Physician Documentation and Coding “ If it isn’t documented, it hasn’t been done”. Background.
Physician billing has been under increased scrutiny by government agencies as well as third-party carriers. Audits by the Office of Inspector General (OIG) revealed that insufficient or lack of documentation was the most common error when medical records were reviewed. Lack of medical necessity was the second most common error. Based on these findings, physicians can expect to see increased fraud and abuse detection efforts by the federal government as well as other third-party payers
Medical record documentation:
a. Chief Complaint or the reason for the encounter;
b. Relevant History (HPI, ROS, PFSH);
c. Physical Examination findings;
d. Prior diagnostic test results;
e. Assessment, clinical impression, or diagnosis;
f. Plan of care; and
g. Date and legible or electronic signature of the provider.
E&M codes are organized into various categories and levels. It is the physician’s responsibility to ensure that documentation reflects the services furnishedand that the codes selected reflect those services.
When determining an E&M visit level there are several categories you must review prior to assigning an E&M level.
1. Location of patient (inpatient, office, home, nursing home, home health etc.)
2. Status of patient (new vs. established)
New patient - has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
3. Office/Inpatient etc. verses Consultation (consultations are still accepted by some commercial payers.
The individual E&M level assignment is based on:
IMPORTANTNOTE: in 2011 NGS clarified the number of exam elements required for Expanded Problem Focused Exam to 2-5 elements and Detailed to 6-7 elements.
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
Medical necessity of an E/M services is based on the following attributes of the service:
You must ask yourself, “Was it necessary to perform and document all the work in the chart for the patient encounter and bill a specific E/M level given the nature of the patient’s presenting problem and chief complaint?”
History of Present Illness & Chief Compliant: c/o of knee, started two days ago. States she tripped in the yard and fell on her rt. knee.
Vital Signs: Wt. 150, BP 120/82, HR 80, RR 16
General Appearance: pleasant but appears in pain
M/S: Good ROM, slight tenderness to touch noted on rt. lateral patella, no redness or heat noted.
Skin: No visible abrasions
Based on documentation and medical necessity this visit would met the criteria to bill E&M level 99213 and diagnosis 719.46 knee pain
Critical Care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous.
Reportable time includes that time which is directly relate to the individual patient’s care whether at the immediate bedside or at the nursing station reviewing results or discussing patient’s care with other health care professionals.
Critical Care time MUST be documented in the patient’s medicalrecord. Time may be documented as total time, for example 75 minutes, or a range such as 6:05 – 7:35.
Counseling &/or Coordination of Care
When counseling and/or coordination of care dominates greater than 50% of the encounter (face-to-face time in the office or other outpatient setting for floor/unit time in the hospital or nursing home), then time shall be considered the key or controlling factor to qualify for a particular level of E&M service. Documentation should reflect the extent of counseling and/or coordination of care.
Total time must be documentedin the medical recordwhen using time based codes
“The patient had numerous question regarding why she had to take so many pills. I spent 45 minutes of the visit discussing each medication and her need to continue taking it.”
99239 Discharge Day Management; more than 30 minutes
Discharge Management time MUST be documented in the patient’s medicalrecord. Time may be documented as total time, for example 75 minutes, or a range such as 6:05 – 7:35.
ICD-9-CM Diagnosis codes are used to report Why the patient received health care services.
For example: Patient c/o lower abdominal pain with burning upon urination. A urinalysis was done in the office which indicated UTI.
Correct diagnosis for visit would be 599.0 UTI
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. Therefore, codes that describe symptoms and signs are acceptable for reporting purposes when a diagnosis has not been established.
For example: Patient seen for left lower abdominal pain and fever. Physician orders x-rays to rule out diverticulitis. Correct diagnoses codes: 789.04 LL Abdominal pain and 780.60 Fever, unspecified
The following are a list of recent finding from audits preformed by NGS (National Government Services) our FI (Fiscal Intermediary)
Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Consequently they will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Therefore the OIG has included this on their 2012 Work Plan. The following are a few issues identified by the Medicare contractors:
1. “Copy and Paste” - this function should never be used on elements that are unique to
each visit, such as: History of Present Illness (HPI), Exam, and Assessment.
2. HPI & ROS (Review of Systems) contradict one another.
3. The note does not make sense. For some notes, when the history section is copied
from a previous note, the description of the patient’s symptoms and the timing just
doesn’t make sense.
4. Guard against cloned notes. For example, if some part of the history is used from a
previous visit, the provider must review it with the patient, and indicate that it is
Corporate Compliance Services has produced this material as an informational reference for providers who furnish and bill for their services. Every reasonable effort has been made to assure the accuracy of the information provided within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain up to date of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid website at http://www.cms.gov.