BASIC DOCUMENTATION AND COMPLIANCE EDUCATION JANUARY 2012 UK Office f Crprate Cmpliance
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.
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!!
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!
Inpatient E/M Services Initial Hspital Care, Observatins, and Cnsultatins require all 3 key cmpnents
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
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.
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
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
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
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
Review f Systems (ROS) Cnstitutinal Eyes Ears, Nse, Muth, Thrat Cardivascular Respiratry Gastrintestinal Geniturinary Musculskeletal Integumentary Neurlgical Psychiatric Endcrine Hematlgic/ Lymphatic Allergic/immunlgic
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.
Past, Family, Scial Histry (PFSH) Past Histry Prir majr illnesses and injuries Prir peratins and/r hspitalizatins Current medicatins Allergies Age apprpriate immunizatins Diet
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
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
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
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.
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
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 (90701-99199) 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
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
Final Medical Decisin Making E/M Level 2/3 Straightfrward Lw Mderate High Number f diagnses/treatment ptins 1 2 3 4 Amunt and/r cmplexity f data 1 2 3 4 Risk f cmplicatins, mrbidity, mrtality Minimal Lw Mderate High
Initial Inpatient E/M Examples 99221 Hspital admissin, examinatin, and initiatin f treatment prgram fr a 67-year-ld male with uncmplicated pneumnia requiring IV antibitic therapy 99222 Initial visit fr a 61-year-ld male with a histry f previus MI, wh nw c/ chest pain 99223 Initial visit fr a 70-year-ld male with cutaneus T-cell lymphma wh has develped a fever and lymphadenpathy
Inpatient Hspital Care Initial Visit Requires 3/3 E/M Cde 99221 99222 99223 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 2-7 8+ rgan systems 8+ rgan systems MDM Straightfrward Mderate High Prblem Lw Severity Mderate Severity High Severity
Subsequent Care E/M Examples 99231 Subsequent hspital care fr a 50-year-ld male with uncmplicated MI wh is clinically stable and withut chest pain 99232 Fllw-up visit fr a 67-year-ld male with CHF wh has respnded t antibitics and diuretics, and has nw develped a mnarthrpathy 99233 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
Inpatient Hspital Care Subsequent Care Requires 2/3 E/M Cde 99231 99232 99233 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 0 0 1 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
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!!!!
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
Critical Care Critical care & ther E/M services may be prvided t the same patient n the same DOS by the same physician 99291 & 99292 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
Critical Care - 99291 99291 Critical care fr the E/M f the critically ill r injured patient; first 30-74 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
Critical Care - 99292 99292 Critical care E/M f the critically ill r injured patient; each additinal 30 minutes 74-104 minutes (99291x1 and 99292x1) 105-134 minutes (99291x1 and 99292x2) 135-164 minutes (99291x1 and 99292x3) 165-194 minutes (99291x1 and 99292x4)
Mdifier -24 Mdifier -24 is used t indicate that an unrelated evaluatin and management service was perfrmed during the pst-perative glbal perid.
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.
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
Electrnic Medical Recrd Dcumentatin Identified Areas f Cncern with regard t EHR dcumentatin: Authrship Integrity Dcumentatin Integrity
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
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.
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