Coding for Physician/Provider Services: Understanding Key Documentation Issues

Coding for Physician/Provider Services: Understanding Key Documentation Issues Presented by Deborah Holzmark, RN, MBA, CPHQ, MCS-P, CMPE Dixon Hughes PLLC (828) 236-5794 dholzmark@dixon-hughes.com

Agenda Compliance Overview Evaluation and Management Coding Other Issues 2

Compliance Overview 3

Compliance is serious business The average specialty practice incurs about 4 times its annual net income in potential liability for inadvertent or deliberate coding errors Auditors from the OIG, CMS and other government bodies estimate that 75-80% of the codes billed by physicians offices lack sufficient documentation for the level of E&M service billed 4

Audit Performance In a National Study Group 40% Non- Compliant BPC Error Percentage 60% Compliant In January 2000, the Archives of Family Medicine published a study by George Kikano et al which compared family physicians billing for E&M services with medical record documentation After reviewing 4137 visits at 138 practices, researchers found errors indicating codes billed were not concurrent with documentation in the charts 43% of the time Upcoding and downcoding occurred at similar frequencies and differed by more than one code in fewer than 4% of visits 5

Compliance is how you conduct your business Besides its legal implications, incorrect coding significantly impacts practice cash flow A/R problems and collection costs escalate The top three reasons practices get audited Beneficiary complaints Whistleblowers Peer comparison for random audit (CERT Testing) Compliance is all about documentation The purpose of coding is to quantify the services provided - like an accounting system Chart notes are treated as evidence to support the codes billed 6

Compliance is serious business There are five types of Federal fraud enforcement options Repayment of overpayment requests Civil monetary penalty Exclusion Civil remedies Criminal Sanctions If indicted for Federal crimes, practices also risk audit by other bodies IRS Commercial Payors State Medicaid Individuals 7

What is Fraud? Definitions of Fraud and Abuse Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program or obtain, by means of false or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. What is Abuse? Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. It also includes the failure to meet professionally recognized standards of care or furnishing medically unnecessary services or items. 8

Common Chart Review Issues Most common error: upcoding one level Most common reason for upcoding: lack of sufficient history documentation Other common errors: Missing notes Incomplete notes Missing supporting documentation (lab results) No mention orders for additional services Downcoding Wrong category Consultation requirements not met 9

History Documentation Higher level codes that require comprehensive history: 99204-99205 New Office 99222-99223 Initial Inpatient 99244-99245 Consults 99254-99255 Consults Inpatient 99344-99345 Home, New 10

Review of Evaluation Management Documentation Guidelines History Physical Exam Medical Decision-making 11

Documentation of History The levels of E&M service are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed and Comprehensive) Each type of history includes some or all of the following elements: Chief Complaint (CC) :This is either Present or Absent History of Present Illness (HPI): This is either Brief or Extended Review of Systems (ROS): This is either Problem Pertinent, Extended or Complete Past, Family, and/or Social History (PFSH): This is 12 either Pertinent or Complete

Documentation of History The extent of these elements you provide must be based on the nature of the presenting problem and clinical judgement. It must be necessary and appropriate to provide the level of history you document. 13

Chief Complaint (CC) A chief complaint is a concise statement describing the symptom, problem, condition or other factor that is the reason for the encounter. YOU MUST ALWAYS DOCUMENT THE CHIEF COMPLAINT! Without a chief complaint, you cannot bill any code. 14

History of Present Illness (HPI) A chronological description of the development of the patient s present illness from the first sign or symptom, or from the previous encounter to present. It includes: Location: RLQ Quality: Burning, aching Severity: Seven on a one to ten scale Duration: For the last seven weeks Timing: Constant pain Context: fell down stairs Modifying factors: Ice doesn t seem to help Associated signs & symptoms: fever 15

History of Present Illness (HPI) For a Brief HPI, you would describe one to three of these For an Extended HPI, you would describe four or more of these 16

Review of Systems The following 14 systems are recognized, you must document patient s personal history of each area: Constitutional symptoms Ears, Nose, Mouth, Throat Respiratory Genitourinary Integumentary Psychiatric Hematologic/Lymphatic Eyes Cardiovascular Gastrointestinal Musculoskeletal Neurological Endocrine Allergic/Immunologic Problem Pertinent: At least one Extended: two to nine of these would be documented Complete: you would document at least ten of these 17

Past, Family and Social History(PFSH) Past History: The patient s past experience with illnesses, operations, injuries and treatments: prior major illness and injuries prior hospitalizations current medications allergies immunizations feeding/dietary status prior operations 18

Past, Family and Social History(PFSH) Family History: A review of medical events in the patient s family, including diseases which may be hereditary or place the patient at risk Health status or cause of death of parents, siblings, children specific diseases related problems identified in the history Hereditary diseases 19

Past, Family and Social History(PFSH) Social History: An age appropriate review of past and current activities marital status current employment occupational hx drugs, alcohol, tobacco education sexual hx Histories are either Pertinent or Complete 20

PFSH A pertinent review: at least one item from any of the three history areas A complete review: at least one item from two of the three history areas for established patient office visits ER visits A complete review: at least one item from all three history areas for new patient office visits initial hospital inpatient consultations 21

Important tips: History You can use a patient information form to collect data, however you must: You must refer to the patient information form in your note and that you reviewed it with the patient AND Document all positive responses in your note, for example if they check a history of heart disease, you must document in your note the details of this problem. 22

History You do not have to re-record a ROS and/or PFSH at each visit, but you must note there has been no change from the previous assessment and note the date of the previous assessment or describe any new information When you do a complete ROS, at least 10 organ systems, those systems with positive or negative PERTINENT responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible, but you must actually review the other systems. 23

Per Medicare: Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. Extensive PFSH is unnecessary for lower-level services. The same applies to ROS. Don't use the term "non-contributory". Don't record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates a lower-level service to have been medically appropriate. 24

Per Medicare: Document an ROS for the system(s) related to the presenting problem. It is required for all levels of systemic review (meaning that it is required for all codes except the least codes in all code families). Record positives and pertinent negatives. Never note the system(s) related to the presenting problem as "negative". Use notations such as "normal" or "negative" only for systems not related to the presenting problem. When using "negative" notation, always identify which systems were queried and found to be negative. Don't count physical observations as ROS (count them as Physical Examination). 25

History Requirements Type of History History of Present Illness Review of Systems Past, Family, and/or Social History Problem Focused Brief (1-3) N/A N/A Expanded Problem Focused Brief (1-3) Problem Pertinent N/A Detailed Extended (4+) Extended (2-9) Pertinent (1 of 3) Comprehensive Extended (4+) Complete (10+) Complete (2 of 3) or (3 of 3) 26

Physical Exam There are four levels of Physical Exam: Problem Focused Expanded Problem Focused Detailed Comprehensive There are Three Types of Documentation Guidelines for Physical Exams: 1995 General Multisystem 1997 General Multisystem 1997 Single Organ Exams 27

General Multi-System Exam Type of Exam Number of Organ Systems Number of Bullets or Elements Problem Focused One or more One to Five Elements Expanded Problem Focused One or more At least Six Elements Detailed Six or more and At least Two Elements OR Two or more and At least Twelve Elements Comprehensive Nine or more All elements AND All systems must have At least Two Elements 28

Constitutional General Multi-System Exam Any three of the seven vital signs (may be done by ancillary staff) sitting or standing BP Supine BP Pulse Respiration Temperature Height Weight General appearance of the patient(e.g.:development, nutrition, body habitus, deformities, attention to grooming) 29

Eyes General Multi-System Exam Inspection of conjuctivae and lids Exam of pupils and irises (e.g., reaction to light and accommodation, size and symmetry) Opthalmoscopic exam of optic disc (e.g., size, C/D ratio,appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages) Lymphatic Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other 30

General Multi-System Ears, Nose, Mouth and Throat Exam External inspection of ears and nose (overall appearance, scars, lesions, masses) Otoscopic exam of external auditory canals and tympanic membranes Assessment of hearing (e.g., whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx 31

Neck General Multi-System Exam Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (e.g., enlargement, tenderness, mass) Respiratory Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement Percussion of chest (e.g., dullness, flatness, hyperresonance) Palpation of chest (e.g., tactile fremitus) Auscultation of lungs 32

Cardiovascular General Multi-System Exam Palpation of heart (e.g., location, size, thrills) Auscultation of heart with notation of abnormal sounds and murmurs Exam of: carotid arteries (e.g., pulse amplitude, bruits) abdominal aorta (e.g., size, bruits) femoral arteries (e.g., pulse amplitude, bruits) pedal pulses (e.g., pulse amplitude) extremities for edema and/or extremities 33

Chest (Breasts) General Multi-System Exam Inspection of breasts (e.g., symmetry, nipple discharge) Palpation of breasts and axillae (e.g., masses or lumps, tenderness) 34

Gastrointestinal (Abdomen) General Multi-System Exam Exam of abdomen with notation of presence of masses or tenderness Exam of liver and spleen Exam for presence or absence of hernia Exam (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated 35

General Multi-System Exam Genitourinary Female: Pelvic exam ( with or without specimens) including exam of external genitalia and vagina exam of urethra exam of bladder exam of cervix exam of uterus exam of adnexa/parametria 36

Musculoskeletal General Multi-System Exam Examination of gait and station exam of joints,bones and muscles of one or more 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 37

General Multi-System Exam The exam of a given area should include: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, crepitation, or contracture Assessment of stability with notation of dislocation, subluxation, or laxity Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements Inspection and/or palpation of digits and nails (e.g.., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) 38

Skin General Multi-System Exam Inspection of skin and subcutaneous tissue (e.g.., rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (e.g.., induration, subcutaneous nodules, tightening) Neurological Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes Examination of sensation (e.g.., by touch, pin, vibration, proprioception) 39

Psychiatric General Multi-System Exam Brief assessment of mental status including: orientation to time, place, person recent and remote memory mood and affect (e.g.., depression, anxiety, agitation) Description of patient s judgement and insight 40

Medical Decision Making Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making Minimal Minimal or None Minimal Straightforward Limited Limited Low Low Complexity Multiple Moderate Moderate Moderate Complexity Extensive Extensive High High Complexity 41

Medical Decision Making L e v e l o f R isk P re se n tin g P ro b le m s D ia g n o stic P ro ce du re s O rd e re d M a n a g e m e n t O p tio n s S e le cte d M in im a l O n s e lf-lim ite d o r m in o r p ro b lem (e g., c o ld, in s ect b ite ) L a b te sts re q u irin g ve n ip u n c tu re C h e s t xra ys E K G /E E G U rin a lys is U S K O H p re p R e s t G a rg le s E la stic B a n d a g e s S u p e rficia l d re s s in gs L o w T w o o r m o re s e lflim ite d o r m in o r p ro b le m s O n e sta b le c h ro n ic illn e ss (e g., H T N, D M, C a ta ra c t) A c ute u n c om p lic a te d illn e ss o r in ju ry (e g., s im ple s p ra in ) P h ys io lo g ic te sts n o t u n d e r s tres s N o n -C V im a g in g w ith c o n tra st S u p e rficia l n e e d le b io p s ie s L a b te st re q u irin g a rte ria l p u n c tu re S k in b io p sie s O T C d ru g s M in o r s u rg e ry w ith n o id e n tifie d ris k fac to rs P T /O T IV F w ith o u t a d d itive s 42

Medical Decision Making Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected Moderate One or more chronic illnesses with mild exacerbation Two or more stable chronic illnesses Undiagnosed new problem Acute illness with systemic symptoms Acute complicated injury (eg., head injury with brief LOC) Physiologic tests under stress Diagnostic endoscopies with no identified risk factors Deep needle biopsy CV imaging studies with contrast and no risk factors Obtain fluids from body cavity Minor surgery with identified risk factors Elective major surgery with no identified risk factors Prescription drugs Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation 43

Medical Decision Making Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected High One or more chronic illnesses with severe exacerbation Acute or chronic illnesses that pose a threat to life or bodily function (eg., multiple trauma, progressive rheumatoid arthritis) An abrupt change in neurological status (eg., sensory loss) CV imaging with risk factors Cardiac EP tests Diagnostic endoscopies with risk factors Discography Elective major surgery with risk factors Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate 44

Office Visits: Initial and Established Code History Physical Decision Making 99201 Problem Focused Problem Focused Straight-Forward 99202 Expanded Problem Focused Expanded Problem Focused Straight-Forward 99203 Detailed Detailed Low Complexity 99204 Comprehensive Comprehensive Moderate Complexity 99205 Comprehensive Comprehensive High Complexity Code History Physical Decision Making 99211 N/A Physician may not be present 99212 Problem Focused Problem Focused Straight Forward 99213 Expanded Problem Focused Expanded Problem Focused Low Complexity 99214 Detailed Detailed Moderate Complexity 99215 Comprehensive Comprehensive High Complexity 45

Special Issues 46

Special Issue: Time Based Services Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim. 47

Time Based Services In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-toface time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided. 48

Time Based Services You must document total time, time spent in counseling/coordination of care and topics/issues addressed Example 45 minute visit, 25 minutes spent in counseling and discussion regarding surgical intervention versus conservative treatment. 49

Time Based Services EXAMPLE: A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy is made. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed. 50

Medicare Overpayments Statistically significant sampling May be audited by party other than Medicare Results with general issues and spreadsheet Extrapolation Request for repayment 51

Medicare Overpayments Review records carefully upon request/seek advice Include everything Check for and include history forms, testing results, previous and subsequent notes if applicable Maintain copies of everything provided!!! 52

Lessons Learned Know the E&M Guidelines Overpayment reviews focus on documentation of any type of visit including new patients, established patients, consults, hospital visits, nursing home visits, etc.. http://www.cms.hhs.gov/mlnedwebgui de/25_emdoc.asp Read the Evaluation and Management Services Guide! 53

Lessons Learned Know your Local/National Coverage Decisions! Overpayment reviews specifically reference LCD s, NCD s and articles from the Medicare Bulletins Part A, Part B, Coverage and Pricing, LCDs Template your key services 54

The constant history Lessons Learned Review of records showing repetition of history documentation exactly the same for each visit In Overpayment review, a primary care physician was requested to repay over $11,000 on review of 99215. Cited history documentation inappropriate 55

Electronic signature Lessons Learned Ensure EMR adequately implements the utilization of electronic signature Overpayment review: cited a large percentage of charts for lack of signature. Overturned on appeal 56

Lessons Learned Flow of electronic information When a visit is printed, does it include the reviewed history? Chart reviews show a request for a visit date of service documentation does not necessarily include printed review of history that would significantly impact code selection 57

What Medicare Says: Medicare expects the documentation to be generated during the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service. The medical record may not be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. Deletions should have only a single thin line drawn through the deletion. These corrections, deletions or additions must be dated and legibly signed or initialed. Every note stands alone, i.e., the services performed must be documented at the outset. 58

What Medicare Says: Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary. All entries must be legible to another reader to a degree that a meaningful review can be conducted. Recommendation is made that only JCAHO approved abbreviations be used to prevent patient care errors and allow for proper review by subsequent readers. Illegible notes will not be used in determining medical necessity of a claim. All notes shall contain the patient s name and be dated and signed by the author. If the signature is not legible and does not identify the author, a printed version should be also recorded. 59

What Medicare Says: The medical record should be complete and legible. Each patient encounter should include: the date the reason for the encounter appropriate history and physical exam review of lab, x-ray data and other ancillary services assessment and a plan of care, including discharge plan (if appropriate) Past and present diagnoses should be accessible to the treating and/or consulting physician Reasons for and results of x-rays, lab tests and other ancillary services should be documented or included in the medical record Relevant health risk factors should be identified. Patient s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented. 60

What Medicare Says: The written plan of care should include, when appropriate: Treatments and medications, specifying frequency and dosage Any referrals and consultations Patient/family education Specific instructions for follow up The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making All entries to the medical record should be dated and authenticated by the physician/provider signature. The CPT/ICD-9-CM codes reported on the CMS-1500 form should reflect the documentation in the medical record. 61

Questions? Deborah Holzmark, RN, MBA, CPHQ. MCS-P,CMPE Dixon Hughes PLLC (828) 236-5794 dholzmark@dixon-hughes.com Thank You! 62