Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014.

Presented by:Presented by:

Karen Kvarfordt, RHIA, CCS-P, CCDSKaren Kvarfordt, RHIA, CCS-P, CCDS

President, DiagnosisPlus, Inc.President, DiagnosisPlus, Inc.

20142014

Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history.

Assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring his/her health over time.

““If it isn’t documented, it didn’t happen”!If it isn’t documented, it didn’t happen”!

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The reason the patient presented to see the physician/provider.

Complete details of the information provided by the patient and by the evaluation of the patient.

The results of diagnostic, consultative, and/or therapeutic services provided to the patient.

The assessment of the patient conditions. The plan for the care of the patient, including advice

from other physician specialists. Other services, procedures and supplies provided to

the patient. The time spent with the patient, if counseling or

coordinating care was provided.

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The style and form of medical documentation depends on the provider. However, it is important that any reader of the medical record be able to understand the service rendered and medical necessity for the service.

The medical documentation must be legiblemust be legible and understandable for all providers who care for the patient. If the handwriting of the physician cannot be read, Medicare auditors, as well as other payers, consider the service as not billablenot billable.

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Is the reason for the patient encounter documented in the medical record? Is the Chief Complaint documented by the physician? Is the diagnosis documented to the highest specificity?

Does the medical record clearly explain the medical necessity of the level of E&M service, diagnostic and therapeutic procedures, support services and supplies provided?

Is the assessment of the patient’s condition apparent in the medical record?

Medical record should tell the patient story!

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Documentation guidelines in the Evaluation and Management Services Guide also indicate that the documentation should be able to validate where the services were rendered and that the services were medically necessary and appropriate.

The ICD-9-CM & CPT codes reported on the UB (facility) & 1500 (professional) should be supported by the documentation in the medical record.

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The history areas and medical decision making areas frequently suffer from lack of detail. It is common to see the words “Patient here for f/uPatient here for f/u” as the chief complaint and the HPI. This is insufficient as is “Patient here to establish Patient here to establish MDMD.”

With decision making, the notations “continuecontinue present medspresent meds” and “f/u 3 monthsf/u 3 months” tells nothing of the problem(s), the status of the problem, and the treatment or management of the problem.

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E&M services refer to visits and consultations furnished by physicians and/or providers.

Billing for a patient visit requires the selection of a CPT code that best represents the level of E&M service provided. Five (5) CPT codes that may be selected to bill

for office or other outpatient visits for a “newnew” patient (99201 – 9920599201 – 99205) and…

Five (5) CPT codes for an “establishedestablished” patient (99211 – 9921599211 – 99215).

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9920199201 – Usually the presenting problem(s) are self-limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Problem focused historyProblem focused examinationStraightforward medical decision

making

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9920299202 – Usually the presenting problem(s) are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Expanded problem focused historyExpanded problem examinationStraightforward medical decision

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9920399203 – Usually the presenting problem(s) are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Detailed historyDetailed examinationMedical decision making of low

complexity

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9920499204 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Comprehensive historyComprehensive examinationMedical decision making of moderate

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9920599205 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Comprehensive historyComprehensive examinationMedical decision making of high

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To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is ‘new’ or already ‘established’.

CPT 2012 Revised Definitions: NewNew - “A new patient is one who has not

received any professional services from the physician or another physician of the exact same specialty and subspecialty who belong to the same group practice within the past three years”.

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EstablishedEstablished – “An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years”.

ExceptionException! Patients seen in the Emergency RoomEmergency Room do not have the distinction of ‘new’ vs. ‘established’.

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ER providers use following CPT codes: 9928199281

Problem focused history & examination Straightforward MDM Usually presenting problem(s) are self limited or

minor. 9928299282

Expanded problem focused history & examination Low complexity MDM Usually presenting problem(s) are of low to moderate

complexity 9928399283

Expanded problem focused history & examination Moderate complexity MDM Presenting problem(s) are of moderate severity

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9928499284 Detailed history and examination MDM of moderate complexity Usually the presenting problem(s) are of high

severity, and require urgent eval by the physician but do not pose an immediate significant threat to life/physiological function

9928599285 Comprehensive history & exam and MDM of

high complexity High severity and pose an immediate

significant threat to life/physiological function

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19951995 Documentation GuidelinesGeneral multi-system exam (7 body areas or 12 body systems)

Problem Focused = 1Expanded Problem Focused = 2-4

Detailed = 5-7Comprehensive = 8 or more

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19971997 Documentation GuidelinesMulti-system exam or one of ten

individualized single system examsGet ‘credit’ for documentation of 3

or more chronic conditions History and Medical Decision Making

are the same for 1995 & 1997 CMS – Use whichever set of results is

most in the physicians’ favor.However, you can’t mix & match!

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The three key components of E&M services are:HistoryPhysical ExaminationMedical Decision Making

Please note that just because the E&M level is dependent on two or three key components, performance & documentation of one component, ie, examination, at the highest level doesdoes notnot necessarily mean that the encounter in its entirety qualifies for the highest level of E&M.

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Chief Complaint – Each note must always include a chief complaint even if the chief complaint describes that the patient is presenting for follow-up of a previous problem, the reason for the visit must be clear as in “Patient presenting for f/u ofPatient presenting for f/u of uncontrolled hypertensionuncontrolled hypertension.”

Usually stated in the patient’s own words. Sometimes referred to as “presenting

problem.” Example: Patient complains of upset

stomach, aching joints, or fever.

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Information that is given by the patientpatient to the physician

The history consists of 3 partsHistory of Present Illness (HPI)Review of Systems (ROS)Past, Family, Social History (PFSH)

Remember! The Chief Complaint Chief Complaint and the HPIHPI must be documented by the physician.

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TYPE OF HISTORY

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

REVIEW OF SYSTEMS

PAST, FAMILY, AND/OR SOCIAL

HISTORY

Problem Focused

Required Brief N/A N/A

Expanded Problem Focused

Required Brief Problem Pertinent

N/A

Detailed Required Extended Extended Pertinent

Comprehensive

Required Extended Complete Complete

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History of Present IllnessHistory of Present Illness – Includes information described by the patient about the current condition including:

Location – refers to the location of the problem/symptoms – left lower quadrant; left leg; right arm; etc.Severity – severity of the presenting problem – mild, severe; increasing; resolving, etc.Timing – the interval of the pain or suffering – every night; constant; comes and goes; intermittent, etc.Modifying Factors – how is the pain symptom modified – relieved by standing erect; better after taking aspirin; walking makes pain worse; etc.Quality – descriptive adjective – dull; sharp; aching; stinging; throbbing, etc.Duration – how long the patient has had the symptoms – two days; since last visit; since this morning, etc.Context – describes how the symptoms began or occurred – after the auto accident; after eating out at a restaurant; when I sit down; etc.Associated Signs and Symptoms – these are significant signs/symptoms that the patient feels are related to/part of their injury or illness – dizziness with nausea; swelling with injury; double vision with headache, etc.

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Alternate HPI Documentation of three chronic illnesses

Must be related to chief complaint Status of each condition must be documented

Example Chief Complaint (CC)

Follow-up of HTN & Lower Extremity Edema HPI –

(1)(1) Patient states that home BP readings have been 130/80 – 145/85 with Diovan. (2)(2) Patient states legs are not as swollen at end of day. (3)(3) She states that headaches are less frequent and severe. (4)(4) She has also been able to lose some weight and has more energy.

BriefBrief HPI consists of 1 to 3 elements of the HPI Extended Extended HPI consists of at least 4 elements of

the HPI or the status of at least 3 chronic or inactive conditions

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Review of SystemsReview of Systems – Includes the patient’s “inventory” of signs and/or symptoms. These are most often answers to questions asked by the provider in order to establish a working diagnosis. Systems are: Constitutional – weight loss, fever, chills, malaise, etc. Ear, nose throat, and mouth – hearing loss, sinusitis, sore throat, oral

cavities, etc. Gastrointestinal – nausea, vomiting, diarrhea, constipation, ulcer, etc. Integumentary – skin rashes, moles, dryness, lumps, pigmentation, etc. Endocrine – polyuria, polydipsia, cold-heat intolerance, diabetes, etc. Genitourinary – hematuria, nocturia, menopause, incontinence, etc. Hematologic/Lymphatic – anemia, bruising, bleeding, lymph node

enlargement, etc. Eyes – diplopia, blurred vision, glasses, etc. Cardiovascular – chest pain or pressure, palpitations, murmur,

hypertension, etc. Musculoskeletal – arthritis, joint stiffness, swelling, myalgias, gout, etc. Neurologic – dizziness, syncope, seizures, vertigo, weakness, tremor, etc. Allergic/Immunologic – allergies to medicine, food, etc./hepatitis, HIV,

etc. Respiratory – cough, wheezing, asthma, etc. Psychiatric – depression, agitation, panic-anxiety, memory disturbance,

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The Review of Systems should be pertinent to the presenting problem – All pertinent positive and negatives should be documented. If all systems are reviewed, after the pertinent systems are documented, the statement “all other systems have been reviewed all other systems have been reviewed and are negativeand are negative” will be appropriate for a complete review of systems. If a separate form is used for the Review of Systems, it

should be dated and initialed by the provider with pertinent comments noted. This can be referred to by documenting “Review of Systems as noted on face sheet dated __ __Review of Systems as noted on face sheet dated __ __ ____ ____ has been reviewed with the following changeshas been reviewed with the following changes”.”.

But be careful in using this statement! It is not necessary But be careful in using this statement! It is not necessary to have a complete ROS for a minor problem such as a to have a complete ROS for a minor problem such as a sprained ankle or sinusitis. Right?sprained ankle or sinusitis. Right?

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Problem PertinentProblem PertinentInquiries about the system directly

related to the problem identified in the HPI.

The patient’s positive responses and pertinent negatives for the system related to the problem should be documented

In the following example, one system – the ear- is reviewed: Chief Complaint: Earache ROS: Positive for left ear pain. Denies dizziness,

tinnitus, fullness or headache30

Extended/Expanded ProblemExtended/Expanded Problem Inquiries about the system directly related to

the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

Patient’s positive responses and pertinent negatives for two to nine systems should be documented.

In the following example, two systems – cardiovascular and respiratory- are reviewed:

Chief Complaint: Follow-up visit in office after cardiac cath. Patient states “I feel great.”

ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of the left leg.

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CompleteComplete Inquiries about the system(s) directly related to the problem(s)

identified in the HPI plusplus all additional (minimum of 10) body systems.

At least 10 organ systems must be reviewed with positive systems or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating “all other systems are negative” is permissible. In the following example, 10 signs & symptoms are reviewed:

Chief Complaint: Patient complains of “fainting spell.” ROS:

Constitutional: weight stable, + fatigue Eyes: + loss of peripheral vision Ear, Nose, Mouth, Throat: no complaints Cardiovascular: + palpitations; denies chest pain, calf pain, pressure or edema Respiratory: + shortness of breath on exertion Gastrointestinal: appetite good, denies heartburn, + episodes of nausea Urinary: denies incontinence, frequency, urgency, nocturia Skin: + clammy, moist skin Neurological: + fainting; denies numbness, tingling and/or tremors Psychiatric: denies memory loss or depression. Mood pleasant.

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Past, Family & Social HistoryPast, Family & Social History May also be documented by “Refer to history on face Refer to history on face

sheet dated __ __ ____ with the following changessheet dated __ __ ____ with the following changes:” Past Medical History – includes adult & childhood

illnesses or trauma, vaccinations & screenings, past surgical history, past & current medications, allergies.

Family History – includes parents, siblings, children, genetic disease of the family or other family history.

Social History – Information about the patient’s habits and circumstances – smoking, alcohol, drug use; sexual orientation, marital status, living arrangements, occupation, education, religion, recent travel.

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History is unobtainable:Patient is unconscious, mentally ill, unable to

speak, intoxicated, etc.No other source is available.

Document the reason why the patient is unable to communicate and also that no other source is available, if applicable.

Physician is given credit for PFSH if unable to obtain from the patient.

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Key Components of Physical ExamShould be pertinent to the presenting presenting

problemproblem, i.e. if an established patient is in for follow-up of allergic rhinitis, a head to toe exam is not necessary.

Should never, ever be copied forward from a previous visit.

Care should be taken when using a check off form with “Normal” – not just go down the line √ off systems!

Some auditors consider “WNLWNL” as “WWe NNever LLooked.

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TYPE OF EXAMINATION DESCRIPTION

Problem Focused Include performance and documentation of 1-5 elements identified by a bullet in 1 or more organ system(s) or body area(s).

Expanded Problem Focused Include performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).

Detailed Include at least 6 organ systems or body areas. For each system/area selected, performance & documentation of at least 2 elements identified by a bullet is expected. May include performance & documentaiton of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.

Comprehensive 1997: Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected.

1995: 8 organ systems must be examined. If body areas are examines and counted, they must be over and above the 8 organ systems.

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The 10 single organ system examinations are:CardiovascularEar, Nose, Mouth and ThroatEyesGenitourinary (male & female)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicalPsychiatricRespiratorySkin

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Specific abnormal and relevant negative findings of the exam of the affected or symptomatic body area(s) or organ system(s) should be documented.

A notation of “abnormal” withoutwithout elaboration is insufficient.

Brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

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Number of diagnosis(es) or management options:All known diagnoses that are being treated or

affect treatmentUndiagnosed conditions that are being

evaluatedTreatments being used, considered or plannedPlays the ‘primary’ role in determining the

correct level of service

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If a diagnostic service is ordered, planned, scheduled or performed at the time of the E&M visit, the type of service should be documented.

Review of labs or any diagnostic tests should be documented.

“WBC elevated” or “chest x-ray unremarkable” is acceptable. The review may be documented by initialing & dating the report that contains the test results.

Decision to obtain medical records or history from someone other than the patient must be documented.

“Old records reviewed” or “additional history obtained from the family” without further elaboration is not sufficient – no credit should be given.

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Risk of significant complications, morbidity, and mortality is based on the risks associated with: Presenting problem(s) or number of

diagnoses and/or risk of complications (Chief Complaint)

Diagnostic procedures orderedPossible management options

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(S)ubjectiveChief Complaint – Each note must always include a chief complaint.

History of Present IllnessReview of SystemsPast Medical, Family and Social History

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Physical Examination – Second of the three key components for evaluation and management is documented by the provider.

Amount and Complexity of DataReview of tests, records, independent review of tracings, specimens, etc.

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Number of diagnoses: The following should be considered:All known diagnoses that are being treated or affect treatment

Undiagnosed conditions that are being evaluated

Risk of complications and/or morbidity or mortality

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Treatment Options:Prescription drug managementDiagnostic testsIV FluidsSurgeriesDecision not to resuscitateReturn to OfficeReferral to another physicianPhysical, Occupational, Speech Therapy

Over the Counter Drugs45

Used in selecting an E&M code only when Counseling and/or Coordination of care represents more than 50% more than 50% of the time spent face-to-face (outpatient) or bedside and on the floor or unit with the patient or family (inpatient).

Both time elements – total length of time for the visit and total length of time involved in Counseling and/or Coordination of care – as well as the nature of the counseling and/or coordination of care must be documented must be documented explicitlyexplicitly in the medical record.

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CPT codes 99354-99357 are used when a physician provides prolonged services involving direct (face-to-face) patient contact beyondbeyond the usual service in either the inpatient or outpatient setting.

Reported in addition to E&M level. Report the total duration of the face-to-

face time spent even if not continuous.

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Bill the first hour with CPT 99354, 99356 Each additional 30 minutes with CPT

99355, 99357 Can only be reported ‘once’ per day Less than 30 minutes is included in the

E&M level Example:

Physician performed a visit that met the definition of visit code 99213 & the total duration of the direct face-to-face services (including the visit) was 65 minutes.Physician bills E&M 99213 and 1 unit of CPT

99354.48

Initial Hospital Care99221 (low severity – 30 minutes)99222 (moderate severity – 50 minutes)99223 (high severity – 70 minutes)

Subsequent Hospital Care99231 (Stable, recovering or improving – 15 minutes at bedside)99232 (Responding inadequately/developed minor complication – 25 min)99233 (Unstable/developed significant complication or new problem – 35

min)

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Documentation does not always include the total time spent performing the discharge day management functionReview of the medical recordCompletion of discharge summary

9923899238Less than 30 minutes

9923999239More than 30 minutes

CPT Default: If time is not documented, then the lesser of

the two is billed, i.e., 99238.

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Requires ‘direct personal management’ from a physician, the absence of which ‘would likely result in sudden, clinically significant or life-threatening deterioration’ of the patient.

Examples:Acute allergic reaction(s)GI bleedSubdural/subarachnoid hemorrhageAMIRespiratory distress/failure

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Critical Care is a ‘time’ driven CPT code. Does not require constant bedside

attendance. Reviewing ancillary studies Discussions with nursing staff, physicians, family

members & documentation of these interventions in the medical record

Billable procedure include (but not limited to):Endotracheal intubationCPRChest tube placementCVP line insertionsEKG interpretation

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Physician(s) MUSTMUST document critical care for the encounter in the record.

State the time spent providing critical care in minutes: 99291 = 30-74 documented minutes 99292 = Each additional 30+ documented

minutes

The HPI & ROS guidelines are not required for Critical Care, however, documentation does need to support medical necessity for the high level of service.

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If it is NOT documented, If it is NOT documented, it did NOT happen!it did NOT happen!

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Karen Kvarfordt, RHIA, CCS-P, CCDSKaren Kvarfordt, RHIA, CCS-P, CCDS

President, DiagnosisPlus, Inc.President, DiagnosisPlus, Inc.

PO Box 486PO Box 486

Pocatello, ID 83294Pocatello, ID 83294

(208) 221-5486(208) 221-5486

Fax: (360) 234-7590Fax: (360) 234-7590

[email protected]@live.com

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