Basics of Coding and Medical Record Documentation

Presented by Angie Nolan, CHA, CPC, CPC-I, PCS, RMA

HIMS EducatorBanner Medical Group

Things we will cover•The Medical Record•Basic Documentation•Functions of the medical record•Key components of E&M codes•Basic E&M coding-new patient services•Basic E&M coding-established patient services•Key points to remember

The Medical Record•Serves as a medical document•Serves as a legal document•Serves as a compliance document•Outlines the patient’s care and treatment rendered•It is imperative that all services provided be supported in the medical record

Basic Medical Record Documentation

•Prompt entries must be made in the medical record•Dictation for documentation should be efficient and thorough•Date and time should accompany all entries•Signature of rendering provider must be legible

Functions of the medical record•Keeps the provider out of the slammer•Supports “medical necessity”•Reduces medical errors and professional liability exposure•Reduces audit exposure•Facilitates claims review•Supports insurance billing•Provides clinical data for education•Provides clinical data for research•Promotes continuity of care among physicians•Indicates quality of care

Key Components of E&M Codes•History

•History of present illness-4 of 8 elements •Review of systems-up to 10 or more organ systems (or a few systems and statement “all other systems have been reviewed and are negative”)•Past, family, and social history-all 3 elements (non-contributory is not acceptable documentation)

•Examination•For a general Multi-System Exam - At least 2 bullets from each of 9 body systems or areas •Or for a single organ system exam please see the 1997 documentation guidelines for requirements for that organ system

•Medical decision making•Straightforward•Low•Moderate•High

Basic E&M Coding•For a NEW patient encounter please note: Three of the three key components – history, exam and medical decision making – are required. 1. If time is used as the key factor in code selection then the documentation must provide that more than half of the total time involved counseling or coordination of care.

Basic E&M Coding•For an ESTABLISHED patient please note: Two of the three key components – history, exam and medical decision making – are required. 1. If time is used as the key factor in code selection then the documentation must provide that more than half of the total time involved counseling or coordination of care.

Key Points to Remember•Documentation is critical in the appropriate selection of E&M services and in the ultimate reimbursement for all of your hard work rendered to your patients•A best defense is always a good defense•Document what you do and do what you document•If it is not documented, it is not billable, therefore it is not a reimbursable service

Basics of Coding and Medical Record Documentation

•Sources•CMS Evaluation and Management Services Guide-2008•CMS 1995 Documentation Guidelines•AMA CPT 2009 Professional Edition

Basics of Coding and Medical Record DocumentationPresented by Angie Nolan, CHA, CPC, CPC-I, PCS, RMA

HIMS EducatorBanner Medical Group

***Angie Nolan is a certified healthcare auditor thru American Institute of Healthcare Compliance as well as a certified professional coder and instructor thru the American Academy of Professional Coders

and has been in the Healthcare field since 1993.