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Documentation for Providers. Office of Corporate Compliance. Objectives. Why Document? E/M Documentation Guidelines History of Present Illness Physicial Examination Medical Decision Making Documentation Examples. Documentation Based on CMS Criteria.

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documentation for providers

Documentation for Providers

Office of Corporate Compliance

objectives
Objectives
  • Why Document?
  • E/M Documentation Guidelines
    • History of Present Illness
    • Physicial Examination
    • Medical Decision Making
  • Documentation Examples
documentation based on cms criteria
Documentation Based on CMS Criteria
  • The presentation materials are based on CMS guidance with respect to regulations and rules associated with billing or submission of claims to government payers.
  • Other payer manuals may be consulted for specific regulations and rules.
why document
Why Document?
  • Evaluation, treatment and monitoring
  • Communication and continuity of care
  • Accurate and timely claims review and payment
  • Appropriate utilization review and quality of care
  • Collection of data for research and teaching

1995 Documentation Guidelines

principles of documentation
Principles of Documentation
  • Be complete and legible
  • Include chief complaint (CC), reason for encounter, assessment, plan of care, date and identity of observer
  • Indicate rationale for ordering diagnostic and/or ancillary services
  • Indicate past and present diagnoses
  • Indicate appropriate health risk factors
  • Show patient’s progress or lack thereof
  • Support service/procedure and diagnosis(es)

1995 Documentation Guidelines

evaluation and management services

Evaluation and Management Services

Documentation Guidelines

Category and Type

slide7

Categories of E/M Services

  • Each E/M service category has special instructions for use
  • Office/Other Outpatient
  • Hospital Inpatient
  • Consultations
  • Hospital Observation
  • Emergency Department
  • Critical Care
  • Neonatal Intensive Care
  • Nursing Facility
  • Domiciliary, Rest Home or Custodial Care
  • Home
  • Case Management
  • Preventive Medicine
  • Newborn Care
  • Special Services

AMA 2004 CPT Manual

type of e m service
Type of E/M Service

AMA 2004 CPT Manual

components
Components
  • Chief Complaint
  • Key Components
    • History
    • Physical Examination
    • Medical Decision Making
  • Contributory Components
    • Nature of presenting problem or illness
    • Counseling
    • Coordination of care
    • Time

AMA 2004 CPT Manual

chief complaint cc
Chief Complaint (CC)
  • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.

1995 Documentation Guidelines

key components

Key Components

History – History of Present Illness

Review of Systems

Past, Family & Social History

history of present illness hpi
History of Present Illness (HPI)
  • The HPI is a chronological description of the development of the patient’s illness from the 1st sign and/or symptom to the present.
  • Current E/M guidelines identify 8 dimensions typically used to provide further elaboration about the patient’s condition.

1995 Documentation Guidelines

dimensions of the hpi
Dimensions of the HPI

AMA 2004 CPT Manual

documentation example of hpi
Documentation Example of HPI
  • 45 year old female patient complains of intermittent sharp pain in her left hip after falling from a ladder today. Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain.
evaluation of example hpi
45 year old female patient complains of intermittentsharp pain in her left hip after falling from a ladder today. Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain.

Location = Hip

Duration = today

Timing = intermittent

Severity = 9 (scale 1-10)

Quality = sharp pain

Context = falling from ladder

Modify Factor = aspirin

Associated S&S = numbness in leg

Evaluation of Example HPI
documentation tips on hpi
Documentation Tips on HPI
  • HPI must be documented by the billing physician
  • HPI, ROS &/or PFSH need not be located in separate sections of the MR note
    • Example: Statement “The patient denies nausea” located in the HPI section may be used in ROS
  • CMS does not recognize documentation of a single element in both the HPI and ROS sections

CMS Documentation Guidance

review of systems ros
Review of Systems (ROS)
  • The ROS is an inventory of body systems obtained through a series of questions asked by the physician seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

1995 Documentation Guidelines

systems included
Constitutional

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

Systems Included

1995 Documentation Guidelines

documentation example of ros
Documentation Example of ROS
  • Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.
evaluation of sample ros
Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative.

Neurological = loss of consciousness

Gastrointestinal = no bowel/bladder problems

All other neg

Evaluation of Sample ROS
documentation tips for ros
Documentation Tips for ROS
  • ROS may be documented by ancillary staff or by patient
    • Physician must review, date and sign
  • Document pertinent positive &/or negative findings
    • Any positive findings must be documented individually
  • “Noncontributory” alone is not acceptable documentation
  • If the patient is unable to give history & care-giver or family member is not available, document reason patient is unable to respond
    • Example: patient unconscious, intubated, poor historian

CMS Documentation Guidance

past family social history pfsh
Past, Family, & Social History (PFSH)
  • The PFSH consists of a review of one or more of the following three areas of the patient’s history:
    • Past History (P)
    • Family History (F)
    • Social History (S)
  • The PFSH is considered to be interval history for subsequent inpatient visits.
    • Interval history - any new history information obtained since the last “physician-patient” encounter

AMA 2004 CPT Manual

documentation example of pfsh
Documentation Example of PFSH

Currently not taking medication, was hospitalized in 1994 for tibia fracture. Does not smoke and lives with husband in Motown. Family history for fracture is negative.

evaluation of example pfsh
Currently not taking medication, was hospitalized in 1994 for tibia fracture. Does not smoke and lives with husband in Motown. Family history for fracture is negative.

Past = no Meds, hospitalization

Social = no smoke, lives with husband

Family = negative

Evaluation of Example PFSH
documentation tips for pfsh
Documentation Tips for PFSH
  • PFSH may be documented by ancillary staff or by patient
    • Physician must review, date and sign
  • “Non-contributory” alone is not sufficient for billing purposes

CMS Documentation Guidance

key component

Key Component

Physical Examination

1995 Documentation Guidelines

as published in 1995 by American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS)

1995 physical examination
Organ Systems

Constitutional

Eyes

Ears, nose, mouth, and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/Lymphatic /Immunologic

Body Areas

Head, including face

Neck

Chest, including breast and axillae

Abdomen

Genitalia / Groin / Buttocks

Back, including spine

Each Extremity

1995 Physical Examination

1995 Documentation Guidelines

1995 level selection
1995 Level Selection

1995 Documentation Guidelines

documentation example of pe
Documentation Example of PE

T 98, BP 138/68, well groomed

Lungs clear

Heart RRR, S1 S2

Abd soft +BS

Ext 4+ edema

Skin intact

evaluation of pe
T 98, BP 138/68, well groomed

Lungs clear

Heart RRR, S1 S2

Skin intact

Abd soft +BS

Ext 4+ edema

Organ Systems:

Const

Respir

Cardio

Skin

Body Areas:

Abd

Ext

Evaluation of PE
documentation tips for pe
Documentation Tips for PE
  • Notation of “abnormal” without elaboration is insufficient documentation
  • A brief statement or notation indicating “negative” or “normal” is sufficient for findings within normal limits
  • Under 1995 DGs, comprehensive PE must consist of evaluation of 8 or more of the 12 organ systems

1995 Documentation Guidelines

medical decision making

Medical Decision Making

Number of Diagnoses

Amount/Complexity of Data

Risk

medical decision making mdm
Medical Decision Making (MDM)
  • MDM refers to the complexity of establishing a diagnosis and/or selecting a management option.
  • MDM is the function of 3 variables
    • Number of diagnoses &/or management options
    • Amount &/or complexity of data that must be obtained, reviewed &/or analyzed
    • Risk of significant complications, morbidity &/or mortality

1995 Documentation Guidelines

number of diagnosis management options
Number of Diagnosis Management Options

1995 Documentation Guidelines

amount and or complexity of data
Amount and/or Complexity of Data
  • Documentation should include:
    • Diagnostic service:
      • Ordered, planned, scheduled or performed
    • Review of tests results
      • Simple notation or initialing & dating
    • Decision to obtain old records or addl History
    • Relevant findings from review of old records
    • Discussion of results with performing physician
    • Direct visualization and interpretation

1995 Documentation Guidelines

risk of complications morbidity and or mortality
Risk of Complications, Morbidity and/or Mortality
  • Refers to patient’s level of risk at the visit
  • Sources of risk
    • Presenting problem
    • Diagnostic procedures ordered
    • Management options selected
  • Illustrated by clinical examples in “Table of Risk”

1995 Documentation Guidelines

documented example of mdm
Documented Example of MDM

A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.

evaluation of mdm
A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.

Number of dx/tx options = new problem with addl workup

Amt/complexity of data = ordered MRI

Risk = prescription management

Evaluation of MDM
documentation tips for mdm
Documentation Tips for MDM
  • Established diagnoses should indicate: Stable, well-controlled, worsening, failing to improve
  • Independent review of diagnostic test should document: visualization of image, tracing or specimen
  • Review of old records, document findings or lack of findings
  • Document co-morbidities, underlying diseases that increase risk of presenting illness
selection of e m level example
Selection of E/M Level - Example
  • History section
    • Detailed
  • Physical Examination
    • Detailed
  • Medical Decision Making
    • Moderate
selection of e m level code
Selection of E/M Level Code

Documentation Guidelines

contributory components

Contributory Components

Counseling and Coordination of Care

Time

counseling and coordination of care
Counseling and Coordination of Care
  • Discussion with patient and/or family with regards to:
    • Diagnostic results, impressions, and/or recommended studies;
    • Prognosis;
    • Risks and benefits of management or treatment options;
    • Instructions and/or follow up;
    • Importance of compliance with chosen treatment or management options;
    • Risk factor reduction; and/or
    • Patient and family education.

AMA 2004 CPT Manual

documenting for time
Documenting for Time
  • When counseling/coordination of care requires more than 50% of visit:
    • Document
      • Total time of visit
      • Time spent providing counseling/coordination
        • May document minutes or percentage of time; i.e., 51% or 20 minutes of the 35 minute visit
      • Nature and extent of counseling/coordination of care
  • Time must be face-to-face for clinic visit or floor time for inpatient visit
definition of consultation
Definition of Consultation
  • “…a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”
  • Payment for consultation is often significantly higher than other E/M service
      • AMA Principles of CPT Coding, Second Edition
consultation vs referral
Consultation:

Requires a physician request for an opinion or advice.

Request and reason for consult must be documented.

Evidence of opinion and/or advice communicated back to requesting physician.

UPIN is required.

Referral:

Is a transfer of care for treatment of a specified problem.

Is for a known problem.

Physician plans to manage the patient’s care and treatment.

No report to referring physician is required.

Consultation vs. Referral
four elements that distinguish a consultation
A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of an unknown or uncertain problem is requested by another physician or appropriate source.

The written or verbal request for a consultation must be documented in the medical record.

The consulting physician may initiate diagnostic or therapeutic services at the consultation or subsequent visit.

The consulting physician’s opinion and any services ordered or performed must be:

a) Documented in the medical record; and

b) Communicated by written report to the requesting physician or other appropriate source.

Four Elements That Distinguish A Consultation
types of inpatient consultations
Initial Inpatient

No difference in new or established

Reported one time during hospital stay

Requires 3 of 3 key components be documented

Follow-up Inpatient

Used to complete an initial consultation

Complete initial consult, initiated by consulting physician

Subsequent consult, initiated by attending physician

Requires 2 of 3 key components be documented

Types of Inpatient Consultations
documentation tips for consults
Documentation Tips for Consults
  • Request for consultation - In a setting in which the medical record is shared between the requesting and consulting physicians (e.g., emergency department, hospital inpatient/outpatient), the request may be documented in the following ways:
    • As part of a plan written in the requesting physician’s progress note;
    • As an order in the medical record; or
    • As a specific written request for the consultation.
  • Report of opinion - In these settings, the report may consist of an appropriate entry in the common medical record.
documentation tips for consults1
Documentation Tips for Consults
  • Request for consultation - In an office setting, the documentation requirement may be met by:
    • A specific written request for the consultation from the requesting physician; or
    • A specific reference to the request in the consultant’s records.
  • Report of opinion - In this setting, the consultation report is a separate document communicated to the requesting physician.
modifier
Modifier

A modifier is appended to a CPT code to indicate the service provided was changed or modified from the CPT code descriptor:

  • Service/procedure has both professional & technical component;
  • Service/procedure was performed by more than one provider or location;
  • Increased or reduced procedure or service;
  • Only part of service was performed;
  • Adjunctive service was performed;
  • A bilateral procedure was performed;
  • Service/procedure was provided more than once; and
  • Unusual events occurred.

2003 CPT Manual

general documentation guidance
General Documentation Guidance
  • Use approved abbreviations or standard specialty abbreviations
  • Handwritten notes should be legible
  • All Medical Record documentation must have identity of author
  • Templates may be utilized as long as those meet the intended use
  • Document abnormal or positive findings
  • When referencing another note, always identify by name and date
advanced beneficiary notices
Advanced Beneficiary Notices
  • ABNs Developed by CMS
    • Waiver for Health Care Items and Services
      • Obtain when service may not be paid by CMS
      • Must not obtain at each visit
    • When the patient refuses to sign
      • Annotate that the patient refused to sign and have second person witness
      • Service may be furnished
      • Patient may still be held liable for charge as they were notified
office of corporate compliance

Office of Corporate Compliance

Reporting Line:

884-1729

Thanks you for this Opportunity