e&m code assignment & validation 2016 - mehima · 2016-03-10 · code assignment &...
TRANSCRIPT
Code Assignment & Validation
Presenter
Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMC
Evaluation & Management Services
Disclaimer
This presentation is for general education purposes only. The information contained in these materials and presented during the lecture or in response to your questions is not intended to be, and is not, legal advice. The laws and regulations at issue in this lecture may be open to interpretation.
This information may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of BNN. No part of this presentation may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from BNN.
2
Objectives
To provide you with an overview of:
Evaluation and management (E/M) code assignment
Review the elements of an E/M code
Review the rules associated with E/M code selection
Principles of medical record documentation requirements
Review documentation basics
Review coding documentation guidelines
Identifying & validating appropriate code assignment
Review details for the medical record review process
Medical record risk and documentation improvement opportunities3
Documentation Rules:Where do they come from?
CPT book language and code descriptors
CMS “Documentation Guidelines”
1995 and 1997 versions available
Additional clarification in the CPT Assistant Articles
Medicare Internet-Only Manuals
CMS NCCI Manual
Payer rules, transmittals, software edits4
8 Interpretations of the CMS DGs
5
What do Payers want from Documentation?
Reasonable proof that services provided are consistent
with coverage policies for enrollees including:
Site of service
Medical necessity of all services provided
Services provided have been accurately reported
6
Not that simple anymore
Unable to just document what is wrong with a patient and
what they want to do
Physicians fail audits in some cases due to 1-2 missing
words
How many rules could there be?
Documentation Rules
7
Documentation Principles/Requirementsof E/M Services The medical record must be complete & legible
Each encounter should include:
Chief Complaint
Patient History
Findings of Physical Exam
Available Results (previous diagnostic tests)
Assessment of Patient Status
Clinical Impression or Diagnosis
Plan for Care
Identification of Observer & Date 8
Documentation Principles/Requirements
Signature requirements per
CMS CR#6698
MLN Matters SE#1419
Services provided must be authenticated by the author. Stamp signatures are NOT accepted.
Acceptable methods:
Electronic signature
Handwritten signature
Signature Log
Signature Attestation Statement: certain form/format is not required; however, MACs have published their own samples
9
Remember…
Medicare has advised that the overarching criterion for code selection should be medical necessity: It would not be medically necessary or appropriate to bill a
higher level of evaluation and management service when a lower level of service is warranted.
(CMS Manual System, Pub 100-4, Ch. 12, Sub Sec 30.6.1A)
Documentation in History, Exam & Medical Decision Making should consistently support medical necessity.
10
Example #1
Patient with well-controlled diabetes comes in c/o stubbed toe. Patient completes history questionnaire at the office. Using the questionnaire, Comprehensive history is obtained (4 HPI, 10 ROS, 3 PFSH) along with a comprehensive exam (8 OS).
Assessment: Contusion toe and stable Diabetes. Patient is instructed to elevate foot, use ice prn and OTC Motrin 200mg. Watch for swelling or circulation issues. Return if worsening.
Option #1: 99215 based on comprehensive history and exam
Option #2: 99213 based on low MDM and either comprehensive history or exam
11
Example #2
Patient presents with abdominal pain. A comprehensive history and exam are documented. Assessment is gastritis; labs were ordered and patient advised to take over the counter medication for pain relief and drink plenty of fluids. Return prn or if not better.
Option #1: 99213 based on low MDM
Option #2: 99215 based on comprehensive history and exam
12
Documentation Principles/Requirements
MDM can vary from visit to visit, although the diagnosis may be the same, the treatment plan(s) can change
The fact that a patient has an underlying condition or chronic problem is only significant if it impacts the encounter on that day (and is documented that it was assessed)
13
Test Yourself
True or False
Additional diagnoses from a problem list can be added to the assessment to help support an E/M level of service.
14
Test Yourself
True or False
A comprehensive exam is required for all patients.
15
Test Yourself
True or False
Non-covered preventive visits may be billed as an E/M level of service to ensure payment.
16
Selecting the E/M Service
Identify the category or subcategory of service
E.g., Category - Office or Other Outpatient Services, Subcategory - New Patient
Review the instructions for the category or subcategory
Review the level of E/M service descriptors
Determine the level of History documented
Determine the extent of the Exam
Determine the complexity of MDM
Select the appropriate E/M service 17
Which Codes Require What?New vs Established?
2 of 3 (examples)
» Office or other outpatient services (established patient)
» Subsequent hospital
» Nursing facility care
» Subsequent observation care
3 of 3 (examples)
» Office or other outpatient services (new patient)
» Emergency department
» Initial observation care
» Initial hospital care
» Consultation Services
» Admit & Discharge on Same Day (inpatient & observation) 18
New – has not received any face-to-face professional services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty/subspecialty within the group practice, within the last three years
Established – has received face-to-face services in the last three years
Documentation Principles/Requirements
The Key ComponentsHistory (conversation) Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Examination (hands-on) Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Medical Decision Making (thought process) Straightforward
Low
Moderate
High
19
Contributory Factors
Counseling
Coordination of Care
Nature of Presenting Problem Can the level of service billed support the medical
necessity of the diagnosis?
Time - Plays a role in Counseling and/or Coordination of Care
20
E/M Coding Requirements
HISTORY: 4 levels determined by the amount of the following documented
History of Present Illness (HPI)
Review of Systems (ROS)
Past, family and/or social history (PFSH)
EXAMINATION: 4 levels determined by the number of Body Areas or Organ Systems examined
CHIEF COMPLAINT (CC): Chief reason for seeing the patient.
• MEDICAL DECISION MAKING: 4 levels determined by the acuity/complexity of patient’s condition– # of Diagnosis/ Management
Options– Amount & Complexity of Data– Risk
21
HistoryChief Compliant (CC)
A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s own words
History of Present Illness (HPI) Further defines and clarifies the chief complaint; expands the chief
complaint and supports medical necessity and provides information to clarify presenting problem
Review of System (ROS) Inventory of body systems obtained through questions to identify
signs and/or symptoms the patient is experiencing - what the patient is telling the provider
Past, family and/or social history (PFSH) Review of the patient’s past medical history (illnesses, injuries,
surgeries); family history and age-related social history 22
Chief Complaint - Nature of Presenting Problem
Each visit record MUST include the reason the patient is being seen (nature of the presenting problem)
If seen in “follow-up” … to what?
If seen for medication management… medication management for what condition(s)?
Failure to document a chief complaint may lead to an unbillable service
Helps support medical necessity
Where can the chief complaint be documented?
Sometimes the chief complaint may change from what the patient says to the nurse, to the information they provide to the provider - make sure any differing information is addressed.
23
Examples Unacceptable – does not describe reason for visit
Follow Up
Follow Up Meds
Could be better
Medication Management for Low Back Pain
6 month follow up (for what) + Diabetes + Hypertension
Good Documentation
6 month follow-up lipids
Monthly follow-up chronic pain of neck and back
6 year well child check
Left wrist pain25
ExampleCC: Patient here for f/u diabetesBad:
HPI: Patient c/o fever and cough x 3 daysROS: No SOB or other cold symptomsExam: ENT: TMs clear, pharynx red. Lungs clear. A&P: URI. Continue OTC meds. Return if worsening
Better:HPI: Patient following diet. Blood sugars at home had been stable but have been slightly elevated. C/O fever and cough x 3 days.A&P: Diabetes, stable. Continue meds.URI. Continue OTC meds. Return if worsening
25
History of Present Illness (HPI)
26
History of Present Illness (HPI)
The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
The HPI further defines and clarifies the chief complaint, expands upon the chief complaint and supports medical necessity, provides information to clarify the presenting problem.
Generally well documented when visit is for acute problem – need the information to diagnose.
27
Elements of the HPI
LocationQuality Severity TimingDuration ContextModifying Factors Associated Signs/Symptoms
28
Brief = 1-3 elements 9924299201 - 9920299212 - 99213
Extended = 4+ elements or update 3+ chronic illnesses
99243 - 9924599203 - 9920599214 - 99215
Status of 3+ Chronic Conditions It is not enough to list just the chronic conditions.
The fact that the patient has chronic conditions and is on medication does not satisfy the documentation guidelines.
Documentation needs to be in the “history” portion of the note -not in the Assessment/Plan. Remember that the history documentation should be the verbal interaction between the provider and the patient without professional interpretation.
Since Sept 10, 2013 can be used with either guidelines (‘95 or ‘97)
ROS and PFSH should also be documented.
29
Chronic Conditions ExampleBad:Patient presents today for follow-up of Diabetes, HTN and Hypercholesterolemia. Continues to take meds.
Better:Patient here today for f/u of Diabetes, HTN and Hypercholesterolemia. States that blood sugars have been in the normal range and she continues on Insulin. Her blood pressure has been 110/70 on average and she has had no further complaints of headaches or blurred vision. She continues to follow her low cholesterol diet and states she has lost 3 lbs.
30
Test Yourself
True or False The following Nursing Initial Screening may be
accepted and counted as appropriate documentation of HPI
Nursing Initial Screening:Pt has a new rash on her arm she would like checked. Some rough spots, red and itchy. Pt noticed rash 5 days ago and getting worse.
Provider Notes:Reviewed and agree with above history of present illness.
31
CMS E/M Services Guide
The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
32
NGS Frequently Asked E/M Questionshttps://www.ngsmedicare.com18. I have heard that four or five years ago NGS issued some sort of correspondence which stated that the history of present illness can only be documented by the provider. I have not been able to find this on the NGS website but have seen it referenced by Yale, among others. Can you verify this?
Answer: There are two elements of history that can be elicited and documented by someone other than the provider: the Review of Systems (ROS) and the Past, Family and Social History (PFSH). A staff member or medical student may elicit this information from the patient, but the provider is obliged to review it, amend it if necessary, and indicate in writing that he/she has done so. The provider is responsible for eliciting and documenting the History of the Present Illness (HPI), since this requires defined clinical skill. That said, the provider may utilize the services of a Scribe in documenting the HPI, as with any other element of an E&M service.
33
Review of Systems (ROS)
34
Review of Systems (ROS)ROS is an inventory of body systems obtained through a series of questions from the provider seeking to identify signs and/or symptoms which the patient may be currently experiencing.
ROS is not a list of past medical conditions (i.e. asthma, diabetes, arthritis)
ROS can be confused with exam elements - remember that the ROS is what the patient is telling the provider (subjective), not what the provider examines (objective)
35
Elements of the ROS
Constitutional
Eyes
ENT
Cardiovascular
Respiratory
Musculoskeletal
Gastrointestinal
Genitourinary
Psychiatric
Integumentary
Neurological
Allergic/Immunologic
Endocrine
Hematologic/Lymphatic
36
None992419920199212
Problem Pertinent = 1 System992429920299213
Extended = 2-9 Systems992439920399214
Complete = 10+ Systems99244 – 9924599204 – 9920599215
ROS - “All Others Negative”The guidelines state: “for services that require a complete ROS, at least 10 organ systems must be reviewed with positive and/or pertinent negative responses individually documented.
For the remaining systems a notation indicating “all other systems are negative” is permissible. In the absence of such a notation, at least 10 systems must be individually documented”
Must document “positive or pertinent negatives” as related to the chief complaint
Must be medically necessary
For your practice, what does “all others” mean? 37
“Hot Button Area”
“Double dipping” - What is it and can it be done?
The intent of the Documentation Guidelines was not to make the provider restate themselves. Information can be counted more than once as long as it is “elaborated on”. CC: Pain in arm
HPI: Pain in right arm
Remember that the guidelines do not state how the note has to be documented. Information can be contained throughout the note. (HX Section)
38
Document Pertinent Positives &/or NegativesWatch for Contradictions
39
Past, Family, Social History (PFSH)
40
Past, Family & Social History (PFSH)
Past HistoryAllergies, Current Medications, Immunizations, Previous Trauma, Surgeries, Previous Illnesses/Hospitalizations.
Family HistoryHealth of Parents, Siblings, Children. Family Members w/ diseases related to the chief complaint.
Social HistoryAge appropriate review of past and current activities, marital status and/or living conditions, employment, military status, occupational history, education, use of drugs, alcohol, tobacco.
NOTE: For categories of subsequent hospital care and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.
41
Past, Family & Social History (PFSH)
42
Complete (2 of 3)99215
Complete (3 of 3)99244 – 9924599204 – 99205
None99241 - 9924299201 - 9920299212 - 99213
Pertinent (1 of any)992439920399214
ROS vs Past HistoryROS vs. Past History
The ROS is an “inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient has or may be experiencing”- again, should be related to the chief complaint.
Allergy - ROS vs. Past History
Counted as ROS if related to the chief complaint or current signs/symptoms. Documentation that the patient has “no allergies” or NKDA is Past History information if the patient has no related complaints.
A list of “diagnoses” that the patient has is not a ROS but rather Past history.
Examples: Patient has Diabetes, Hypertension, COPD
Patient c/o increased thirst prior to taking her insulin for her Diabetes and her COPD seems to be worse with increased SOB
43
Documentation Guidelines (DG) - (Per CMS)
ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.
The review and update may be documented by: Describing any new ROS and/or PFSH information or
noting that there has been no change in the information; and
Noting the date and location of the earlier ROS and/or PFSH.
44
Documentation Guidelines (DG) - (Per CMS)
The ROS and/or PFSH may be recorded by the ancillary staff or on a form completed by the patient (e.g. an ROS Intake Form).
To document that the physician reviewed the ROS and/or PFSH information, there must be a notation supplementing or confirming that the information was recorded by someone else.
The provider of the service must document the chief complaint (CC) and history of present illness (HPI)
45
Documentation Guidelines (DG) - (Per CMS)
“Non-contributory” Can be interpreted as “not medically
necessary” - try to stay away from this terminology
46
Documentation Guidelines (DG) - (Per CMS)
If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes the provider from obtaining a history.
47
Determining the History Score: To qualify for a given type of history all of the elements must be met or exceeded
E/M Level LEVEL HPI ROS PFSH
992419920199212
Problem Focused Brief(1-3 HPI)
N/A N/A
992429920299213
Expanded Problem Focused
Brief(1-3 HPI)
Problem Pertinent(1 ROS)
N/A
992439920399214
Detailed Extended(4 or more HPI)
Extended(2-9 ROS)
Pertinent(1 PFSH)
99244-9924599204-9920599215
Comprehensive Extended(4 or more HPI)
Complete(10+ ROS)
Complete(Est: 2 PFSH)(New: 3 PFSH)
48
EXAM - 1995 vs 1997 Guidelines
49
EXAM - 1995 vs 1997 Guidelines
What are the differences?
1995 Guidelines are more generic
Body Area (BA): Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine
Organ System (OS): Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psyche, Respiratory, Skin
1997 Guidelines are very specific and use “bullets”
Numeric requirements
Parenthetical examples are for clarification
“and” really means “or”
• 1995 Guidelines– Expanded problem focused vs
detailed– No guidelines– Be consistent
• 1997 Guidelines– General Multi-System vs Specialty
Exams
• Both are accepted for now.
• Currently, there are no proposed guidelines in the pipeline.
50
1995 Exam Guidelines (NGS)Body Area (BA)
Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine
Organ System (OS)
Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin
Problem Focused (99241, 99202, 99212)
1 BA/OS
Expanded Problem Focused (99242, 99202, 99213)
2-7 BA’s/OS’s - limited
Detailed (99243, 99203, 99214)
2-7 BA’s/OS’s - extended (or 2 or more, at least 1 in detail)
Comprehensive (99244-99245, 99204-99205, 99215)
8+OS’s (only OS’s count toward a Comprehensive exam) OR
Complete exam of a single organ system
51
1995: Note
When using the 1995 Guidelines, the documentation of vital signs or general appearance of the patient will give credit for the “constitutional” organ system.
The “constitutional” organ system is not used as one of the systems that can be documented in detail to give credit for a “detailed exam” as the documentation should be specifically related to the “chief complaint”.
52
2-7 areas or systems
expanded documentation of the areas and/or systems examined;
requires more than checklists;
needs to have normal/abnormal findings expanded upon
53
1995 Detailed Exam (NGS E/M Documentation Training Tool)
1997 Exam GuidelinesTwo types of examinations: General Multi-System Exam - body areas and
organ systems
Single Organ System Exam - more extensive exam of a specific organ system 10 single organ system exams
• Cardiovascular• ENT• Eye• Genitourinary• Hematologic/Lymph
• Musculoskeletal• Neurological• Psychiatric• Respiratory• Skin 54
1997 Guidelines - General Multi-System Exam
Body Area (BA) Head, Neck,
Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine
Organ System (OS) Constitutional, Cardio,
ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin
Problem Focused (99241, 99201, 99212)
1-5 bulleted items
Expanded Problem Focused (99242, 99202, 99213)
6-11 bulleted items in one or more organ system or body area
Detailed (99243, 99203, 99214)
12-17 bulleted items; 2 bulleted items in 6 systems or areas or 12 bulleted items in at least 2 areas or systems
Comprehensive (99244-99245, 99204-99205, 99215)
18+ bulleted items; 2 bulleted items in at least 9 organ systems or document every element in each box with a shaded border and at least one element in each box with an un-shaded border.
55
Exam DG
Specific abnormal/relevant negative findings of the affected body area/organ system should be documented. A notation of “abnormal” without elaboration is not sufficient.
Describe abnormal or unexpected findings in asymptomatic areas/systems.
Briefly note negative or normal to document normal findings in unaffected areas/systems.
56
“Hot Button Areas” - Exam
There is a difference between the 1995 and 1997 guidelines. Review the “exam” elements for both sets of guidelines and decide which is best for your group/specialty.
ROS vs. Exam - cannot count as both(ROS is the talk, Exam is the walk).
Having patient give their height and/or weight is not “exam”. Vitals are the “measurement of”.
57
Medical Decision MakingNumber of Diagnoses or Treatment Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or Morbidity or Mortality
Determining the MDM Score (SF, Low, Mod, High)
58
Medical Decision Making (MDM) Elements
The “thought process” of the physician Complete documentation of “thought process” including
issues being ruled out will support medical necessity and higher levels of service billed.
Refers to the complexity of establishing the diagnosis and developing a treatment plan based on the following: Number of Diagnoses and/or Management Options Amount and/or Complexity of Data Reviewed Risk of Complications, Morbidity or Mortality
59
Types of Medical Decision Making
Four levels recognized:
Straightforward
Low complexity
Moderate complexity
High complexity
60
Medical Decision Making (MDM) Elements
Number of Diagnoses or Management Options
Amount or Complexity of Data Reviewed
Risk of Complications, Morbidity or Mortality
2 of the 3 elements of Medical Decision Making must be met or
exceeded61
MDMNumber of Diagnoses/Management Options
Number of Diagnoses or Management Options Considered
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician. 62
MDM
For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plan and/or further evaluation.
Only conditions that are assessed and impact the encounter are determining factors when selecting the level of visit (i.e., chronic conditions, co-morbidities)
63
MDMNumber of Diagnoses/Management Options
MDMNumber of Diagnoses/Management Options
64
Bad example:
MDMNumber of Diagnoses/Management Options
65
Bad example:
MDMNumber of Diagnoses/Management Options
66
Better example:
MDMNumber of Diagnoses/Management Options
For a presenting problem with an established diagnosis the record should reflect whether the problem is:
Improved, well controlled, resolving or resolved
Inadequately controlled, worsening, or failing to change as expected
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis or as “possible”, “probable”, or “rule out” (R/O) diagnosis:
Outpatient diagnoses coding rule: Use signs & symptoms for your final diagnosis instead of a possible dx.
67
Quantifying Diagnosis and Management Option
Number of Diagnoses and Management Options PointsSelf Limiting or Minor Problems - Stable, Improved or Worsening (Maximum of 2) 1
Established Problem - Stable Improved 1
Established Problem - Worsening 2New Problem - No Additional Work-up Planned(Maximum of 1) 3
New Problem - Additional Work-up Planned 4
Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive68
Self Limited Problem
Self limited/minor vs. new problem There is no definition in the CMS E/M Guidelines
Examples include a cold, an insect bite and tinea corporis.
CPT Manual E/M Services Guidelines, Nature of Presenting Problem defines a "self-limited or minor" problem as “one that runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status or has a good prognosis with management/ compliance."
69
NGS E/M FAQAdditional Work-up
17. How does NGS interpret “additional work up?“
Answer: NGS does not differentiate between diagnostic tests done on the same date of service as the encounter, and those scheduled following the encounter. Either would be considered “additional workup planned."
70
Quantifying Amount of Complexity of Data Reviewed
71
Amount & Complexity of Data Points
Ordered and/or reviewed clinical lab test (1 point max) (CPT 80000) 1
Ordered and/or reviewed radiology test (1 point max) (CPT 70000) 1
Ordered and/or reviewed test in the CPT Medicine Section (1 point max) (CPT 90000)
1
Discussed the test results with performing or interpreting physician (1 point max) 1
Decision to obtain old records or additional HX from someone other than patient, e.g., family, caretaker, previous physician (1 point max)
1
Reviewed and summarized old records or and/or obtained history from someone other than patient and/or discussion case with another health care provider (2 points max)
2
Independent visualization of image, tracing or specimen (2 points max) 2
Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive
Quantifying Amount of Complexity of Data Reviewed
“Independent visualization and direct view of image” - is this worth 1 or 2 points?
Guidelines state “the direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented”
General feeling is that it depends on who is billing for the interpretation. If the same provider (group) is also billing for the interpretation then only 1 point is awarded; however if the provider (group) is not billing for the interpretation, then 2 points will be awarded.
72
Quantifying Risk
Table indicates three areas of risk: Risk of the presenting problem(s) Risk of Diagnostic procedure(s) ordered Risk of Management option(s)
Documentation Guidelines state: Highest Level of Risk in any category
determines overall risk
73
Table of RiskRisk Level Presenting Problem(s) or Diagnostic Procedure or Management Options
Min (1)
One self-limited or minor problem, eg cold, insect bite, tinea corporis Venipuncture CXR,EKG,EEG Urinalysis, KOH US
Rest Gargle Elastic bandages Superficial dressings
Low (2)
Two or more self-limited or minor problems One stable chronic illness, eg well controlled Acute uncomplicated illness or injury, eg cystitis, simple sprain (full recovery w/o
functional impairment is expected)
PFT Non-cardiac imaging
studies Superficial needle
biopsies Arterial puncture Skin biopsies
OTC drugs Minor surgery w/o risk PT OT IV fluids w/o additives
Mod (3)
One or more chronic illnesses with mild exacerbation, or side effects of tx Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness (or
increased probability of prolonged impairment)
Stress tests Endoscopies w/o risk
factors Deep/incisional biopsies Card cath w/o risk Obtain cavity fluid from
body cavity, eg, lumbar puncture, Thoracentesis, culdocentesis
Minor surgery w/risk Elective major surgery w/o risk Prescription drug management Therapeutic nuclear meds IV fluids w/additives Closed reduction of fracture or
dislocation
High (4)
One or more chronic illnesses with severe exacerbation, progression, or side effects from tx
Acute/chronic illness/injury that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe RA, psychiatric illness w/potential threat to self or others, peritonitis, acute renal failure (or high probability of severe, prolonged impairment)
An abrupt change in neurologic status, eg, seizure, TIA, weakness or sensory loss
Cardiac catheter w/risk EPS studies Endoscopies w/risk Discography
Elective major surgery w/risk Emergency major surgery Parenteral controlled
substances Drug therapy requiring
intensive monitoring for toxicity DNR decision or to de-escalate
care because of poor prognosis
74
MDM: Risk ofSignificant Complications, Morbidity, &/or Mortality
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.
The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.
75
Determining MDM
Reminder: Two of the three elements in the table must be met or exceeded 76
Corresponding E/M Code
Level of MDM # of Diagnosisor Mgmt Options
Amount or Complexity of Data Reviewed
Risk of Complications,Morbidity, or Mortality
99241-9924299201-9920299212
Straightforward Minimal(1)
Minimal or None(0-1)
Minimal(1)
992439920399213
Low Complexity Limited(2)
Limited(2)
Low(2)
992449920499214
Moderate Complexity
Multiple(3)
Moderate(3)
Moderate(3)
992459920599215
High Complexity Extensive(4)
Extensive(4)
High(4)
Medical Necessity
Supported in the documentation of: Chief Complaint/presenting problem
why the patient presents for services
Relevant exam components pertinent to chief complaint and flow to medical decision making
Medical decision making establishing a working diagnosis and
corresponding treatment plan that addresses the chief complaint
77
Validation Process
Purpose, Scope, Approach
78
Purpose, Scope, ApproachPurpose
To prevent possible legal & financial implications
To maintain/promote
Compliance Detection
Correction
Prevention
Verification
Comparison79
Purpose, Scope, Approach
Scope Determine whether you will perform a retrospective vs
prospective review Determine the number of charts per provider
Recommended: 10 – 20 encounters Determine a reasonable time frame you will select from Determine your focus
Example: E/M full claim review, focused review Select charts
Random: Select every 5th or 10th chart Targeted: only 99214s & 99215s
80
ApproachPresent results in a professional and educational
mannerProvide providers the opportunity to review and study
the results
Review and discuss results with provider one-on-one
Approach your meeting with the provider as a learning opportunity for both of you
Discuss documentation improvement opportunities
81
Purpose, Scope, Approach
Purpose, Scope, Approach
Monitor and Track Results
Work at correcting problems identified
Establish an on-going reporting and feedback system
Record error rates and trends in documentation
Example: not documenting a thorough history or not recording a valid chief complaint, invalid signatures
Document and respond to systematic issues/concerns uncovered during the review or your discussions
Address over coding to minimize potential pay back
Address under coding to maximize potential payments82
Remember…
Accept the Fact that No Tool Can Replace A Provider In Determining Medical Necessity
Communicate
Timely
Concisely
In terms in which providers can relate83
In the World of Electronic Health Record
EHR Concerns- Functionality, Templating, Cloning, etc.
84
Coding Aspects of the EHRs Is an electronic health record (EHR) a
great way to capture coding information?
How does your EHR capture coding information?
Does your EHR code for you?Is it accurate?
85
Is an EHR a great way to capture coding information?
Yes, information is legible, easily accessible, regardless of documentation location; information is recorded for years to come.
No, nothing is fool proof. If providers do not use the system as
intended, it may become a compliance issue
Vendors/IT are not always familiar with rules/regulations
86
How does your EHR Capture Coding Information?
History and Exam are relatively easy to abstract from EHRs
Text boxes
Check off boxes
Free text
Areas of weaknesses in most EHRs are the most subjective areas of the SOAP:
History of present illness
Medical decision making
How is Medical Decision Making quantified? 87
Does your EHR code for you?Is it Accurate?
Which Guidelines are used - 1995 vs. 1997?
Do you have the ability to modify the requirements?
Does the EHR program suggest changing documentation to support the higher levels of code?
88
EHR Coding Functionality
Providers need to understand the concepts of coding to use an EHR to its fullest coding capabilities
Elimination of non-compliant coding functionality
89
Medical Necessity Challenges
» Unlike EHRs, paper records provide an overall sense of an authentic entry:
» Diagnosis may help if the qualifying descriptors are present (e.g., critical nature of the patient’s condition, life-threatening)
» Data ordered and treatment options give a reasonable insight into the provider’s impression of the acuity of the patient’s illness.Example:
» “Return prn” indicative of a low MDM
» Hospitalization, surgery and complex evaluations indicate moderate to high MDM
90
What is “Cloning?”NGS – Policy Educationhttps://ngsmedicare.com
Documentation is considered cloned when it is worded exactly like or similar to previous entries
It can also occur when the documentation is exactly the same from patient to patient:
All diabetic patients start to look alike (no individuality); or
Every patient visit looks alike (difficult to differentiate one visit from another)
91
NGS – Policy Educationhttps://ngsmedicare.com
Whether the documentation was the result of an Electronic Health Record, or the use of a pre-printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient.
Cloning may be the most worrisome aspect of an EHR
92
EHR Review Approach to Identify Cloning
Obtain 5-10 charts per provider; at least 3-4 from same patient, in sequence
Interpret patterns in documentation to identify potential cloning
Note concerns for quality and liability
93
Cloning / Templating
94
Overview / Introduction to
Scribes
95
Guidelines for “Scribe”
Providers using the services of a “scribe” must adhere to the E/M Documentation Guidelines, but in addition:
Medical record must indicate the name of the person who is “acting as a scribe for Dr. X”
Provider is expected to deliver the service and is still responsible for the medical record
Provider must authenticate the medical record confirming that the note is accurate
96
Overview / Introduction to
Incident-to Billing
97
Incident-to BillingMedicare Internet-Only Manual (IOM) 100-02 Chapter 15, Section 60
CMS allows services of certain nonphysician practitioners to be billed as incident-to a physician’s professional services
NGS: Under Medicare Part B, “incident-to” provisions apply in an office setting only. There is no incident-to billing in a facility under Part B. (Only POS=11)
98
Incident-to Billing Requirements The following requirements are associated with "incident to"
billing as defined by Medicare:
Physician-initiated course of treatment and continued active participation in the course of treatment and management
Direct supervision: physician is physically present in the same office suite
Both practitioners are employed by the same entity
Billed under the physician who is in the office that day, not necessarily the physician who initiated the plan of care
Incident-to billing does not apply to new patients or established patients with new problems 99
E/M DocumentationThe Impact of ICD-10-CM
100
ICD-10-CM – Sample Summary of Results
101
Determination Definition # of Claims %
Outpatient ClaimsAgree * No coding changes (up to 9 codes reviewed)
* Agree with claim or coding summary112 40 %
Additional code(s) supported
* Medical record documentation supported additional ICD-10-CM code(s); or* Reporting of additional ICD-10-CM code(s) was required based on the official coding guidelines.
44 16 %
Incorrect code(s) * Medical record documentation supported different ICD-10-CM code(s) compared to the code(s) reported* Documentation to support a diagnosis code was not provided
87 30 %
Both:* Additional code(s) supported and* Incorrect code(s) reported
40 14 %
Total # of claims 283
ICD-10-CM Simple Documentation Tips
When Applicable, remember to document:
Acuity Acute, Chronic, Acute on Chronic
Severity Mild, Moderate, Severe
Laterality Right, Left, Bilateral
Cause & Effect Due to, With, Secondary to, Complicated by, Caused by, etc.
Anatomic Site Specificity
102
Reference for Guidance Centers for Medicare and Medicaid Services (CMS)
Billing Rules
Bundling Edits
http://www.cms.hhs.gov/
National Government Services (NGS)
Local MAC
https://www.ngsmedicare.com/
103
104
Contact Information
Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMCManager
BAKER | NEWMAN | NOYES LLC
Toll Free: 1-800-244-7444
Fax: 207-774-1793 105