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Physician documentation and coding if it isn t documented it hasn t been done

Physician Documentation and Coding“If it isn’t documented, it hasn’t been done”


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

If it isn t documented it hasn t been done
If it isn’t documented, it hasn’t been done”

Medical record documentation:

  • Facilitates physician’s and other healthcare professionals ability to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time;

  • Used for communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care;

  • Allows for accurate and timely claims review and payment;

  • Is accessed and used for utilization review, quality of care evaluations, research, education ; and

  • Serves as a legal document to verify care provided, if necessary.

General principles of medical record documentation
General Principles of Medical Record Documentation

  • The medical record should be complete and legible.

  • The documentation for each patient encounter should include:

    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.

  • If not documented, the rational for ordering diagnostic and other ancillary services should be easily inferred.

  • Past and present diagnoses should be accessible to the treating and /or consulting physician.

General principles of medical record documentation cont
General Principles of Medical Record Documentation (cont.)

  • Appropriate health risk factors should be identified.

  • The patient’s progress, response to and changes in treatment, and revisions of diagnosis should be documented.

  • The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

  • Most importantly, if not documented they’ve not been done!

E m coding
E&M Coding

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.

E m coding1
E&M Coding

The individual E&M level assignment is based on:

  • History, which includes the chief complaint. The chief complaint is a required element for each date of service billed,

  • Exam (using ’95 or ’97 Guidelines)

    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 decision making

  • Other measures of work

    • Coding based on Time

    • Nature of presenting problem

E m coding cont
E&M Coding (cont.)

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:

  • The number, acuity, and severity and/or duration of problems addressed through the history, physical, and medical decision-making,

  • The context of the encounter among all other services previously rendered for the same problem.

  • The complexity of documented co-morbidities that clearly influenced physician work

  • The physical scope encompassed by the problems (i.e., the number of physical systems affected).

    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?”

E m coding example
E&M Coding Example

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


  • Knee Pain - X-ray, 3-view rt. Knee. Call office in 2 days for x-ray results and progress report. Take Aleve as directed for pain.

    Based on documentation and medical necessity this visit would met the criteria to bill E&M level 99213 and diagnosis 719.46 knee pain

Time based coding
Time Based Coding

Critical Care

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.

Time based coding1
Time Based Coding

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

For example:

“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.”

Time based coding2
Time Based Coding

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.

Diagnosis coding
Diagnosis Coding

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

Diagnosis coding1
Diagnosis Coding

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

Audit findings
Audit Findings

The following are a list of recent finding from audits preformed by NGS (National Government Services) our FI (Fiscal Intermediary)

  • Insufficient Documentation – medical documentation does not include pertinent patient facts.

  • Medically Unnecessary – Claims which contained enough documentation in the medical record to make an informed decision that the services billed were not medically necessary based on Medicare Coverage Policy.

  • Incorrect Coding – documentation did not support E&M code assigned.

  • Documentation did not support medical necessity of the level assigned.

  • Illegible or missing provider signatures.

Oig 2012 work plan
OIG 2012 Work Plan

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


Oig 2012 workplan cont
OIG 2012 Workplan cont.

  • OIG continues to identify overpayments made by contractors to physicians that incorrectly billed the place of service on the claim.

  • Incident –to: OIG identified this as potentially vulnerable to overutilization and potential quality issue as Medicare beneficiaries may receive care by unqualified personnel.

  • OIG will review potentially inappropriate payments related to pre-populated templates. Templates are acceptable but need to watch over-customization which could effect quality of care.

  • Over-documentation in the EHR which could lead to billing a higher level of service than medically necessary.


  • - CMS Physician Center; included most references/resources, including links to all CMS manuals

  • - E/M Services Guide; 1995 & 1997 E/M Documentation Guidelines

  • - Medicare Claims Processing Manual, Chapter 12 – Physicians/NPP

  • - OIG Compliance Program Guidance for Individual and Small Group Physician Practices


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