than as an instructional guide. Improper disclosure or distribution of this material is not permitted to any unauthorized persons or third parties except by written agreement. 16
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