Guide to Documentation and Medical Coding 2017

Transcription

1 Guide to Documentation and Medical Coding 2017 Office of Compliance 933 Bradbury SE, Suite 3053 Albuquerque, NM Phone: Fax:

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3 ii Table of Contents INTRODUCTION... V CHAPTER 1 TEACHING PHYSICIANS... 1 WHEN AM I A TEACHING PHYSICIAN?... 1 RESIDENTS AND FELLOWS... 1 MEDICAL STUDENTS AND DOCUMENTATION... 2 NON-PHYSICIAN PROVIDERS (NPPS)... 3 TEACHING PHYSICIAN DOCUMENTATION... 3 CMS RULES AND TEMPLATES FOR EVALUATION AND MANAGEMENT (E/M) SERVICES... 5 E/M SERVICES IN AN OUTPATIENT PRIMARY CARE EXCEPTION SITE TEACHING PHYSICIAN ATTESTATIONS CHAPTER 2 ICD CHAPTER 3 CPT PROCEDURES PROCEDURE CODING MEDICAL NECESSITY BUNDLING/UNBUNDLING CORRECT CODING INITIATIVE PHYSICAL PRESENCE DOCUMENTATION INCIDENT TO SERVICES SPLIT/SHARED VISITS OBSERVATION VISITS OBSERVATION FLOWSHEET CHAPTER 4 EVALUATION AND MANAGEMENT SERVICES NEW VS. ESTABLISHED INITIAL VS. SUBSEQUENT TIME-BASED E/M CODES AVERAGE INTRASERVICE TIME... 58

4 CONSULTATION VS. TRANSFER OF CARE E/M KEY COMPONENTS HISTORY OF PRESENT ILLNESS REVIEW OF SYSTEMS PAST, FAMILY, SOCIAL HISTORY PHYSICAL EXAMINATION MEDICAL DECISION MAKING COUNSELING AND COORDINATION OF CARE CHAPTER 5 SURGICAL PROCEDURES CHAPTER 6 ANESTHESIA CHAPTER 7 MODIFIERS CHAPTER 8 COMPLETING THE CHARGE DOCUMENT CHAPTER 9 DOCUMENTATION COMPLETION APPENDIX A SINGLE ORGAN SYSTEM PHYSICAL EXAM CRITERIA APPENDIX B EVALUATION AND MANAGEMENT CODE SELECTION TABLES APPENDIX C - CERNER PROCESS INSTRUCTIONAL SITES iii

5 This guide is intended to be a tool to assist providers with documentation requirements. If you have any thoughts on how to make this tool more user-friendly or beneficial, please send your comments and suggestions to the Compliance Coordinator Edition Volume II iv

6 INTRODUCTION Concise but complete documentation of medical and surgical care is an extremely complex process. Consequently, compliance has developed this manual as a reference guide to provide information and clarification for physicians and other qualified healthcare providers on the following: 1. Documentation requirements unique to teaching physicians; 2. Selecting the first-listed (primary) and other diagnoses for coding visits; 3. Documenting the appropriate level of Evaluation and Management services; and 4. Substantiating other types of procedures. Compliance has a dedicated Compliance Educator with primary responsibility for developing and enhancing education. The Compliance Educator is available to perform seminars as well as group or one-on-one educational sessions for faculty, residents, and advanced practice clinicians (both professional and facility). Providers are encouraged to direct any questions or requests for training to the Compliance Educator at JOMartinez@unmmg.org. v

7 Other resources for information about teaching physician rules and specific documentation requirements may be found at: (Novitas Solutions, New Mexico s Medicare Administrative Contractor (MAC)) (Association of American Medical Colleges) (Centers for Medicare & Medicaid Services) vi

8 The intent of this manual is to offer guidance and suggestions, but is not intended as a substitute for legal advice. vii

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10 CHAPTER 1 Teaching Physicians DEFINITION A teaching physician is a physician (other than a resident) who involves residents (including interns and fellows in Graduate Medical Education programs) in the care of his or her patients. WHEN AM I A TEACHING PHYSICIAN? You are assuming the role of a teaching physician during any episode of care in which a resident participates. This may include: (1) Services provided partly by you and partly by the resident; (2) Care provided jointly by you and the resident; (3) Care provided by the resident in an outpatient primary care exception setting under your direction. If you see the patient by yourself and no part of the service is provided by a resident in conjunction with your services, you are NOT functioning as a teaching physician for that episode of care. RESIDENTS and FELLOWS Residents are individuals participating in an approved graduate medical education (GME) program approved for purposes of direct GME payments to a hospital. Interns are included in this definition. 1

11 For the purposes of billing, care must be taken to interpret the term Fellow correctly. If this term is being used to identify physicians who are in accredited fellowship programs for which payment is received by the hospital via the Medicare cost report, these individuals are categorized the same as residents for billing purposes. If, however, the term Fellow is being used to designate junior faculty who are not part of an accredited fellowship program, they may be able to bill under their own provider numbers. MEDICAL STUDENTS AND DOCUMENTATION Medical students are often present during patient care encounters. Any contribution and participation of a medical student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident. Their documentation of certain portions of the patient s history (review of systems and/or past/family/social history) may be used by the teaching physician for billing as long as he/she indicates review and confirmation or supplementation. The teaching physician may NOT refer to a student s documentation of history of present illness, physical exam findings, or medical decision making in the resident s or teaching physician s personal note. If the medical student documents Evaluation & Management (E/M) services, the resident/ teaching physician must verify and re-document the history of present illness as well as perform and re-document the physical exam and medical decision making activities. 2

12 NOTE: UNM policy does not allow medical students to act as scribes for residents or teaching physicians in documenting other portions of evaluation and management services. Fellow = resident Intern = resident Medical student does not = resident NON-PHYSICIAN PROVIDERS (NPPs) Certified Nurse Practitioners, Physician Assistants, Certified Registered Nurse Anesthetists, Certified Nurse Midwives, and certain other categories of non-physician providers are able to bill under their own provider numbers for services that fall under the scope of their licensure by the State of New Mexico. UNMMG bills for non-physician providers who are UNM employees, while UH bills for most of its own non-physician employees. Non-physician providers may not serve as teaching physicians for residents, and may not use documentation by students in their own disciplines to support their billing. (For split/shared visits, see Chapter 3, p.47). TEACHING PHYSICIAN DOCUMENTATION Documentation is written/dictated notes recorded in the patient s medical records by a resident, and/or teaching physician, or others as outlined in specific situations regarding the service furnished. Documentation may be dictated and transcribed, hand-written, or computer-generated. 3

13 Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR (b), documentation must identify, at a minimum, the service furnished, whether the teaching physician was physically present, and the participation of the teaching physician in providing the service. In the context of an electronic medical record, the term macro means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. It is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a password protected system. In addition to the teaching physician s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. NOTE: It is insufficient documentation if both the resident and the teaching physician use macros only. Payment for physician services furnished in teaching settings is made only if the services are: Personally furnished by a physician who is not a resident; or 4

14 Furnished by a resident where a teaching physician was physically present during the critical or key portions of the service; or Certain evaluation and management services furnished by a resident under the conditions governing the primary care exception (see pg.12). The Medicare Claims Processing Manual, Chapter 12, Section 100 defines conditions for payment of Teaching Physician Services. This section also defines physical presence as the teaching physician is located in the same room (or partitioned or curtained area if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service. CMS RULES AND TEMPLATES FOR EVALUATION AND MANAGEMENT (E/M) SERVICES For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association s Current Procedural Terminology (CPT) and any applicable documentation guidelines. For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following: 5

15 They performed the service or were physically present during the key or critical portions of the service when performed by the resident; and The participation of the teaching physician in the management of the patient. When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and teaching physician if the teaching physician refers to the resident s note and indicates presence, participation, and agreement. The combined entries must support the medical necessity of the service. All entries and addendums must include the date of service and date of entry. NOTE: Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician for E/M services. CMS EXAMPLES OF UNACCEPTABLE DOCUMENTATION FOR E/M SERVICES Agree with above. Rounded, reviewed, agree. Discussed with resident. Agree. Seen and agree. Patient seen and evaluated. Legible countersignature or identity alone. Such documentation is not acceptable because it is not possible to determine whether the teaching 6

16 physician was present, evaluated the patient, and/or had any involvement with the plan of care. SCENARIOS Following are four (4) common scenarios for teaching physicians providing E/M services followed by minimally acceptable documentation for each scenario: Scenario #1 The teaching physician personally performs all the required elements of an E/M service without the resident present. In this scenario, the resident may or may not have performed the E/M service independently. In the absence of a note by a resident, the teaching physician must document as he or she would document an E/M service in a nonteaching setting. Where a resident has written notes, the teaching physician s note must reference the resident s note. The teaching physician must document that he or she performed the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient. For payment, the composite of the teaching physician s entry and the resident s entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician. 7

17 MINIMALLY ACCEPTABLE DOCUMENTATION FOR: Scenario #1: (with resident notes) Admitting Note: I saw and evaluated the patient on the day of service. I discussed the case with the resident. I reviewed the resident s note and agree with the findings and plan as documented in the resident s note. Follow-up Visit: Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident s note. Follow-up Visit: Hospital Day #5. I saw and examined the patient. I agree with the resident s note except the heart murmur is louder, so I will obtain an echo to evaluate. (Without Resident notes in this scenario) The teaching physician must document as he/she would document an E/M service in a non-teaching setting. Scenario #2 The resident performs the elements required for an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service. In this case, the teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the 8

18 service and that he or she was directly involved in the management of the patient. The teaching physician s note should reference agreement with the resident s note or add additional information. For payment, the composite of the teaching physician s entry and the resident s entry together must support the medical necessity and the level of the service billed by the teaching physician. MINIMALLY ACCEPTABLE DOCUMENTATION FOR: Scenario #2 Initial or Follow-up Visit: On (date seen by teaching physician) I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident s note. Follow-up Visit: On (date seen by teaching physician) I saw the patient with the resident and agree with the resident s findings and plan. Scenario #3 The resident performs some or all of the required elements of the service in the absence of the teaching physician and documents his/her service. The teaching physician independently performs the key portions of the service with or without the resident present and, as appropriate, discusses the 9

19 case with the resident. In this instance, the teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient. The teaching physician s note should reference the resident s note. For payment, the composite of the teaching physician s entry and the resident s entry together must support the medical necessity and the level of the service billed by the teaching physician. Scenario #4: When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day: 10 a. The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident s note in lieu of redocumenting the history of present illness, exam, medical decision-making, review of systems and/or past/family/social history provided that the patient s condition has not changed, and the teaching physician agrees with the resident s note. b. The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient s

20 condition and course at the time the patient is seen personally by the teaching physician. c. The teaching physician s bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision making regardless of whether the combination of the teaching physician s and resident s documentation satisfies criteria for a higher level of service. For payment, the composite of the teaching physician s entry and the resident s entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician. MINIMALLY ACCEPTABLE DOCUMENTATION FOR: Scenarios #3 and #4 Initial Visit: On (date seen by teaching physician) I saw and evaluated the patient. I reviewed the resident s note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs. Initial or Follow-Up Visit: I saw and evaluated the patient. Discussed with resident and agree with resident s findings and plan as documented in the resident s notes. 11

21 Follow-up Visit: See resident s notes for details. I saw and evaluated the patient and agree with the resident s finding and plans as written. Follow-up Visit: I saw and evaluated the patient. Agree with resident s note but lower extremities are weaker, now 3/5; MRI of L/S spine today. E/M SERVICES IN AN OUTPATIENT PRIMARY CARE EXCEPTION SITE The teaching physician physical presence requirement is waived for residency programs in designated primary care specialties (Medicine, Family Medicine, Pediatrics and OB/GYN) in certain outpatient sites. This rule applies only to: E/M services ( ) and ( ) Initial Preventive Physical Examination (IPPE) (G0402) Initial Annual Wellness Visit (G0438) Subsequent Annual Wellness Visit (G0439) It does not apply to procedures, preventive medicine services (other than the three Medicare services listed above), or any other services. 12

22 For primary care exception services, the following conditions must be met: 1. The resident must have completed 6 months or more of residency training. 2. The teaching physician must: Direct the care from such proximity as to constitute immediate availability. Not direct the care of more than 4 residents at one time. Have no other responsibilities at the time. Have primary medical responsibility for patients cared for by the resident. Ensure that care furnished is reasonable and necessary. Review with the resident, during or immediately after each visit, the patient s medical history, physical exam, diagnosis, and record of tests and therapies. Document the extent of his or her own participation in the review and direction of the services furnished to the patient. SEE TEACHING PHYSICIAN ATTESTATION EXAMPLES FOR PRIMARY CARE EXCEPTION ENCOUNTERS ON PAGE

23 PRIMARY CARE EXCEPTION (PCE) CLINICS The following UH clinics have been designated as Primary Care Exception sites: 1209 University Clinic Atrisco Heritage Family & Community CTH Pediatric Well Child Clinic Family Practice Clinic General Pediatric Clinic Gynecology Clinic Maternal Fetal Medicine Clinic Maternity & Infant Gynecology Clinic Maternity & Infant Obstetric Clinic Milagro Clinic (SE Heights and Family Practice) North Valley Clinic (4 th Street Clinic) Northeast Heights Clinic Obstetrics Clinic Pediatric Primary Care Walk-in Clinic Senior Health Center Southeast Heights Clinic Southwest Mesa Center for Family & Community Health SRMC Primary Health Westside Clinic Young Children s Health Center 14

24 TEACHING PHYSICIAN ATTESTATIONS Compliance provides examples of Teaching Physician Attestations and required documentation for the following other categories of services. Primary Care Exception E/M Encounters Minor Procedures Endoscopy Surgical, High-risk and Complex Procedures Interpretation of Diagnostic Radiology, Pathology, and other Ancillary Tests Interventional Procedures Anesthesiology These examples can be found in Guidelines posted in PowerChart under Resources, Document Management, Clinical Documentation Guidelines under Compliance Resources. There are several Guidelines specifically related to Teaching Physician Attestations. 15

25 PRIMARY CARE EXCEPTION ATTESTATIONS While the patient was in clinic or immediately following the patient leaving the clinic, I reviewed the patient s medical history, the resident s findings on physical examination, the patient s diagnosis and treatment plan with the resident and agree with the information above. "Case discussed with Dr. Resident at time of visit. Patient presents a diagnosis of. I agree/ revise with treatment with. I agree/ revise with diagnosis of and plan of care." "Patient case reviewed/discussed with Dr. Resident at time of visit. Given a history of, exam and assessment show (state test findings of significance). I agree/revise plan of care as." 16

26 MINOR PROCEDURES Medicare defines minor procedures as those taking 5 minutes or less to complete and that involve relatively little decision making once the need for the procedure is determined. The Teaching Physician (TP) must be present for the entire procedure in order to bill for the service. The documentation may be provided by the TP or the resident. Counter signature must be done by the teaching physician. A minor procedure includes: 1) exam of the site; 2) informed consent; 3) procedure itself; and 4) follow-up plan and instructions. It is not appropriate to bill for a clinic visit in addition to the procedure if there is no significant, separately identifiable service above and beyond these. Documentation: The procedure should be completely described, and the note should be physically separated from other documentation for the same date of service (separate paragraph labeled procedure ). Teaching Physician Attestation Examples: Procedure performed with (by) Dr. TP. Dr. TP was present during the entire procedure. Dr. TP observed me perform this procedure. 17

27 ENDOSCOPY For Medicare patients, the TP must be present with the patient for the entire viewing portion of the endoscopy, including the insertion and removal of the scope. Viewing via a monitor in another room does not meet the teaching physician physical presence requirement. Performing concurrent endoscopic procedures is also not acceptable. As with minor procedures, the TP presence must be explicitly stated in the documentation, which may be made by a resident and should be countersigned by the TP, or made personally by the TP. I was present during the entire viewing portion of this endoscopy from insertion of the scope until removal of scope. SURGICAL, HIGH RISK AND COMPLEX PROCEDURES The teaching physician is responsible for the preoperative, operative, and post-operative care of the patient. The teaching physician determines the key or critical portions and: Must be present with the patient during all critical and key portions of a single procedure or two overlapping procedures. 18

28 Does not need to be present during opening or closing of a procedure unless these activities are considered by the surgeon to be key or critical parts of the procedure. The choice of whether to be scrubbed in to the case is up to the teaching physician. Must be immediately available to furnish services during the entire procedure, including the opening and closing, if necessary. Immediately available has been defined as able to return to the OR if necessary. Must not become involved in a second overlapping procedure until all key portions of the first procedure have been completed. Must arrange for another physician to be immediately available to intervene in the first case if the TP leaves the OR to become involved in the key portion of an overlapping procedure. May not bill for any case if involved in three concurrent procedures. Must personally perform or observe the resident perform the post-op visits considered by the TP to be key visits during the post-op period. 19

29 OVERLAPPING SURGICAL PROCEDURES In order to bill for two overlapping surgeries, the teaching surgeon must be present during the key portions of both operations. Therefore, the key portions may not take place at the same time. When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure. No billing is allowed for more than two concurrent procedures. The TP must personally document: key portion for each of overlapping procedures performed using patient-specific terms to describe personal service provided/observed; he/she personally or another physician was immediately available to return to either procedure in the event of complications; name of other surgeon(s) immediately available for the closing of the first case once the TP begins the key portion of a second case. I was present and I participated during the critical and key portions of this procedure and Dr. Jones was immediately available during the remainder of the procedure. I interpret the critical and key portions of this procedure to have been. I was present and I participated during the entire procedure except for the opening and/or closing, which overlapped with the opening and/or closing of another case. The overlapping portions were non- 20

30 key portions, and I remained immediately available. I was present and I participated during the entire procedure except for the opening and/or closing, which overlapped with the key portion of another case. I interpret the key portion(s) of this case to be. Dr. Jones was assigned to be immediately available during the overlapping portions of these cases. INTERPRETATION OF DIAGNOSTIC RADIOLOGY, PATHOLOGY, AND OTHER DIAGNOSTIC ANCILLARY TESTS The report may be dictated by either the TP or the resident. If the resident prepares and signs the report, the TP must indicate in an attestation to the report that he/she has personally reviewed the film or tracing and the resident s interpretation and either agrees with it or edits the findings. The Teaching Physician must perform or review the interpretation. If the teaching physician s signature is the only signature on the interpretation, it may be assumed that he/she is indicating they personally performed the interpretation. A simple countersignature by the TP of the resident s interpretation is insufficient documentation. If a medical student dictates the report, the teaching physician s documentation would need to indicate contemporaneous presence with the medical student during the performance of the procedure, not just review of the images/slides. 21

31 I have reviewed the film and agree with the findings in this report. I have reviewed the results of this test and revise the findings as stated in the report above as follows. Films or tracings and interpretation reviewed and verified by/with Dr. TP. I have reviewed all diagnostic slides and have edited the gross and/or microscopic portion of this report as part of pathologic assessment and final diagnosis. INTERVENTIONAL PROCEDURES Includes interventional radiologic and cardiologic supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and transesophageal echocardiography. The TP must be present with the patient during all critical and key portions and remain available to furnish services for the duration of the entire procedure. Per CMS, the terms key and critical are interchangeable and it is the Teaching Physician who determines what portions of the procedure are key and critical. Key portions of two procedures performed may not overlap. Observation via a monitor from another location is not acceptable to satisfy the presence requirement. If the CPT code description includes both supervision and interpretation, the TP must be present with the patient for the entire radiological 22

32 portion of the interventional procedure, as both portions are being paid. If the TP is present for the entire procedure, documentation may be made by the TP or a resident. If TP is involved in overlapping cases, the documentation must be done personally by the TP. Entire procedure performed in the presence of/with Dr. TP and interpretation verified by same. No overlapping procedures. I was present for the key surgical and imaging portions of the procedure, performed with (by) Dr. Resident. The key portion(s) of this procedure was (were). I (or another TP) was immediately available thereafter through the completion of the procedure. I have reviewed the films and confirm (or revise) the interpretation of Dr. Resident as. SINGLE SURGICAL OR OTHER COMPLEX PROCEDURE When the TP performs a single surgical or other complex procedure, the report may be dictated by the TP or by a resident on his/her behalf. I was present to observe Dr. Resident perform the critical and key portion of this procedure. NOTE: For anesthesia services see Chapter 6 and for anesthesia modifiers see Chapter 7. 23

33 24 CHAPTER 2 ICD-10 (Effective October 1, 2015) Diagnostic Coding and Reporting Guidelines for Outpatient Services These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits. Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under Conventions Used in the Tabular List. Section I.B. contains general guidelines that apply to the entire classification. Section I.C. contains chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Information about the correct sequence to use in finding a code is also described in Section I. The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other. Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that: The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to

34 inpatients in acute, short-term, long-term care and psychiatric hospitals. Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. A. Selection of first-listed condition In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors. 1. Outpatient Surgery When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis 25

35 (reason for the encounter), even if the surgery is not performed due to a contraindication. 2. Observation Stay When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. B. Codes from A00.0 through T88.9, Z00-Z99 The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. C. Accurate reporting of ICD-10-CM diagnosis codes 26 For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the

36 patient s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these. D. Codes that describe symptoms and signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99) contain many, but not all codes for symptoms. E. Encounters for circumstances other than a disease or injury ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00-Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. See Section I.C.21. Factors influencing health status and contact with health services. 27

37 F. Level of Detail in Coding 1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. 2. Use of full number of characters required for a code A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable. G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the firstlisted diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. 28

38 H. Uncertain diagnosis Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, longterm care and psychiatric hospitals. I. Chronic diseases Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. 29

39 K. Patients receiving diagnostic services only For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/ radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. 30 Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

40 L. Patients receiving therapeutic services only For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second. M. Patients receiving preoperative evaluations only For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation. 31

41 N. Ambulatory surgery For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive. O. Routine outpatient prenatal visits See Section I.C.15. Routine outpatient prenatal visits. P. Encounters for general medical examinations with abnormal findings The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first-listed diagnosis. A secondary code for the abnormal finding should also be coded. Q. Encounters for routine health screenings 32 See ICD-10-CM Official Guidelines for Coding and Reporting FY 2015, Section I.C.21. Factors

42 influencing health status and contact with health services, Screening. ADDITIONAL ICD-10-CM INFORMATION CMS provides the following information regarding ICD-10. The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets on October 1, ICD-10 consists of two parts: ICD-10-CM diagnosis coding which is for use in all U.S. health care settings. ICD-10-PCS inpatient procedure coding which is for use in U.S. hospital settings. Guidance is found in the Official Coding and Reporting Guidelines Section of ICD-10-CM Manual. The change to ICD-10 does not affect CPT coding for outpatient procedures. ICD-10-CM Code Structure ICD-10 diagnosis codes have between 3 and 7 characters. The first three characters are the heading of a category of codes that may be further subdivided by the use of any or all of the 4 th, 5 th, and 6 th characters. Digits 4-6 provide greater detail of etiology, anatomical site, and severity. A code using only the first three digits is to be used only if it is not further subdivided. 33

43 A code is invalid if it has not been coded to the full number of characters required. This does not mean that all ICD-10 codes must have 7 characters. The 7 th character is only used in certain chapters to provide data about the characteristic of the encounter. Examples of where the 7 th character can be used include injuries and fractures, as illustrated in the following tables: Value A D S Injuries and External Causes Description Initial encounter Subsequent encounter Sequela Value A B D G K P S Fractures Description Initial encounter for closed fracture Initial encounter for open fracture Subsequent encounter for fracture with routine healing Subsequent encounter for fracture with delayed healing Subsequent encounter for fracture with nonunion Subsequent encounter for fracture with malunion Sequela A dummy placeholder of X is used with certain codes to allow for future expansion and/or to fill out empty characters when a code contains fewer than 34

44 6 characters and a 7 th character applies. When a placeholder character applies, it must be used in order for the code to be considered valid. Below are specific examples of ICD-10 diagnosis codes. The use of combination codes, increased specificity, and the X placeholder is illustrated: Code Description Combination Codes Atherosclerotic heart disease of native I coronary artery with unstable angina pectoris Increased Specificity Non-displaced fracture of base of neck S72.044G of right femur, subsequent encounter for closed fracture with delayed healing Laterality Malignant neoplasm of lower-outer C quadrant of right female breast Malignant neoplasm of lower-outer C quadrant of left female breast X Placeholder Primary open-angle glaucoma, H40.11X2 moderate stage Significant improvements over ICD-9-CM: Expanded to include health-related conditions and to provide greater specificity at the 6 th character level and with a 7 th character extension. Expanded injury codes 35

45 Creation of combination diagnosis symptom codes Addition of up to seven-character alphanumeric sub-classifications Addition of laterality in code assignment Below is a summary of the Chapters found in the ICD-10-CM Tabular List of Diseases and Injuries. Chapter 36 Code Range Est. # of Codes 1 A00-B99 1,056 Description Certain infectious and parasitic diseases 2 C00-D49 1,620 Neoplasms 3 D50-D E00-E F01-F G00-G H00-H59 2,452 8 H60-H I00-I99 1, J00-J K00-K Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine, nutritional and metabolic diseases Mental, Behavioral and Neurodevelopmental disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system

46 12 L00-L M00-M99 6, N00-N Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system and connective tissue Diseases of the genitourinary system Chapter Code Range Est. # of Codes 15 O00-O9A 2, P00-P Q00-Q R00-R S00-T88 39, V00-Y99 6, Z00-Z99 1,178 Description Pregnancy, childbirth and the Puerperium Certain conditions originating in the perinatal period Congenital malformations, deformations and chromosomal abnormalities Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Injury, poisoning and certain other consequences of external causes External causes of morbidity Factors influencing health status and contact with health services 37

47 DOCUMENTATION IMPROVEMENT With ICD-10-CM becoming effective 10/1/15, a behavioral change in documentation habits for most providers will be necessary. The definition of a Principle Diagnosis will not change. It is: The condition established after study to be chiefly responsible for the admission of the patient to the hospital. Specific and ample documentation in the medical record as well as describing the diagnoses as accurately as possible is critical for coders to report the correct diagnosis codes. These are the elements to keep in mind when documenting: Specificity Be specific in all these areas! Site of disease, condition, injury Acuity, type, stage Laterality Severity of Illness Common Manifestations Infectious Agents Secondary Diagnoses Complications and Co-morbidities Chronic Conditions 38

48 Underlying Conditions Procedure Details Timing (onset, worsening, etc.) COMPONENTS OF A DIAGNOSIS A complete diagnostic statement includes site, etiology, and laterality where appropriate. All elements must be present to code accurately. If an external cause is known for cases involving injury or poisoning, it should also be documented. Examples: 1) Incomplete: Fracture, toe Complete: Closed fracture, L 5 th metatarsal, hit by rock 2) Incomplete: Metastatic CA lung (Is it metastatic to the lung or from the lung?) Complete: Lung mets, unknown primary 3) Incomplete: Drug OD Complete: Coma due to methadone OD 39

49 FIRST-LISTED DIAGNOSIS (Formerly Primary Diagnosis ) Official definition: The diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided, to the highest degree of certainty. The first-listed diagnosis may be an: -Existing condition -New condition diagnosed during visit -Current injury -Sign or symptom/abnormal test result -Late effect -Routine exam -Other: follow-up, aftercare, observation UNACCEPTABLE FOR DIAGNOSIS CODING Diagnoses documented as probable, likely, possible, suspected, r/o (rule/out), questionable are not acceptable for physician coding and billing. Diagnosis must be documented to the highest level of certainty. Use symptoms that are prompting the r/o. If r/o diagnosis is given, the coders must look for symptoms to code from your documentation, which in turn causes a delay in the claims processing. Example: Not Acceptable: r/o UTI Acceptable: frequency, dysuria, r/o UTI 40

50 WHAT GETS CODED AND WHAT DOESN T? In the following examples, the conditions that would be coded (under the guidelines) are underlined: Abdominal pain due to gastritis. Abdominal pain, probably due to gastritis. Abdominal pain with nausea and vomiting. Abdominal pain, r/o ileus. These examples show how coding is affected by a few simple changes to wording in diagnosis documentation. 41

51 CHAPTER 3 CPT Procedures PROCEDURE CODING CPT (Current Procedural Terminology), published annually by the AMA, is used to define virtually all procedures. All CPT codes consist of 5 digits. Two digit modifiers may be added to procedure codes to indicate special circumstances affecting the status of the procedure code (See Chapter 7 Modifiers). It is critical that physicians familiarize themselves with the wording used in CPT to describe various procedures to ensure that their documentation matches the description for the code(s) being billed. Evaluation and Management (E/M) codes represent a small number of codes but a large portion of procedures performed. These are the visit codes. (See Chapter 4 Evaluation and Management Services) MEDICAL NECESSITY According to the Social Security Act, Section 1862(a)(1)(A), Medicare will not cover services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicare states Medical necessity is the overarching criterion for payment in addition to the 42

52 individual requirements of a CPT code. 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. 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. The American Medical Association (AMA) defines medically necessary services as Health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician or other health care provider. Medical necessity for procedures is demonstrated through the use of documented diagnoses and/or symptoms, which warrant the provision of the service. If more than one service is provided, include diagnostic documentation for each and be explicit and detailed. 43

53 BUNDLING/UNBUNDLING Bundling refers to the use of a single CPT code to cover all portions of an individual operative episode. For example: the code for appendectomy also includes the laparotomy opening, any incidental visualization or exploration, the closure, and normal uncomplicated follow-up care. Unbundling services results in claim denials and possible sanctions by payers. CORRECT CODING INITIATIVE This CMS-initiated program is now used by many other payers; its goal is to prevent unbundling and detect inappropriate use of other code pairs such as those that might be mutually exclusive or contradictory. A significant number of edits under this program are for what is known as standards of medical/surgical practice, which means that the payer has determined that only the most comprehensive code of the pair will be paid. There are approximately 100,000 code pairs in this editing system. PHYSICAL PRESENCE DOCUMENTATION In order to bill for procedures the teaching physician must be physically present during the procedures, with limited exceptions. The specific documentation requirements for physical presence during each type of procedure can be found in Chapter 1. 44

54 CPT vs. REIMBURSEMENT The presence of a code in the CPT book that describes a particular procedure does not mean that any or all payers will reimburse for that service. INCIDENT TO SERVICES Medicare Benefits Policy Manual, Chapter 15, Section 60 states Incident to a physician s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness. Services that are performed by employees of a facility, instead of the physician, are not billable by the physician. Incident to billing is not allowed in UH facilities because they are hospital based. However, any outpatient clinics that are not considered a UH facility and fit the incident to guidelines may bill. The requirements are: 1. There must be a physician service to which the ancillary services are incidental. This means the physician must have seen the patient first to determine a course of treatment to be provided by the NPP. New patient visits or established patient visits involving a new condition cannot be billed as incident to and would have to be billed under the NPP s name and provider number. 45

55 2. Services and supplies must be medically necessary and be such that would typically be provided in a doctor s office to be treated as incident to. 3. Services are furnished under the physician s direct supervision meaning the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the NPP performs the services. The physician does not have to be in the same room. 4. The NPP can bill incident to a physician if the physician is an employee, leased employee, or independent contractor of the legal entity billing and receiving payment for the services or supplies. 5. Documentation must clearly link the services of the NPP to the services of the supervising physician. Evidence of this would be signature and credentials of the NPP along with the cosignature and credentials of the supervising physician as well as documentation in the medical record indicating the physician s involvement in the patient s care. 46

56 SPLIT/SHARED VISITS By definition the term split/shared E/M service, is used by CMS to describe an encounter where the service is provided partially by a non-physician provider (NPP) and partially by a physician. In this circumstance, the encounter may be billed under the physician s provider number, resulting in higher reimbursement than if it was billed by the NPP. Reference Medicare Claims Processing Manual, Chapter 12, Section Split/Shared concept applies only to evaluation and management services. For the purposes of this policy, an NPP is a nurse practitioner, clinical nurse specialist, certified nurse midwife, or a physician assistant. Services provided must be within the scope of practice for an NPP in New Mexico. General points to remember: Split/Shared services are allowed in the hospital setting only (inpatient, outpatient, and emergency room). Procedures, consultations, critical care, and skilled nursing facility E/Ms are NOT eligible for billing under the split/shared concept. There must be a documented face-to-face encounter with the patient by the physician and the NPP. If the physician does not see the patient face-to-face, the service cannot be billed by the physician. In these cases, the NPP may bill for his or her personally provided services. 47

57 Policy applies only to NPP s not nurses, medical students, residents, or other employees. Medical necessity is the overarching criteria for payment in addition to the individual requirements for a CPT code. Physician and NPP do not have to see the patient at the same time but must see the patient on the same calendar date even if at same or separate times of the day. Documentation must support the level of service reported; each provider must document his/her service as soon as practicable after the service in order to maintain an accurate record. Under CMS rules for Split/Shared, visits may be billed either by the NPP or the Physician (not both) using the combination of their individually documented services to select and support the level of E/M reported. (See examples below.) Documentation from the Attending Physician should demonstrate at least one of three elements of an E/M encounter (HPI, Exam, or MDM) to show that a face-to-face encounter occurred. Simply agreeing with the NPP is not acceptable. Both the Attending Physician and the NPP must clearly identify services they each provide, document and sign the work they perform. Physician should reference the NPP note used in combination with the physician s note to support the service billed. The School of Medicine (SOM) and UNMMG employed NPPs can bill Split/Shared visits under the physician s name and provider number in 48

58 accordance with CMS rules. The UH employed NPPs cannot unless a lease agreement exists between UH and UNMMG. UNM Hospital Bylaws do not allow NPP admitting privileges. There must be an Attending statement for billing purposes. Examples of Acceptable Physician Documentation I personally saw and examined patient. Discussed with NPP and agree with NPP s findings and plan as documented in the CRNP s note. Patient s wife was present at bedside. Patient reports that he is beginning to feel better but continues to have abdominal pain. Examination shows abdominal tenderness. CT revealed no evidence of intestinal obstruction. Continue IV and medications. I personally saw and examined the patient and found. Key portions were reviewed and I agree with the diagnosis documented by (name of NPP), whose note is available for further detail. 49

59 Examples of Unacceptable Physician Documentation I saw the patient with the NPP and agree with findings. Seen and agree. I evaluated the patient. Discussed with CRNA/PA and agree with NPP s findings and plan as documented in the CRNA/PA s note. No comment at all or counter-signature only. OBSERVATION VISITS Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. CMS Publication , Medicare Claims Processing Manual, Chapter 12, Section In other words, CMS is saying observation services are provided to a patient who is in an outpatient status who is requiring monitoring or additional therapeutic services in order to determine if the patient should be admitted as an inpatient or discharged to home. (See Observation Flowsheet page 54) 50

60 To place a patient in observation a written order is required and should clearly state what service is being requested (i.e., Place in Observation ). There should be no misunderstanding whether the patient is being admitted to inpatient or to observation. Observation services must be ordered by a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. Coders should look for a written order (required) that clearly states the physician is requesting observation status (i.e. Admit to Observation or Place in Observation, etc.). Observation orders must be patient specific. General standing orders are not acceptable and observation should never be ordered for standard recovery time following a surgical procedure. Even though physicians report observation services on a per day basis, observation care is reported in hours by the hospital. Reporting observation time starts when the patient s medical record indicates the time that the patient was placed in a bed in accordance with a physician s order. Observation services should not be billed for time which is being spent on diagnostic or therapeutic services or procedures. Hospitals should calculate the procedure time and deduct it from the total number of hours of observation. Time ends when the clinical or medical interventions have been completed, including follow-up care furnished by hospital staff and physicians that may take place after a physician 51

61 has ordered the patient be released or admitted as an inpatient. For Medicare, the hours must equal or exceed 8 hours. Observation is usually less than 24 hours. Only in rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. For a physician to bill observation care codes, there must be a medical observation record for the patient which contains dated and timed physician s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This observation record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter. The physician must satisfy the E/M documentation guidelines for furnishing observation care. In addition to meeting the documentation requirements for history, examination, and medical decision making, the medical record should also include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care. OBSERVATION CODING SCENARIOS When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range , shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, should not be reported for this scenario. 52

62 When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from CPT code range , and CPT observation care discharge CPT code On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code ( ) for the first day of observation care, a subsequent observation care code ( ) for the second day of observation care, and an observation care discharge CPT code for the observation care on the discharge date. When observation care continues beyond 3 days, the physician shall report a subsequent observation care code ( ) for each day between the first day of observation care and the discharge date. When a patient receives observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date, Observation or Inpatient Care Services (Including Admission and Discharge Services) from CPT code range shall be reported. The observation discharge, CPT code 99217, cannot be reported for this scenario. 53

63 Observation Flowsheet Can patient s condition be evaluated/treated within an observation timeframe and/or is rapid improvement anticipated within an observation? No Inpatient admission is appropriate. Yes Yes Observation is appropriate. Does the patient/s condition require further treatment/ evaluation that can only be provided in a hospital setting (i.e., inpatient or observation)? START Unsure No Alternate level of care is appropriate (outpatient, home healthcare, etc. Additional time is needed to determine if inpatient admission is medically necessary; Observation is appropriate. 54

64 CHAPTER 4 Evaluation and Management Services Evaluation and management services consist primarily of physician face-to-face visits (or other qualified health care practitioners) in all settings (clinic, hospital, nursing home, etc.). Knowledge of several basic E/M concepts is necessary for thorough understanding and application of the codes. NEW vs. ESTABLISHED A new patient is someone who has not received any professional services from the physician/ qualified health care professional or another provider of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. UNMMG is considered a single group under this definition. The specialty of the provider for billing purposes is determined by how he/she is enrolled with the payer. An established patient is one who has received professional services from the physician/qualified health care professional or another provider of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. (See Decision Chart p. 56) When NPPs are working with physicians, they should be considered as working in the exact same specialty and exact same subspecialties as the physician. 55

65 56

66 INITIAL vs. SUBSEQUENT This concept applies to: Hospital inpatient services Observation Normal newborn care Pediatric and neonatal critical care Nursing facility services The first visit by the attending/teaching physician for this episode of care is the initial visit, while all others during this stay are subsequent. TIME-BASED E/M CODES Some evaluation and management services are defined strictly by time unit (day, hour, etc.). Hospital discharge day management Critical care Nursing facility discharge day management Prolonged services Physician standby Care plan oversight Preventive medicine counseling For these services, documentation must include mention of the time spent (total time or start and end times) of the teaching physician. 57

67 AVERAGE INTRASERVICE TIME Many E/M codes have been assigned an average intraservice time as part of their definitions. These averages are based on observation by the AMA that is predictive of the work involved in E/M services. Intraservice times are defined as: Face-to-face time: Outpatient Time that the attending physician spends face-toface with the patient and/or family. This includes the time in which the physician performs tasks such as obtaining a history, performing an examination, and counseling the patient. Unit/floor time: Inpatient Unit/floor time includes the time that the physician is present on the patient s hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient s chart, examines the patient, writes notes, and communicates with other professionals and the patient s family. Service Intraservice Time Levels I II III IV V Office/outpatient, new Office/outpatient, established Outpatient consults Inpatient, initial Inpatient, subsequent Inpatient consult Home visit, new Home visit, established

68 CONSULTATION vs. TRANSFER OF CARE A Consultation is a service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician. Five essential components (the five R s) must be present in the patient s medical record in order to bill for a consultation: 1. Reason. Medically necessary reason for a consultation. The requesting physician must document the reason. 2. Request. A written or verbal request for the consultation. This can be in the form of an order, a consultation request form, or simply documentation by the consultant such as I was asked by Dr. Jones to see this patient for consultation of. 3. Review. The consultant s history, examination and medical decision-making, and any other services performed or ordered. 4. Report. A written report of the findings to the requesting physician. In a setting where the requesting physician and the consultant share the same medical record, this communication can be in the chart; it does not have to be a formal letter. 5. Return. Shows a transfer of care has not occurred and that the consultant is sending the patient back to the referring physician. 59

69 The consultant may initiate diagnostic and/or therapeutic services. Only one consultation should be reported by a consultant per inpatient admission; the subsequent hospital or nursing home care codes should be used by the consultant for services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem. On the outpatient side, a follow-up visit to the consultant would be reported using the appropriate codes for established patient office visits. If an additional request for an opinion or advice regarding the same or a new problem is received from another physician or other appropriate source, the office consultation code may be used again. Beware of orders to evaluate and follow or the statement I will follow the patient with you. Each consultation must stand on its own in meeting the five basic criteria: reason, request, review, report, return. Consultations initiated by the patient or family and not requested by a physician should be coded using the office visit codes. Referral = The patient is referred with the expectation that the receiving physician will take over the management of the condition in question. This is a referral, not a consult. Transfer of care = The process whereby a physician who is providing management for some or all of a patient s problems relinquishes this responsibility to another physician who explicitly 60

70 agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation, but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service. NOTE: As of January 1, 2010, CMS does not allow payments for consultations. However, other payers still allow payment for them. UNMMG will manage payer variances on the backend. Physicians should continue billing consults as previously done. 61

71 E/M KEY COMPONENTS Evaluation and Management services are comprised of seven (7) components which are used in defining the level of service. The first three (3) components are considered key components in selecting the level of E/M service, based on documentation of the level of intensity/complexity. 1) History 2) Examination 3) Medical decision-making 4) Counseling 5) Coordination of care 6) Nature of presenting problem 7) Time Scoring of the E/M level is based on individual scores for the key components, which are then aggregated into a single score for the encounter. A sample score sheet may be found at the end of this chapter. HISTORY The history portion of E/M services has four (4) subcomponents: Chief Complaint (CC) A concise statement describing the symptom, problem, condition, diagnosis, physicianrecommended return, or other factor that is the reason for the encounter, usually stated in the patient s own words. 62

72 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 has eight (8) elements that may be present: 1) Location: site 2) Quality: characteristic, sensation, or pattern 3) Severity: intensity or degree 4) Duration: length of time has existed 5) Timing: when the problem occurs 6) Context: circumstance surrounding the condition 7) Modifying factors: factors attempted that may relieve 8) Associated signs and symptoms: other problems/symptoms accompanying main problem Levels of HPI None Brief Extended 0 elements documented 1-3 elements documented or status of 1-2 chronic conditions 4 or more elements documented or the status of 3 chronic conditions Documenting the HPI The HPI may be documented only by the resident or the teaching physician. Medical student documentation of the HPI may not be used or referenced for billing purposes. 63

73 REVIEW OF SYSTEMS (ROS) An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. The Review of Systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options. Fourteen (14) systems are counted in the review of systems: 1. Constitutional 2. Eyes 3. Ears, nose, mouth, throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergy/Immunologic 64

74 Levels of ROS None reviewed Problem-pertinent 0 systems 1 system reviewed Extended 2 to 9 systems reviewed Complete 10+ systems reviewed Documenting the ROS The review of systems 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. If the review of systems is taken by the resident or attending physician, the patient s positive responses and pertinent negatives for each system must be individually reviewed and documented by the provider. For the remaining systems Novitas- Solutions, Inc. accepts the statement All other systems are negative. In the absence of this statement, at least ten systems must be individually documented to qualify for a Complete Review of Systems. 65

75 PAST, FAMILY, SOCIAL HISTORY (PFSH) Past History: The patient s past history including experiences with illnesses, operations, injuries, and treatments. Family History: The patient s family history including a review of medical events, diseases, and hereditary conditions that may place the patient at risk. The term "noncontributory" may be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem. Social History: The patient s social history including an age appropriate review of past and current activities. Levels of PFSH Pertinent Complete 1 history area documented 2 history areas documented: ER, established outpatient visit, established home, established domiciliary 3 history areas documented: new outpatient; new home; initial consult, initial observation; initial inpatient; and comprehensive nursing facility, assessments; new patient domiciliary care; and new home care patients 66

76 Documenting the PFSH PFSH may be documented by a physician, medical student, or ancillary staff. 67

77 FINAL LEVELING OF THE HISTORY There are four (4) levels of History based on the scores of the three components (HPI, ROS, PFSH): LEVEL Problemfocused Expanded problemfocused Detailed Comprehensive HPI/Chronic Conditions Brief 1-3 or status of 1-2 chronic conditions Brief 1-3 or status of 1-2 chronic conditions Extended 4 or more or status of 3 chronic conditions Extended 4 or more or status of 3 chronic conditions ROS None Pertinent 1 Extended 2-9 Complete 10+ PFSH None None Pertinent 1 Complete 2 or 3 How to score: Circle the levels previously scored for each component: HPI, ROS, and PFSH. Find the circle closest to the top of the grid, and draw a line from it to the level listed in the left column. The scoring is based on the lowest element. Example: If the review of systems is pertinent (1 system reviewed) then the level of history is expanded problem-focused. The overall scoring of the history will be used in the calculation of the final level for the episode of care. 68

78 CMS HISTORY DOCUMENTATION GUIDELINES 1. Best Practice: The CC, HPI, ROS, and PFSH should be listed as separate elements of history. Each element must stand on its own in order to be counted. 2. There is no need to re-record a ROS and/or PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting there has been no change in the information; and Noting the date and location of the earlier ROS and/or PFSH. 3. 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 and must be signed and dated by the teaching physician. 4. 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 obtaining a history. Otherwise, these elements cannot be counted. 69

79 PHYSICAL EXAMINATION The physical examination may be a general multisystem exam or a single organ system exam. The type and content of the exam are selected by the examining physician and are based upon clinical judgment, the patient s history, and the nature of the presenting problem. This section will cover the general multi-system exam. A link is provided in Appendix A for the criteria for the eleven (11) single organ system exams: 1. Cardiovascular 2. Ears, Nose, Mouth, and Throat 3. Eyes 4. Genitourinary (Female) 5. Genitourinary (Male) 6. Hematologic/Lymphatic/Immunologic 7. Musculoskeletal 8. Neurological 9. Psychiatric 10. Respiratory 11. Skin Documenting the Physical Exam (PE) The physical examination may be documented by a Resident or the Teaching Physician. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) must be documented. A notation of abnormal without elaboration is insufficient. 70

80 Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. A brief statement or notation indicating negative or normal is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). Leveling the Physical Examination Either exam criteria (1997 or 1995) may be used for leveling. There are four levels of physical examination, based on the number of exam elements documented in the patient s medical record. For the general multi-system exam the levels are: Problem-focused: (1997) 1-5 bullets (or) (1995) 1 organ system/body area Expanded Problem-focused: (1997) 6 or more bullets (or) (1995) 2-7 systems/areas Detailed: (1997) 12+ bullets from 2+ systems (or) (1995) 2-7 systems/areas extended exam of affected body area/organ system required Comprehensive: (1997) 9 systems with at least 2 bullets each General multi-system exam (or) Complete exam of a single organ system. (1995) Documentation guidelines state, The medical record for a general multi-system exam should include findings of 8+ of the 12 organ systems. 71

81 GENERAL MULTI-SYSTEM EXAMINATION Constitutional Measurement of any 3 of the following 7 vital signs: -sitting or standing blood pressure -supine blood pressure -pulse rate and regularity -respiration -temperature -height -weight General appearance of the patient (e.g., development, nutrition, body habitus, deformities, attention to grooming) Eyes Inspection of conjunctivae and lids Examination of pupils and irises (e.g., reaction to light and accommodation, size, and symmetry) Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages) 72

82 Ears, Nose, Mouth and Throat External inspection of ears and nose (e.g., overall appearance, scars, lesions, masses) Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (e.g., whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth, and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx Neck Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (e.g., enlargement, tenderness, mass) 73

83 Respiratory Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (e.g., dullness, flatness, hyperresonance) Palpation of chest (e.g., tactile fremitus) Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs) Cardiovascular Palpation of heart (e.g., location, size, thrills) Auscultation of heart with notation of abnormal sounds and murmurs Examination of: carotid arteries (e.g., pulse amplitude, bruits) abdominal aorta (e.g., size, bruits) femoral arteries (e.g., pulse amplitude, bruits) pedal pulses (e.g., pulse amplitude) extremities for edema and/or varicosities 74

84 Chest (Breasts) Inspection of breasts (e.g., symmetry, nipple discharge) Palpation of breasts and axillae (e.g., masses or lumps, tenderness) Gastrointestinal (Abdomen) Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum, and rectum including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated 75

85 Genitourinary Male Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity, tenderness) Female Pelvic examination (with or without specimen collection for smears and cultures) including: Examination of external genitalia (e.g., general appearance, hair distribution, lesions) and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Examination of urethra (e.g., masses, tenderness, scarring) Examination of bladder (e.g., fullness, masses, tenderness) Cervix (e.g., general appearance, lesions, discharge) Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) 76

86 Lymphatic Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other Musculoskeletal Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones, and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, crepitation, or contracture Assessment of stability with notation of any dislocation (luxation) subluxation or laxity Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic, with notation of any atrophy or abnormal movements 77

87 Skin Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic Test cranial nerves with notation of any deficit Examination of deep tendon reflexes with notation of any pathological reflexes (e.g., Babinski) Examination of sensation (e.g., by touch, pin vibration, proprioception) Psychiatric Description of patient s judgment and insight Brief assessment of mental status including: Orientation to time, place, and person Recent and remote memory Mood and affect (e.g., depression, anxiety, agitation) 78

88 MEDICAL DECISION MAKING Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: 1) the number of possible diagnoses; 2) the number of management options that must be considered; 3) the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and/or 4) the risk of significant complications, morbidity and/or mortality as well as comorbidities, associated with the patient s presenting problem(s), the diagnostic procedure(s), and/or the possible management options. Documenting the Medical Decision Making Number of diagnoses or Management Options 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. 79

89 Amount and/or complexity of data reviewed The amount and/or complexity of data to be reviewed are based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include: A decision to obtain and review old medical records and/or obtain history from sources other than the patient (increases the amount and complexity of data to be reviewed); Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test (indicates the complexity of data to be reviewed); and The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed). Risk of significant complications, morbidity, and/or mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories: Presenting problem(s); Diagnostic procedure(s); and Possible management options. 80

90 LEVELING MEDICAL DECISION MAKING Table 1 Number of Diagnoses or Treatment Options A B C D Problem(s) Status Number Points Result Self-limited or minor Est. problem (to examiner); stable, improved Est. problem (to examiner); worsening New problem (to examiner); no additional workup planned New problem (to examiner); additional workup planned TOTAL Multiply the number in columns B & C and enter the product in column D. Enter a total for column D. Bring total to line A in Final Result for Complexity (Table 4 below) Table 2 Amount and/or Complexity of Data Reviewed Reviewed Data Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care 2 provider Independent visualization of image, tracing or specimen itself (not simply review of report) 2 TOTAL Bring total to line C in Final Result for Complexity (Table 4 below) 81

91 Tables of Risk (Presenting Problem(s), Diagnostic Procedure(s) Ordered, Management Options Selected): Table 3a: Presenting Problem(s) Level of Presenting Problem(s) Risk One self-limited or minor problem, Minimal e.g., cold, insect bite, tinea corporis Two or more self-limited or minor problems One stable chronic illness, e.g., well Low controlled hypertension or non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness/injury, e.g., cystitis, allergic rhinitis, simple sprain One or more chronic illnesses w/mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, e.g., lump in breast Moderate Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis Acute complicated injury, e.g., head injury with brief loss of consciousness One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, High pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure Abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss Circle level of Presenting Problem 82

92 Tables of Risk (Presenting Problem(s), Diagnostic Procedure(s) Ordered, Management Options Selected): Table 3b: Diagnostic Procedure(s) Ordered Level of Diagnostic Procedure(s) Ordered Risk Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Minimal Urinalysis Ultrasound, e.g., echo KOH prep Physiologic tests not under stress, e.g., pulmonary function tests Non-cardiovascular imaging studies with contrast, e.g., barium enema Low Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Moderate Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram cardiac cath Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests High Diagnostic endoscopies with identified risk factors Discography Circle level of Diagnostic Procedure(s) Ordered 83

93 Tables of Risk (Presenting Problem(s), Diagnostic Procedure(s) Ordered, Management Options Selected): Table 3c: Management Options Selected Level of Management Options Selected Risk Rest Gargles Minimal Elastic bandages Superficial dressings Over-the-counter drugs Minor surgery with no identified risk factors Low Physical therapy Occupational therapy IV fluids without additives Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Moderate Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation Elective major surgery (open, percutaneous or endoscopic with identified risk factors) Emergency major surgery (open, percutaneous or endoscopic) High Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to deescalate care because of poor prognosis Circle level of Management Options Selected Enter highest level out of the 3a, 3b, or 3c Tables in Final Result for Complexity (Table 4) 84

94 Table 4: Final Medical Decision Making Score In the table below, circle the results from the three areas scored above: Diagnosis/Management Options, Diagnostic Data Reviewed, and Risk. (Tables 1, 2, 3a, 3b, or 3c) Type of Medical Decision Making Straightforward Complexity (SF) Low Complexity (L) Moderate Complexity (M) High Complexity (H) Diagnosis and/or Treatment Options Amount of Data Risk 1 1 Minimal 2 2 Low 3 3 Moderate 4 4 High The overall type of Medical Decision Making is determined by throwing out the lowest score and then using the level indicated by the lower of the two remaining scores. Example: If the scores are Diagnosis Options: 1; Data: 3; and Risk: Low, the final score for Complexity of Medical Decision Making would be Low (L). 85

95 CMS MEDICAL DECISION MAKING DOCUMENTATION GUIDELINES Number of Diagnoses or Management Options For a presenting problem with an established diagnosis, the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or b) 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 differential diagnoses or as possible, probable, or rule/out (R/O) diagnoses. The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, therapies, and medications. If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested. 86

96 Amount and/or Complexity of Data to be Reviewed If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, e.g. lab or x-ray, should be documented. The review of lab, radiology and/or other diagnostic tests should be documented. An entry in a progress note such as "WBC elevated" or "chest x-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results. A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. Relevant finding from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed or "additional history obtained from family without elaboration is insufficient. The results or discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented. The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented. 87

97 Risk of Significant Complications, Morbidity, and/or Mortality Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented. If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure (e.g., laparoscopy), should be documented. If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented. The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied. 88

98 FINAL LEVELING OF THE E/M SERVICE The final scoring of the evaluation and management service is based on the combined scoring of the key components: History, Physical Exam, Medical Decision Making. For some services, all three key components must meet the final level selected and, for some, only two of the three must meet that level. Neither CMS nor CPT dictates which key element must be present to meet that level. The following table defines these categories: NOTE: Volume of documentation is not the only criteria on which to base a level of service. Medical necessity is first and foremost in determining the level to bill; however, Medical Necessity and Medical Decision Making are two different issues. Medical Necessity involves documentation that the patient s condition actually needed the treatment (i.e., level of history, exam, etc.) for an E/M service. 3 key components required New Outpatient Initial Inpatient Initial Inpatient Consult Office Consults Observation Services ER Services Nursing Facilities New Home Care 2 key components required Established Outpatient Subsequent Inpatient Subsequent Nursing Facility Established Home Patient 89

99 Example of scoring for New Outpatient: E/M Code Hx PE MDM PF PF SF EPF EPF SF D D L C C M C C H For a new outpatient, all three key components must be at or above the selected level. In this case, the history was detailed and the physical exam was detailed but the documentation of medical decision making showed it to be straightforward. Thus, the final evaluation and management service level is a Scoring grids for other E/M services may be found at 90

100 COUNSELING AND COORDINATION OF CARE Two other components of evaluation and management services are Counseling and Coordination of Care. Counseling refers to discussion concerning: prognosis diagnostic results and recommended studies instructions for treatment and/or follow-up risks and benefits of treatment options importance of compliance with treatment plan risk factor reduction patient or family education Coordination of Care contact with other health care providers on behalf of the patient Note: Coordination of care provided on a day when there is no face-to-face contact with the patient is not part of an E/M service. This would be reported under Care Plan Oversight or Case Management codes. 91

101 SELECTION OF E/M CODE BASED ON COUNSELING AND COORDINATION OF CARE If Counseling and Coordination of Care constitute more than 50% of the time with the patient, the level of service may be selected based on time instead of the key components. Sufficient detail must be documented in the medical record to justify the code if time is the basis for selection. Documentation must include: Total visit time Time spent on counseling/coordination of care Details as to what was discussed Attending/mid-level time only (not resident/student time) EXAMPLE DOCUMENTATION A total of 15 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care. We discussed in depth the importance of primary prevention of coronary disease with aggressive treatment of high cholesterol. I also educated the patient about lifestyle modifications which may improve blood pressure. (Outpatient/Office, Established Patient = 99213) 92

102 93

103 DEFINITION 94 CHAPTER 5 Surgical Procedures Surgical procedures generally take place in an Operating Room (OR). However, OR can include settings such as catheter labs, procedure rooms, day surgery settings, etc. Minor procedures (as related to Teaching Physician Rules) are defined as those taking 5 minutes or less. See chapter 1 for requirements. Basic surgical procedure concepts are: TECHNIQUE: OPEN vs. CLOSED It is extremely important to document if some parts of the procedure are open and some are closed. Closed includes endoscopic/laparoscopic, percutaneous/needle, aspiration, brush, closed treatment of fractures. The coding of a given procedure for billing purposes may be based on the technique; complete documentation is imperative. SITE and LATERALITY Accurate coding depends on specificity of site and sometimes on laterality. Examples: reduction fx leg (incomplete) ORIF fx distal R tibia (complete) With the implementation of the ICD-10 coding system in October 2015, laterality will be part of the standard coding rubric.

104 EPONYMS When documenting eponymic procedures, it is advisable to include a description in case the eponym isn t listed in the coding book. SEPARATE PROCEDURE This designation in CPT means that the procedure should not be reported in addition to the code for the total procedure or service of which it is considered an integral component. GLOBAL SURGICAL PACKAGE Evaluation and management (E/M) services) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical); The operation itself; CPT surgical procedure codes include: The surgical procedure; Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia; Immediate postoperative care, including dictating operative notes and talking with the family and other physicians or other qualified health care professionals; Writing orders; 95

105 Evaluating the patient in the postanesthesia recovery area; Typical postoperative follow-up care. This is known as a global surgical package. All surgical procedures have a global period of 0, 10, or 90 days: 0 days = day of surgery only 10 days = day of surgery plus 10 follow-up days = 11 days total 90 days = day before surgery, day of surgery plus 90 follow-up days = 92 days total Additional care during the global period will be rejected for payment unless it is accounted for by use of a modifier indicating the circumstances that made additional care necessary. CRITICAL CARE BY SURGEON POST-OP Critical care services (CPT codes and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician are not included in the Global Surgical Package. NOTE: Seeing the patient in the ICU for wound check is not critical care. 96

106 CHAPTER 6 Anesthesia Charges for general, epidural, or monitored anesthesia care are generally calculated using a formula that combines: a) base units, based on the surgical procedure being performed; b) time units, based on 15-minute segments; c) additional units for special circumstances such as patient's age, emergency surgery, etc. The units are multiplied by a conversion factor specific to geographic locale in order to arrive at a reimbursement amount. Anesthesiologists may provide services: 1. Personally performed: Either a physician alone or TP with resident in a single case, the TP must be present during all critical (or key) portions of the procedure, including induction and emergence. 2. Medically Directed: Anesthesiologist is directing two, three, or four cases (no more than four concurrent cases) with residents or non-physician anesthetists (Certified Registered Nurse Anesthetists or Anesthesia Assistants). 3. Supervision: More than four concurrent cases. Concurrency is defined as an overlap in cases of one minute or more. Example on next page: 97

107 Example: Case A 08:05 to 13:25 Case B 10:40 to 11:30 Case C 13:25 to 14:50 Cases A and C are concurrent. Cases A and B are concurrent. Cases B and C are not concurrent with each other. It is not possible to perform a personally provided case and conduct a medically supervised case at the same time. Conditions for Payment Payment may be made for physician medical direction of one service or two through four concurrent services if each service meets the following criteria: For each patient, the physician 1. performs a pre-anesthetic examination and evaluation; 2. prescribes the anesthesia plan; 3. personally participates in the most demanding aspects of the anesthesia plan including, if applicable, induction and emergence; 4. ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual as defined in operating instructions; 98

108 5. monitors the course of anesthesia administration at frequent intervals; 6. remains physically present and available for immediate diagnosis and treatment of emergencies; and 7. provides indicated post-anesthesia care. Documentation Requirements The physician (or member of a group of physicians) must document in the patient's medical record that he or she performed the pre-anesthetic exam and evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence, where applicable. I was present for the induction, emergence, and key portion of the anesthesia service and immediately available throughout the duration of the service. 99

109 CHAPTER 7 Modifiers A modifier may be added to a CPT procedure code to indicate that a service or procedure has been altered by a specific circumstance but not changed in its basic definition or code. Use of modifiers may be important in indicating to payers why payment should be made for a specific service that might otherwise be denied. It is important to use modifiers with the correct category of CPT codes. Not all modifiers can be used on all codes. MODIFIERS VALID ONLY WITH E/M CODES -24 Unrelated E/M service by the same provider during a post-operative period Modifier -24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an E/M service unrelated to the problem requiring surgery. A diagnosis code unrelated to the diagnosis requiring surgery is needed. 100

110 E/M MODIFIERS (cont'd) -25 Significant, separately identifiable E/M service by the same provider on the same day as a procedure or other service Modifier -25 indicates that the patient s condition on a specific day required a significant, separately identifiable E/M service above and beyond the procedural service performed that day. The E/M service may be prompted by the condition which necessitated the procedure, thus a different diagnosis is not necessarily required. Procedures include: 1) examination of the site or area; 2) informed consent; 3) documentation of the procedure itself; 4) follow-up plan and instructions. This documentation is not considered separate from the procedure and it is not appropriate to charge a clinic visit if this is the only documentation present. The significant, separately identifiable documentation must stand on its own as an E/M service to be billable (must be unplanned). If the E/M service is on the day before or day of a surgical procedure with a 90-day global, and the E/M service resulted in the decision to perform the surgery, use a 57 modifier instead of a Mandated service Modifier -32 should be used if the provider is aware that the patient is being seen for a mandatory second or third opinion prior to a surgical procedure, or for other services mandated by a third party payer or regulatory requirement. 101

111 E/M MODIFIERS (cont'd) -57 Decision for surgery Modifier -57 is used with an Evaluation and management service that resulted in the initial decision to perform a major surgery. Used only with E/M services on the day before or the day of a surgical procedure with a 90-day global surgery period. -GE Service performed by a resident without the presence of a teaching physician under the primary care exception. Modifier GE is valid only with E/M codes to and to and HCPCS codes G0402, G0438 and G0439. Not valid with any other codes. (See Chapter 1 for primary care exception rules.) MORE OR LESS THAN NORMAL SERVICE PERFORMED -22 Increased procedural services When the service provided is greater than that typically required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure code number. May be used with any procedure code except E/M. Should not be used routinely. Requires submission of a report to support substantial additional work and the reason for the additional work in order to get increased reimbursement, to be submitted by coder. 102

112 MORE OR LESS THAN NORMAL SERVICE (Cont.) -52 Reduced services Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician s discretion. -53 Discontinued procedure Used to denote a surgical or diagnostic procedure terminated by the physician because of concerns about the procedure s impact on the patient s wellbeing. Used only if discontinued after anesthesia was administered. Do not use for elective cancellation of procedure prior to anesthesia. -54 Surgical care only Split care modifier. Use when the surgeon provides only the actual surgical procedure itself and does not provide any of the pre-operative or postoperative management, which is provided by another physician. For UNMMG providers, this modifier should only be used if the pre-op and/or post-op care is being done by providers from a different department or by providers outside UNM. -55 Post-operative management only Split care modifier. Use when one physician performed the postoperative management and another physician performed the surgical procedure. For UNMMG providers, this modifier should only be used if the surgical and/or pre-op care is being done by providers from another department, or from outside UNM. 103

113 MORE OR LESS THAN NORMAL SERVICE (Cont.) -56 Pre-operative management only Split care modifier. Use when one physician performed the pre-op management and another physician performed the surgical procedure. For UNMMG providers, use only if two different departments or one provider is outside UNM. SURGICAL SERVICES DURING GLOBAL PERIOD -58 Staged or related procedure or service by the same physician during the postoperative period. Use when a procedure during the 10 or 90 day surgical global period was a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. Do not use this modifier to report the treatment of a problem or complication that requires a return to the OR during the global period. See modifiers 79 or Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period Only used if the current procedure is related to the first and requires a return to the operating room (unplanned procedure following initial procedure). This could be due to a complication. Not used for a staged procedure (see modifier 58). 104

114 MORE OR LESS THAN NORMAL SERVICE (Cont.) -79 Unrelated procedure or service by the same physician during the postoperative period Used to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. In this instance it would be usual to have a different diagnosis than that for the original procedure. MODIFIERS FOR MULTIPLE PROCEDURES -50 Bilateral procedure Bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate procedure code and billing the code only once. The use of this modifier is only applicable to services/procedures performed on identical anatomic sites, aspects, or organs. It should not be used to describe procedures on both sides of the body but on only one organ, such as excision of skin lesions (the skin is considered a single organ). See modifier 59. Modifier -50 should not be used if the CPT code description specifically states the procedure is bilateral, or for procedures where the organ is considered to be midline, such as bladder, uterus, esophagus, and nasal septum. 105

115 MODIFIERS FOR MULTIPLE PROCEDURES (Cont.) -51 Multiple Procedures When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedures(s) or service(s) may be identified by appending the modifier -51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated add-on codes. -76 Repeat procedure by same physician Procedure repeated subsequent to the original procedure or service (general interpretation is on the same day). -77 Repeat procedure by another physician Procedure repeated subsequent to the original procedure or service (general interpretation is on the same day). -78 Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period Procedure performed during the postop period of the initial procedure (unplanned procedure following initial procedure), related to the first procedure and requires use of operating/procedure room. 106

116 MODIFIERS FOR MULTIPLE PROCEDURES (Cont.) -59 Distinct procedural service Indicates that a procedure is a different session or encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate area of injury, was distinct or independent from other services performed on the same day. This modifier is a modifier of last resort which should only be used if there is no other appropriate modifier that describes the situation. For example, if a bilateral procedure is done, it should be billed once with a modifier 50, rather than once with no modifier and once with a 59. Modifiers to Define Specific Subsets of Modifier -59 X{E,P,S,U} -XE Separate Encounter A service that is distinct because it occurred during a separate encounter. -XP Separate Practitioner A service that is distinct because it was performed by a different practitioner. -XS Separate Structure A service that is distinct because it was performed on a separate organ/structure. -XU Unusual Non-overlapping Service A service that is distinct because it does not overlap usual components of the main service. 107

117 MODIFIERS USED FOR TEACHING PHYSICIAN ENCOUNTERS -GE Service performed by a resident without the presence of a teaching physician under the primary care exception. Modifier GE is valid only with E/M codes to and to and HCPCS codes G0402, G0438 and G0439. Not valid with any other codes. (See Chapter 1 for primary care exception rules.) -GC This service has been performed in part by a resident under the direction of a teaching physician This modifier must be used any time a resident is involved in a billable service. NOTE: For E/M services and provided under the primary care exception, see modifier GE instead. MODIFIERS THAT IDENTIFY SURGEON/ PRACTITIONER PARTICIPATION -62 Two surgeons When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes for that procedure as long as both surgeons continue to work together as primary surgeons. If one of the surgeons acts as an assistant for any part of the procedure, see modifier

118 MODIFIERS THAT IDENTIFY SURGEON/ PRACTITIONER PARTICIPATION (Cont.) -66 Surgical team Used for highly complex procedure requiring the services of several physicians. Reports required for payment. All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing by report. -80 Assistant surgeon Used to identify surgical assistant. If the assistant is present for the entire procedure or a substantial portion of the procedure, the same procedure code is used, with a modifier 80 appended. -81 Minimum assistant surgeon Can be used if the assistant surgeon is only present for a small portion of the entire procedure. -82 Assistant surgeon when a qualified resident surgeon is not available This modifier is only to be used when there is a residency program in place but there is no qualified resident available in this specific case to serve as a surgical assistant. -AS Non-Physician Practitioners (NPPs) Assistant-at-Surgery To be used when a physician assistant, nurse practitioner, or clinical nurse specialist serves as surgical assistant. 109

119 MODIFIERS FOR IDENTIFYING PROFESSIONAL vs. TECHNICAL COMPONENTS OF A PROCEDURE -26 Professional Component Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier -26 to the usual procedure number. Note: This modifier must be reported in the first modifier field. -TC Technical Component Under certain circumstances a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure code number. Note: This modifier must be reported in the first modifier field. 110

120 MODIFIERS FOR IDENTIFYING ANATOMICAL SITES AND LATERALITY -LT Left Side (left side of body) -RT Right Side (right side of body) -E1 Upper left, eyelid -E2 Lower left, eyelid -E3 Upper right, eyelid -E4 Lower right, eyelid -F1 Left hand, second digit -F2 Left hand, third digit -F3 Left hand, fourth digit -F4 Left hand, fifth digit -F5 Right hand, thumb -F6 Right hand, second digit -F7 Right hand, third digit -F8 Right hand, fourth digit -F9 Right hand, fifth digit -FA Left hand, thumb 111

121 MODIFIERS FOR IDENTIFYING ANATOMICAL SITES AND LATERALITY (Cont.) -T1 Left foot, second digit -T2 Left foot, third digit -T3 Left foot, fourth digit -T4 Left foot, fifth digit -T5 Right foot, great toe -T6 Right foot, second digit -T7 Right foot, third digit -T8 Right foot, fourth digit -T9 Right foot, fifth digit -TA Left foot, great toe -LC Left circumflex coronary artery -LD Left anterior descending coronary artery -LM Left main coronary artery -RC Right coronary artery 112

122 MODIFIERS FOR ANESTHESIA SERVICES Anesthesia Modifiers: The following modifiers are used only for time-based anesthesia codes: -AA Anesthesia services performed personally by an anesthesiologist -AD Medical supervision by a physician: more than four concurrent anesthesia procedures -QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals -QS Monitored anesthesia services (MAC) -QX CRNA service with medical direction by a physician -QY Medical direction of one CRNA by an anesthesiologist -QZ CRNA service without medical direction by a physician -23 Unusual Anesthesia Occasionally a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier -23 to the procedure code of the basic service. 113

123 -47 Anesthesia by surgeon If a physician personally performs the regional or general anesthesia for a surgical procedure he/she also performs, this modifier is added to the surgical code and no anesthesia code is used. Does not apply to local anesthesia by surgeon. ANESTHESIA PHYSICAL STATUS MODIFIERS -P1 Physical Status Modifier P1 A normal healthy patient. -P2 Physical Status Modifier P2 A patient with mild systemic disease. -P3 Physical Status Modifier P3 A patient with severe systemic disease. -P4 Physical Status Modifier P4 A patient with severe systemic disease that is a constant threat to life. -P5 Physical Status Modifier P5 A moribund patient who is not expected to survive without the operation. -P6 Physical Status Modifier P6 A declared brain-dead patient whose organs are being removed for donor purposes. 114

124 GENERAL MODIFIER (ANY CODE) -GZ Item or service expected to be denied as not reasonable and necessary; no ABN on file This modifier is used for services to Medicare patients for which the diagnosis does not meet the local medical review policy (LMRP) definitions to justify payment for the procedure as medically necessary. PROCEDURE-SPECIFIC MODIFIERS Routine Foot Care Modifiers: The following modifiers are used when providing routine foot care -Q7 One class A finding -Q8 Two class B findings -Q9 One class B and two class C findings See the Podiatry charge document for additional information and applicable procedure codes. Telemedicine Modifiers: The following modifiers are used to denote services provided via telecommunications systems: -GQ Asynchronous (teleradiology) -GT Interactive See telemedicine charge document for additional information and applicable procedure codes. 115

125 Hospice Modifiers: -GV Attending physician not employed or paid under arrangement by the patient s hospice provider -GW Service not related to the hospice patient s terminal condition Mammography Modifiers: -GG Screening and diagnostic mammogram on the same patient on the same day -GH Diagnostic mammogram converted from screening mammogram on the same day Laboratory Modifier: -91 Repeat clinical diagnostic laboratory test on same date. Do not use if tests are re-run to confirm initial results or due to technical problems. 116

126 CHAPTER 8 Completing the Charge Document In many patient care settings, it is the provider's responsibility to complete a charge document in order to bill. Charge documents are customized to specialty and/or clinic. The following elements are necessary for UNMMG billing system charge entry: 1. Patient ID: usually indicated with a label. If no label is available, minimum information needed is name, medical record number, and FIN (episode) number. 2. Provider name and number 3. CPT codes for procedure(s) performed. 4. CPT modifiers, as appropriate. 5. ICD-10-CM diagnosis codes for the first-listed diagnosis and up to three additional diagnoses, sequenced according to national coding guidelines and linked to the CPT codes. 6. Date of service. 7. Facility. 8. Billing area. 9. Location. 10. Referring physician full name and address, for consultation charges and diagnostic testing. 117

127 11. Resident s name and provider number (if applicable). 12. Teaching physician s presence noted (if applicable). Documentation must be present in the patient s medical record (paper or electronic) to support every professional charge billed. 118

128 CHAPTER 9 Documentation Completion Documentation to support billing must be contained in the patient s medical record. PowerChart is considered to be the official medical record at University Hospital. It is not acceptable to use documentation outside of PowerChart, such as shadow charts or office notes, to support billing. For services by UNMMG providers at institutions and facilities other than University Hospital, it is expected that documentation to support billing will be found in the official medical record at that facility. According to the UNM Hospital Policy titled Documentation of Clinical Activities by UNMH Medical Staff and House Staff : 1. Medical Staff and House Staff shall chart legibly and completely, and shall authenticate each entry by signature, date, and time. All orders shall be authenticated by the ordering Medical Staff or House Staff by signature, date, and time. 2. Any addenda to previously recorded entries shall be made under a separate entry, and shall be authenticated by signature, date, and time the addendum was made. Teaching physicians may make addenda to reports generated by residents through: 1) Dictation; 2) Use of a teaching physician template in PowerChart; or 3) Direct entry into PowerChart by typing. Follow these steps: a. Locate and open the document in PowerChart. 119

129 b. Click on the Modify Document icon (looks like a pen and paper). c. Either type the addendum freehand or click on the Template icon (looks like a rubber stamp). d. Select a template from the selection list. There are two choices: a) Teaching Physician with Date or b) Teaching Physician (you can highlight any line and type T to take you to Teaching Physician with Date (press the down arrow key to highlight Teaching Physician Statement). e. Click the insert button. Replace the date as needed and add comments to the end of the template. f. Click on Sign to complete the addendum. Note: All addenda must be dated with the actual date patient was seen and the date the addenda entered into the medical record. 3. Documentation of routine inpatient clinical encounters shall be completed in a timely manner, preferably immediately following the provision of care, but no later than 24 hours after the inpatient clinical encounter. This includes completion of both the dictated or written clinical entry and any relevant billing. 4. Documentation of routine outpatient clinical encounters shall be completed in a timely manner, preferably immediately following the 120

130 provision of care, but no later than 72 hours after the outpatient clinical encounter. This includes completion of both the dictated or written clinical entry and any relevant billing. 5. Discharge summaries shall be dictated or written within 24 hours after discharge. 6. A discharge summary is required for all discharges following inpatient stays, except for normal newborns who stay for maternal reasons. For normal newborns who stay for maternal reasons a final progress note may be written in lieu of a discharge summary; the final progress note shall be identified as being in lieu of a discharge summary. 7. All operative and procedural reports shall be written or dictated immediately after the surgery or invasive procedure and shall be available on the chart within twenty-four hours. 8. A medical record is considered to be complete when all elements have been addressed and a signed discharge summary or abbreviated hospital summary is present. Any medical record not completed within fourteen (14) days of discharge of the patient, and without unusual extenuating circumstances that would preclude completion of the medical record, is defined as a delinquent medical record. Note: Same Process for Dynamic Doc. (See pg. 141) 121

131 APPENDIX A Single Organ System Physical Exam Criteria In addition to the general multi-system physical exam detailed in Chapter 4, the 1997 documentation guidelines authorize the use of eleven single organ system exams: 1) cardiovascular 2) ears, nose, mouth, and throat 3) eyes 4) genitourinary (female) 5) genitourinary (male) 6) hematologic/lymph/immunologic 7) musculoskeletal 8) neurological 9) psychiatric 10) respiratory 11) skin Criteria and scoring for these exams may be found at Click on Jurisdiction H, Evaluation & Management, look for 1997 Documentation Guidelines. 122

132 APPENDIX B Evaluation and Management Code Selection Tables The tables on the following pages may be used to score the documentation in the patient s medical record and assign the appropriate level of evaluation and management code. Abbreviations used in the tables: History (Hx) and Physical Examination (PE) PF EPF D C C = Problem-focused = Expanded problem-focused = Detailed = Comprehensive = Comprehensive Medical Decision-Making (MDM) SF L M H = Straightforward = Low complexity = Moderate complexity = High complexity The tables are organized by site of service, and the number of key elements required at a given level is noted. Where typical intra-service times have been defined by CPT, they are provided for reference in encounters where counseling and coordination of care constitute more than 50% of the total time with the patient. 123

133 EVALUATION & MANAGEMENT OFFICE OR OTHER OUTPATIENT SERVICES New Patient All 3 components required E/M Typical Hx PE MDM Code Time PF PF SF 10 min EPF EPF SF 20 min D D L 30 min C C M 45 min C C H 60 min Established Patient 2 components required E/M Typical Hx PE MDM Code Time min PF PF SF 10 min EPF EPF L 15 min D D M 25 min C C H 40 min Consultations Outpatient (New or Est.) 3 components required E/M Typical Hx PE MDM Code Time PF PF SF 15 min EPF EPF SF 30 min D D L 40 min C C M 60 min C C H 80 min 124

134 Initial Observation Care (New or Established) 3 components required E/M Time Hx PE MDM Code Unit D or C D or C SF or L per day C C M per day C C H per day Subsequent Observation Care (New or Established) 2 components required E/M Time Hx PE MDM Code Unit PF PF SF or L per day EPF EPF M per day D D H per day Observation Care Discharge E/M Description Code Observation Care Discharge (used to report all services provided to a patient on discharge from observation status if the discharge is on other than the initial date of observation status. Time Unit per day 125

135 Observation or Inpatient Care Services (Including same day Admission & Discharge) 3 components required E/M Typical Hx PE MDM Code Time D or C D or C SF or L 40 min C C M 50 min C C H 55 min HOSPITAL INPATIENT SERVICES Initial Hospital Care 3 components required E/M Typical Hx PE MDM Code Time D or C D or C SF or L 30 min C C M 50 min C C H 70 min Subsequent Hospital Care-2 components required E/M Typical Hx PE MDM Code Time PF PF SF or L 15 min EPF EPF M 25 min D D H 35 min HOSPITAL DISCHARGE SERVICES E/M Code DESCRIPTION Hospital Discharge Day Management Hospital Discharge Day Management Time 30 min or less More than 30 min 126

136 CONSULTATIONS Inpatient (New or Est.) 3 components required E/M Typical Hx PE MDM Code Time PF PF SF 15 min EPF EPF SF 30 min D D L 40 min C C M 60 min C C H 80 min PROLONGED SERVICES (With Direct Patient Contact) Outpatient E/M Code DESCRIPTION Prolonged physician service in the office or other outpatient setting requiring direct patient contact beyond the usual service (same as above) Time First hour (30 74 minutes) Each additional 30 min Note: These codes must be used in addition to a basic outpatient service code on the same date. 127

137 Inpatient E/M DESCRIPTION Code Prolonged physician service in the inpatient or observation setting, requiring unit/floor time beyond the usual service (same as above) Time First hour (30 74 minutes) Each additional 30 min Note: These codes must be used in addition to a basic inpatient service code on the same date. PRONLONGED SERVICES (Without Direct Patient Contact) E/M Code DESCRIPTION Prolonged evaluation and management service before and/or after direct patient care (same as above) Time First hour (30 74 minutes) Each additional 30 min Note: These codes are used when a prolonged service is provided that is neither face to face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an E/M service that is beyond the usual physician or other qualified health care professional service time. 128

138 CARE PLAN OVERSIGHT SERVICES E/M DESCRIPTION Code Supervision of a patient under care of home health agency (patient not present) within a calendar month; (same as above) Supervision of a hospice patient (patient not present) within a calendar month; (same as above) Supervision of a nursing facility patient (patient not present) within a calendar month; (same as above) PREVENTIVE MEDICINE Time minutes 30 min or more minutes 30 min or more minutes 30 min or more All preventive medicine services require: Comprehensive history (no chief complaint or HPI required) Comprehensive physical exam (multi-system, based on age and risk factors) Counseling/risk factor reduction interventions Note that the definitions of comprehensive history and physical exam are not the same as those used in the other E/M services. 129

139 PREVENTIVE MEDICINE SERVICES New Patient E/M DESCRIPTION Code Initial comprehensive preventive medicine Evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; Infant (age younger than 1 year) (same as above) Early childhood (age 1 through 4 years) (same as above) Late childhood (age 5 through 11 years) (same as above) Adolescent (age 12 through 17 years) (same as above) years (same as above) years (same as above) 65 years and older

140 PREVENTIVE MEDICINE SERVICES Established Patient E/M DESCRIPTION Code Periodic comprehensive preventive medicine Reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; Infant (age younger than 1 year) (same as above) Early childhood (age 1 through 4 years) (same as above) Late childhood (age 5 through 11 years) (same as above) Adolescent (age 12 through 17 years) (same as above) years (same as above) years (same as above) 65 years and older 131

141 INPATIENT NEWBORN CARE SERVICES The following codes are used to report the services provided to newborns (birth through the first 28 days) in several different settings. Use of the normal newborn codes is limited to the initial care of the newborn in the first days after birth prior to home discharge. If the newborn is discharged home and then readmitted, they are considered to be a pediatric patient, even if less than 28 days old. E/M services for the newborn include maternal and/or fetal and newborn history, newborn physical examination(s), ordering of diagnostic tests and treatments, meetings with the family, and documentation in the medical record. E/M Code Description Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant. Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center. Subsequent hospital care, per day, for evaluation and management of normal newborn. Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date. Time Unit per day Per day Per day Per day

142 INPATIENT CONTINUING INTENSIVE CARE These services are for infants who are not critically ill but who continue to require intensive observation, frequent interventions, and other intensive services. E/M Code Description Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant. Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center. Subsequent hospital care, per day, for evaluation and management of normal newborn. Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date. Time Unit per day Per day Per day Per day 133

143 INPATIENT NEONATAL CRITICAL CARE E/M Description Code Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger. Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger. Time Unit Per day Per day 134

144 INPATIENT PEDIATRIC CRITICAL CARE E/M Code Description Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age. Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age. Time Unit Per day Per day Per day Per day 135

145 CRITICAL CARE SERVICES E/M Code DESCRIPTION Critical care, evaluation and management of the critically ill or critically injured patient; (same as above) Time First minutes) Each additional 30 min Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s), to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient s condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient s condition continues to require the level of attention described above. Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service 136

146 only if both the illness or injury AND the treatment being provided meet the above requirements. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility. Total Duration of Critical Care Less than 30 minutes minutes (30 minutes 1 hr. 14 min.) minutes (1 hr. 15 min. 1 hr. 44 min.) minutes (1 hr. 45 min. 2 hr. 14 min.) minutes (2 hr. 15 min. 2 hr. 44 min.) minutes (2 hr. 45 min. 3 hr. 14 min.) 195 minutes or longer (3 hr. 15 min. etc.) Codes Appropriate E/M Codes x x 1 AND x x 1 AND x x 1 AND x x 1 AND x and as appropriate Time that can be reported as critical care is the time spent engaged in work directly related to the individual patient s care (at bedside or elsewhere on the floor or unit). IF the patient is unable or clinically incompetent to 137

147 participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient s condition or prognosis, or discussing treatment or limitations of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient. Resident time spent without the teaching physician and time spent teaching the resident is not reportable. Time may be documented as continuous clock time or intermittent in aggregated time increments (e.g. 50 minutes of continuous clock time or five ten-minute blocks of time spread over a given calendar date). Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill patient. The following services are included in critical care when performed during the critical period by the physician providing critical care and cannot be billed separately: Interpretation of cardiac output measurements (93561, 93562), chest x-rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases, and information data stored in computers (ECGs, blood pressures, hematologic data (99090), gastric intubation (43752, 43753), temporary transcutaneous pacing (92953), ventilator management ( , 94660, 94662), and vascular access procedures (36000, 36410, 36415, 36591, 36600). Other services performed should be reported separately. 138

148 NURSING FACILITY SERVICES (Nursing facility codes are also used in psychiatric residential treatment facilities.) Initial Nursing Facility Care New/Established Patient 3 components required E/M Typical Hx PE MDM Code Time D or C D or C SF/L Per day C C M Per day C C H Per day Subsequent Care 2 components required E/M Typical Hx PE MDM Code Time PF PF SF Per day EPF EPF L Per day D D M Per day C C H Per day Nursing Facility Discharge Services E/M DESCRIPTION Code Nursing facility discharge day management (same as above) Time 30 minutes or less More than 30 minutes Annual Nursing Facility Assess 3 components required E/M Typical Hx PE MDM Code Time D C L/M 30 min 139

149 EMERGENCY DEPARTMENT SERVICES No distinction is made between new and established patients in the emergency department. Emergency Department Visit 3 components required E/M Hx PE MDM Typical Time Code PF PF SF EPF EPF L EPF EPF M D D M C C H -- HOME SERVICES New Patient 3 components required E/M Typical Hx PE MDM Code Time PF PF SF 20 min EPF EPF L 30 min D D M 45 min C C M 60 min C C H 75 min Established Patient 2 components required E/M Typical Hx PE MDM Code Time PF PF SF 15 min EPF EPF L 25 min D D M 40 min C C H 60 min 140

150 APPENDIX C- CERNER PROCESS INSTRUCTIONAL SITES SynergE3 web site (contains information on how to work in Dynamic Documentation): shtml : Overview New Note Modify Note Tagging Provider Letter Provider Letter Customization (Dynamic Documentation Basic Overview Next Page) 141

151 Dynamic Documentation Basic Overview 142

152 Starting a Note 1. On the Menu, click Add next to Documentation 2. Select Type NOTE: The personal Note Type List will default. 3. Select appropriate Note Template 4. Click OK NOTE: Save note periodically 5. Tab through each section using auto text of free test to complete NOTE: For more information on Auto Text and Tagging see How To? Webpage WARNING: An Auto test Conversion notification window may open. Check the box and click OK to bypass. 6. Click Sign/Submit. NOTE: If you click Save, then click OK. 143

153 7. Click Sign. Note Functions: Warning: Refresh will open a decision window. Steps performed one time. a. Click Refresh smart template b. Check box Remember my selection c. Click Refresh 144

154 Edit/Modify note 1. On the Menu, click Documentation. 2. Locate and double-click note. NOTE: If the note has been signed only an addendum can be added. 3. Make Edits. 4. Click Sign/Submit, Save, Save & Close, Cancel as appropriate Note: If the note is saved it is not a finalized document and can only be viewed by you. 145

155 To forward a note: a. Right-click on the note. b. Click Forward c. Select forward action. d. Enter last name in the To field, then press <ENTER> Note: Click on to assist in finding a name. e. Enter Comments (optional) f. Click OK. Tagging (p. 1) 146

156 Tagging is a new feature that allows one to copy text items and place them into a Dynamic note. Unlike copy and paste, Tagging can be done consecutively and all tagged items will be stored. Scanned images and Forms cannot be tagged. Tags are specific to the Patient Encounter Your account Tagging can be performed before or during a note creation. To Tag Items: 1. Locate and highlight the content you wish to tag 2. Click the Tag icon NOTE: The tag icon will automatically appear above the highlighted text. Continue to Tag text as needed until done. 3. Open Dynamic note 4. The tags will appear to the left of the note. Drag and drop tags into the section Note: To remove tag from the note, click the Undo icon 147

157 NOTE: Tagged items will remain in the patients chart/note until the note is signed. Tracking of Tags: Tags are footnoted for you. A footnote will appear at the bottom of the note indicating where that tag came from. See graphic Provider Letter (p. 1) 148

158 Any clinic note or partial note can be sent to internal and external providers. The recipients will be selected first, then the document(s). HIM will mail letter to those selected. 1. On the Toolbar, click arrow on Communicate. 2. Click Provider letter. To Complete the Recipients: 3. The Providers name in the search field. Then press <Enter>. Note: Both external (referring) and internal providers may be searched for in the address book. Optional: Check box to send a copy to the Consulting providers inbox. 4. Address book will open. Move name to Send to box, then click OK. Note: Name will appear in the Recipient window once recognized. 5. To add an External provider that is not listed in the address book click Add Free Text recipient 6. Complete the yellow required fields. Grey fields are optional. Note: To make a Recipient a Favorite, click the Star icon.. 7. In the Primary column, check box next to primary/main Recipient. All others will be CC d on the letter. 8. In to To field, type Mailout and then press <Enter>. 9. Click OK to close window. 149

159 To Complete the Letter: 1. Click in the document and type to add text. 2. To select document, click Browse Documents. 3. Adjust date at the top 4. Select document to view contents 5. Click Attach Full Document to include entire document OR Highlight specific test within the document, then click Attach Text Selection. Selected text will appear in the lower pane. Provider Letter (p.2) Continue to attach additional documents or selected text as needed. 6. Click OK to close the window. Note: Attached documents will be listed at the top of the letter window window.. Selected text will appear within the To attach Results, click Add Results

160 8. Click item you wish to include, then click Include Selected. NOTE: To select multiple items hold <Ctrl> key known and select all items. Then click include Selected. Optional: To Preview note, click Preview. 9. Click OK to send. Create an Order in PowerChart Add Single Order (one-off order) From within PowerOrder: 1. Click Add icon 2. Type the first few letters of order in the Find field. 151

161 Power tip: Use * to expand the search to anything that includes that order. Example: *test will bring up everything from Cardio Stress Test to testosterone. 3. Click the name of desired medication or order from those displayed. 4. If an Order Sentences window appears, select the most appropriate. Click Ok. 5. Click Done to close the search window. 6. Review and adjust order details as needed. 7. Click Sign in the lower right corner of the screen. 8. Click Refresh button For Workflow Overview MPAGE please view at: Page/CM/PowerChart_Content.cfm 152

162 Workflow Overview (p.1)mpage 153

163 Workflow (p. 2) MPAGE Additional Education can be found on the UH Intranet, SynergE3 in the menu on the right side of the homepage. Web address: Page/CM/PowerChart_Content.cfm will take you directly to the PowerChart, Provider How To home page. Overview of additional education on Synergy3: Attending Confirmation Tips 2. Downtime Resources 3. Clinical Documentation Improvement/ICD/10Value Based Care

164 Clinical Documentation Improvement (CDI) Training Online training for Precyse available ICD-10 web training modules for providers (log in using your username in lower case leters for the username AND password) Additional ICD-10 Web training module info From the SynergE3 website the menu on the right side of the page contain How To s for Providers & Nursing Staff. Page/CM/PowerChart_Content.cfm 155

165 Additional Education: Downtime: - Powerplans - Procedures Pharmacy: - CPOE Updates - Drug Shortages Documentation How To's - for Providers - for Nurses & Staff Electronic Medical Record (EMR): - Request Changes Workflow MPAGE Medcale 3000 Dictation Auto Text: To request new templates/autotext for your division or department please submit the Request for a new or modified Clinical Document. Submit a Help Desk Ticket Click link Click Use Windows Login (blue font) Click New Request (at the top) 156

166 Fill out "Request Details" field. Enter "Who is submitting this request" if not already filled out. Click Submit (blue arrow) 157

167 Questions about the content of the manual and/or suggestions for improvement should be forwarded to Compliance at

168 Call the Compliance Hotline The hotline is anonymous and available 24 hours a day, 7 days a week, 365 days a year! For Ethics Concerns or Questions!