4/5/2011. presenting problem(s) and 1997 Documentation Guidelines. Paula M Wright, CPC, CPMA, CPC I, CEMC. Over document

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1 The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is depended upon clinical judgement and the nature of the presenting problem(s). Paula M Wright, CPC, CPMA, CPC I, CEMC 1995 and 1997 Documentation Guidelines 4/5/ CODING UPDATES 2 Over document Word processing software Electronic medical record Formatted note systems Facilitate Carry over Fill in Auto populate Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to theprevious entries. Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. 4/5/ CODING UPDATES 3 4/5/ CODING UPDATES 4 1

2 4/5/ CODING UPDATES 5 4/5/ CODING UPDATES 6 Paula M Wright, CPC, CPMA, CPC I, CEMC Q2035 Q2036 Q2037 Q2038 Q2039 Afluria Vaccine, 3 yrs & >, IM Flulaval Vaccine, 3 yrs & >, IM Fluvirin Vaccine, 3 yrs & >, IM Fluzone Vaccine, 3 yrs & >, IM NOS, 3 yrs & >, IM 4/5/ CODING UPDATES 8 2

3 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component each additional vaccine/toxoid component DtaP intramuscular administration: (CPT Vaccine code reported in addition) 4/5/ CODING UPDATES 9 4/5/ CODING UPDATES 10 Coding for a 2 month old infant based on current immunization schedule DTaP (IM) Admin: 90460, 90461, Vaccine: Rotavirus (oral) Admin: Vaccine: Hepatitis B and Haemophilus Admin: 90460, influenza type b (IM) Vaccine: Inactivated Poliovirus (IM) Admin: Vaccine: Pneumococcal conjugate vaccine, 13 valent (IM) Admin: Vaccine: TOTAL: X 5 and X 3 4/5/ CODING UPDATES Influenza virus vaccine, split virus, preservative free, for intradermal use 4/5/ CODING UPDATES 12 3

4 90664 Influenza virus vaccine, pandemic formulation, live, for intranasal use Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use Coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS) for an individual who: is no longer within the 12 monthsof of the effective dateof Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. CR7079: Effective January 1, 2011:Implementatin April 4, /5/ CODING UPDATES 13 4/5/ CODING UPDATES 14 G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit. G0439 Annual wellness visit; includes a personalized prevention plan of service (pps), subsequent visit. Establishment of an individual s medical/family history Establishment of list of current providers and suppliers that are regularly involved in providing medical care Measurement of height, weight, BMI (or weight circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on patient s medical/family history Detection of any cognitive impairment that the patient may have Review of patient s potential (risk factors) for depression or mood disorders, past or present using appropriate tools 4/5/ CODING UPDATES 15 4/5/ CODING UPDATES 16 4

5 SUBSEQUENT OBSERVATION CARE Review of patient s functional ability and level of safety based on direct observation. Establishment of a written screening schedule for the patient for the next 5 10 years Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended.. Furnishing of personalized health advice to the patient and a referral, as appropriate, to health education or preventive counseling services Any other element(s) determined appropriate by the Secretary of Health and Human Services through he National Coverage Determination (NCD) process. Subsequent observation care, per day, for the evaluation and management of a patient, which requires at 2 of these 3 key components: Problem focused interval history Problem focused examination Straightforward or low complexity medical decision making Expanded problem focused interval history Expanded problem focused examination Moderate complexity medical decision making Detailed interval history Detailed examination High complexity medical decision making 4/5/ CODING UPDATES 17 4/5/ CODING UPDATES Debridement, subcutaneous tissue (includes epidermis & dermis if performed); first 20 sq cm or less each additional 20 sq cm or part thereof Debridement, muscle &/or fascia (includes epidermis, dermis, subcutaneous tissue ifperformed); first20sqcm sq or less each additional 20 sq cm or part thereof Debridement, bone (includes epidermis, dermis, subq tissue, & muscle &/or fascia if performed); first 20 sq cm or less each additional 20 sq cm or part thereof G0440 Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less G0441 Application of tissue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; each additional 25 sq cm 4/5/ CODING UPDATES 19 4/5/ CODING UPDATES 20 5

6 ZERO GLOBAL DAYS 4/5/ CODING UPDATES 21 6