Medical Documentation and Coding Iris Stendig-Raskin,MSN,CRNP,WHNP-BC Clinician/Colposcopist February 26,2010

1. Medical Documentation and CodingIris Stendig-Raskin,MSN,CRNP,WHNP-BC Clinician/ColposcopistFebruary 26,2010

2. Overview: • What is OPA? • Title X • Documentation Review • Coding • Putting it all together

3. Office Of Population Affairs (OPA) • One of 12 offices that comprise the Office of Public Health and Science • AdvisesSecretary of Health on reproductive health topics including: • Adolescent pregnancy • Family planning and sterilization • Administers Family Planning program authorized under Title X of the Public Health Service Act (PHSA) http://www.hhs.gov/ophs/

4. 2010 OPA Family Planning Program Priorities • Assuring the delivery of quality family planning and related preventive services, where evidence exists that those services should lead to improvement in the overall health of individuals, with priority for services to individuals from low income families. • Expanding access to a broad range of acceptable and effective family planning methods and related preventive health services that include natural family planning methods, infertility services, and services for adolescents, including adolescent abstinence counseling.The broad range of services does not include abortion as a method of family planning. http://www.hhs.gov/opa/familyplanning/policyplanningeval/programpriorities/index.html

5. 2010 OPA Family Planning Program Priorities • Providing preventive health care services in accordance with nationally recognized standards of care.This includes, but is not limited to, breast and cervical cancer screening and prevention services;sexually transmitted disease and HIV prevention, testing, and referral;and, other preventive health services. • Emphasizing theimportance of counseling family planning clients on establishing a reproductive life plan, and providing preconception counseling as a part of family planning services, as appropriate;

6. 2010 OPA Family Planning Program Priorities • Assuring compliance with State laws requiring notification or the reporting of child abuse, child molestation, sexual abuse, rape or incest; • Encouraging participation of families, parents. and/or legal guardians in the decision of minors to seek family planning services; and providing counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities; and • Addressing the comprehensive family planning and other health needs of individuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations, and partnering with other community-based health and social service providers that provide needed services.

7. S0-What is Title X???? X X

8. What is TITLE X? • Established in 1970-broad bi-partisan support • James Scheuer (D-NY) • Joseph Tydings (D-MD) • Charles Percy (R-IL) • George Bush (R-TX) • Mandates to serve both men and women • 1995-first grant awarded re: male research

9. Title X Overview • Provides federal funds for project grants to public and private nonprofit organizations for the provision of family planning information and services which: • Improve maternal and infant health • Lower the incidence of unintended pregnancy • Reduce the incidence of abortion; and • Lower rates of sexually transmitted diseases.

10. What Services does TITLE X Provide? • Contraceptive information,and provision of all contraceptive services • Gynecological examinations • Basic lab tests • Screening services for STD and HIV • High blood pressure • Anemia • Breast and cervical cancer • Pregnancy testing • Community education and outreach • http://www.hhs.gov/opa/familyplanning/toolsdocs/2001_ofp_guidelines.pdf

11. Title X Program Guidelines • Initial Visit: Must be offered and documented: • Education • Counseling • Informed Consent • History (personal, medical, and family) • Exam • Lab Testing • Follow-Up and Referral http://www.hhs.gov/opa/familyplanning/toolsdocs/2001_ofp_guidelines.pdf

12. Title X Program Guidelines • Return Visit: Must be documented: • History • Exam • Lab Testing • Follow-Up and Referral

13. For Female Clients: Contraceptive use past and present (and adverse effects) Menstrual history Sexual history OB history Gynecological conditions STI history (including HBV and HIV) Pap smear history In utero exposure to DES For Male Clients: Sexual history STI history (including HBV and HIV) Urological Conditions Histories of Reproductive Functions Must Include the Following:

14. Laboratory Testing:On Site or Referral • Anemia assessment • Gonorrhea and chlamydia test • Wet mounts • Diabetes testing • Cholesterol and lipids • Hepatitis B testing • Syphilis serology • Rubella titer • Urinalysis

15. Method Counseling: individualized dialogue covering the following • Result of physical exam and lab studies • Effective use of contraceptive methods, including NFP, and the benefit and efficacy of the method • Possible side effects /complications • How to discontinue the method selected and information regarding back-up method use, including the use of certain oral contraceptives as post-coital emergency contraception; • Planned return schedule • Emergency 24 hour number • Location where emergency services can be obtained, and • Appropriate referral for additional services as needed

16. Medical Charts: Definition and Purpose • Definition: • A medical chart is a confidential document that contains detailed and comprehensive information on an individual and the care experience related to that person. • Purpose: • The purpose of a medical chart is to serve as both a medical and legal record of an individual's clinical status, care, history, and caregiver involvement. The specific information contained in the chart is intended to provide a record of a person's clinical condition by detailing diagnoses, treatments, tests and responses to treatment, as well as any other factors that may affect the person's health or clinical state. • http://www.surgeryencyclopedia.com/La-Pa/Medical-Charts.html

17. Medical Records • Must be established for every client seeking clinical services • Must be maintained in accordance with accepted medical standards and State laws regarding retention.

18. Medical Records….must • Be readily accessible • Confidential • Secured when not in use • Systematically organized to ease retrieval • Be complete,legible, and accurate reflecting all client contact • Be signed by the clinician and all other health care personnel who have made entries into the chart: name,title, and date

19. Content of the client record • Personal data • Medical history, exam forms,lab tests, results and follow-up • Treatment and special instructions • Schedule re-visits • Informed consent • Refusal of services • Allergies

20. Content of the client record • Problem list at the front of the chart identifying on-going issues and completion date • Contact information • Financial information should be kept separate from the medical record • Confidentiality and release of records: • A confidentiality signed form must be signed and in the chart • When information is requested, only release specific information requested.

21. Documenting • Should always be objective..document what you observed, care that you gave. • Use accurate, specific descriptions. • I.e.: uterine size: 12-14 cms vs. large uterus • Describe patient’s behavior in factual, impartial manner. • I.e.: Client staggered around office, slurred speech, unable to respond to questions posed vs. client is drunk. • I.e.: Client entered the office, yelling obscenities and demanding to see the clinician vs. client is nasty and hostile.

22. Do’s of Charting • Do insure that you have the correct chart • Do write legibly • Do chart immediately • Do date every entry • Do date every page • Do sign every entry • Do fill in the blanks: all negatives and positives • Do chart immediately http://www.corexcel.com/html/body.documentation.page6.ceus.html

23. Do’s of Charting • Do insure that every chart contains an emergency contact • Do insure that every page contains client name and identifying number, date of birth, etc • Do chart errors by drawing a single line through entry; note ‘error’, initial and date. • Do make legible corrections: date and sign. • Do draw a line through empty space at the end of an entry • Do use only center approved abbreviations.

24. Do’s of Charting • Do check for spelling • Do document all client contact and services-including phone calls • Do use objective wording rather than subjective • Do chart client’s subjective data by directly quoting it-using quotation marks • Do chart only what has been done;not what has not been done • Do chart what the client response was • When documentation continues on the next page, insure that client’s identifying name and number is noted as well as note continued –with a signature on the prior page.

25. Do’s of Charting • Doinsure that every entry contains • Date • Method of contact • Reason for contact • Procedures done/information given • Outcome/plan of care • Signature

26. Don’ts to ‘bear in mind’ when charting • Don’t scribble, obliterate any entry • Don’t use white-out to correct mistakes • Don’t file the chart without insuring that complete documentation has occurred • Don’t place any financial information in the body of the medical chart • Don’t use ditto marks • Don’t use none of the above: use yes or no responses or check-off boxes.

27. Don’ts to ‘bear in mind’ whencharting • Don’t omit any medical information about the client even if it might be regarded as potentially embarrassing to the client • Don’t use staff names without identifying their role: • Don’t write-referred to Jane Smith without noting who she is

28. Do Not alter a client’s chart: This is a criminal offense • Donot add information at a later date without documenting that this was done • Don’t add an entry so that it appears to be written at an earlier time • Don’t add inaccurate information • Don’t destroy records. http://www.corexcel.com/html/body.documentation.page6.ceus.html

29. Actual Notations from medical charts funny or not?????? • Exam of genitalia indicates that he iscircus-sized • Both breasts are equal and reactive to light • The skin was moist and dry • She is numb from her toes down • Lab tests indicated abnormal lover functions • Patient was alert and unresponsive • Occasional,constant, and infrequent headaches • Has fireballs in the uterus • The pelvic exam will be done later on the floor • Patient has two teenage children;no other abnormalities.

31. Coding 101

32. Defining the terms • What is a CPT code? • What is an ICD-9 code? • What is the relationship between the two?

33. Defining the terms • CPT codes: • Current Procedural Terminology • Provides uniform language that accurately describes medical, surgical and diagnostic services. • 5 digit numeric code that is used to describe medical,surgical,radiology, laboratory, anesthesiology and evaluation/management services of health care providers • http://www.med.ufl.edu/complian/Q&A/cpt-codes.html

34. Defining the Terms • ICD-9-CM Codes: • International Classification of Diseases,9th revision,Clinical Modification • Used to code signs, symptoms,injuries,diseases, and conditions • http://www.med.ufl.edu/complian/Q&A/cpt-codes.html.

35. So, What’s the Relationship… • ICD-diagnosis • CPT-procedure • The critical relationship is that the diagnosis supports the medical necessity of the procedure; and- • Software enables payers to look at logical relationship • If matches: reimbursement occurs: ‘clean claim’… • If not-rejection. • Overcoding: fraud • Under coding: Lost revenue

36. E and M codes:Evaluation and Management • Sub-set of CPT codes • Describes: • Complexity of care provided • Place of service (outpatient or inpatient) • Type of service (examples) • New versus established • Consult • Preventive

37. Determining the Right Code • 3 Key Components to Consider when Determining E and M • History • Exam • Medical Decision Making

38. History: 4 Types • Problem Focused • Expanded Problem Focused • Detailed and • Comprehensive

39. History Component: Documentation needs to include: • New or established patient • Chief complaint • HPI (history of the present illness) • location,duration, severity, associated signs and symptoms, timing • PFSH Elements: • Past medical history • Social • Family

40. History Component: • ROS (Review of Systems) • Allergic/Immunologic • Cardiovascular • Constitutional Symptoms • Ears,Nose,Throat, Mouth • Endocrine • Eyes • Gastrointestinal (GI) • Genitourinary (GU) • Hematologic/Lymphatic • Integumentary • Musculoskeletal • Neurological • Psychiatric • Respiratory

41. Exam: 4 Types: • Problem Focused • Expanded Problem Focused • Detailed • Comprehensive

42. Medical Exam: • Cardiovascular • Constitutional (vitals,etc) • Breasts (Chest) • HEENT • Extremities • GI (abdomen) • Genitourinary • Integumentary • Lymphatic • Musculoskeletal • Neurological • Psychiatric • Respiratory

43. Medical Decision-Making: 4 Types: • Refers to complexity of determining a diagnosis and/or selection of a treatment option. Measured by documenting: • Number of diagnosis • Management options • Complexity of data to be reviewed. • Straightforward • Low Complexity • Moderate Complexity • High Complexity

44. New Patient 99201:Problem Focused 99202:Expanded Problem Focused 99203:Detailed 99204:Comprehensive 99205:Comprehensive Established Patient 99211:No Clinician 99212:Problem Focused 99213:Expanded Problem Focused 99214:Detailed 99215:Comprehensive E and M Coding:

45. How to Choose a Code: Established Patient

46. How to Choose a Code: New Patient

47. V72.31: GYN exam routine-with/without pap V25.9:Contraceptive Management V25.02:Initiation of Contraception V25.1: IUD Insertion V25.04:Counseling FP V65.44: HIV Counseling V74.5: STI Screening V65.5: Worried Well V65.45:Counseling STD’s V73.98:Chlamydia Screening Common GYN Codes: V Code:used to diagnose when there is no problem or condition

48. Menstrual /Bleeding Issues 625.3: Dysmenorrhea 625.4: PMS 626.7: Bleeding Post coital 626.4:DUB/Irregular Cycle 626.0: Amenorrhea Breast: 611.6:Galactorrhea 611.71:Mastodynia 611.72: Breast Mass/Lump STI/Infectious Conditions 616.10:Bacterial Vaginosis 131.01: Trich Vaginitis 078.19:Viral Warts/Condyloma 054.10:Herpes (Genital) 623.5: Vaginal Discharge 799.63: Urinary Urgency 788.1: Dysuria 112.1:Candidiasis 614.9:PID 078.0:Molluscum Common GYN codes:

49. Female Conditions 625.0:Dyspareunia 218.9: foreign body in vagina 789.30: ovarian cyst 620.2: ovary-enlarged 625.9: vulvar pain/ vulvodynia Cervix/Pap/Colpo 795.03:Pap/LGSIL 795.01: Pap/ASCUS 795.02: Pap/ASC-H 795.05:Pap/HPV+HR 795.04:Pap/ HSIL General Health 789.00: Abdominal Pain 280.9:Anemia 401.9:Hypertension 278.01: Obesity 625.9: Pelvic Pain:Unspecified 782.1:Rash: Non-Specific Skin Eruption 455.6: Hemorrhoids 785.6: Lymph Node Enlargement Common GYN codes:

50. Cases for Discussion: • 18 y.o., new patient presents for an initial visit with complaint of vaginal discharge. A pap test, GC/CT, RPR, HIV, and wet mount is obtained. She is diagnosed with bacterial vaginosis. • 22 y.o. presents for a repeat pap secondary to a colposcopy follow-up. Her colpo was 6 months ago. Pap and biopsy showed LSIL and HPV. • 30 y.o. presents with complaint of ‘burning’ and painful bumps. What tests would you do? • 25 y.o. with complaint of irregular menses. Last gyn exam 18 months ago. Interested in contraception. What would you offer her?