Demonstrating the Chain of Medical Necessity Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP AAPC Fellow Vice President 1
Dr. Evan Gwilliam Education Bachelor s of Science, Accounting - Brigham Young University Master s of Business Administration - Broadview University Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic Certifications Certified Professional Coder (CPC) - AAPC Certified Chiropractic Professional Coder (CCPC) - AAPC Qualified Chiropractic Coder (QCC) - ChiroCode Certified Professional Coder Instructor (CPC-I) - AAPC Medical Compliance Specialist Physician (MCS-P) - MCS Certified Professional Medical Auditor (CPMA) AAPC, NAMAS Certified ICD-10 Trainer AAPC Certified MIPS Healthcare Professional (CMHP) 4Med Fellow AAPC 2
Take-away Document the entire Episode of Care Learn to use the Chain of Medical Necessity Create powerful diagnostic statements Use a solid diagnostic code hierarchy Create meaningful goals Know how to convey Medical Necessity through E/M codes 3
Episode of Care 4
Episode of Care
From the new and improved documentation chapter in the 2018 DeskBook
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Medical Necessity Services or items reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member -CMS How can you prove medical necessity?
Chain of Medical Necessity 1. History of onset 2. Patient complaint 3. Exam findings 4. Diagnosis 5. Treatment plan 6. Progress
Chain of Medical Necessity 1. History of onset Explain why the patient has a complaint Document mechanism of trauma for acute patients For chronic patients, try to establish why the patient decided to come in today, rather than another time
Chain of Medical Necessity 2. Patient complaint 3. Exam findings Relate exam findings to complaint Functional loss should be documented in the complaint (ADLs) and consistent with the exam findings.
Chain of Medical Necessity 4. Diagnosis The diagnosis should provide a plausible explanation for the symptoms. Clinical criteria from the history and exam should match up with the diagnosis.
5. Treatment Plan Should be appropriate for the diagnosis. Care given because of provider technique, philosophy, or just routine is not medically necessary. Treatment should transition from passive to active. Avoid cookie cutter care. Plans should vary for different ages and different diagnoses. Chain of Medical Necessity
Chain of Medical Necessity 6. Progress Goals should be specific to each patient and measurable Outcomes Assessment Tools are the best way to quantify functional progress Goals must be evaluated and updated over time See chapter 4.4 of the 2018 DeskBook for more on goals
Chain of Medical Necessity 1. History of onset 2. Patient complaint 3. Exam findings 4. Diagnosis 5. Treatment plan 6. Progress
Does you care plan answer these questions? 1. Why are you treating the patient? 2. What are you going to do with the patient? 3. How long and how often are you going to see the patient? 4. What are you and the patient trying to accomplish? 5. How do you know when you have accomplished the goals?
ICD-10 Heirarchy 1. Nerve-related disorders (e.g. radiculopathy) 2. Acute injuries (e.g. sprains and strains) 3. Structural diagnoses (e.g. degenerative disc disease) 4. Functional diagnoses (e.g. difficulty with walking) 5. Soft tissue problems (e.g. myalgia) 6. Symptoms (e.g. neck pain) 7. Complicating factors/comorbidities (e.g. diabetes) 8. External causes (e.g. place and activity)
ICD-10 Tips Follow ICD-10 guidelines (Excludes1, NOS) When coding for symptoms, add the phrase due to for better specificity. Complicating factors may also be coded, if relevant. Learn to document a Diagnostic Statement or Clinical Impression that matches the code requirements. 18
ICD-10 Guidelines
Functional Goals 1. What is the activity (sleep, walk) the patient will be able to perform? 2. Under what conditions (how far or for how long) will they be able to do it? 3. How well will they be able to do it (without assistance, without increased pain)? 4. When will this be accomplished (2 weeks, 2 months)? Keep them patient-centered! 21
Weak Care Plans Only address frequency and duration of visits, and neglect goals entirely OR Include goals, but o They are only subjective o They do not address function o They are not measurable 22
Short term goals restated: 1. Reduce pain 2. Increase pain-free ROM 3. Restore normal vertebral segmental motion 4. Increase ability to move affected area Short term goals improved: 1. Reduce VNRS from 8/10 to 5/10 within 2 weeks 2. Increase pain-free ROM by 50% within 2 weeks 3. If you restore normal vertebral segmental motion, you can t adjust anymore, right? 4. Same as number 2? 23
Two weeks later Assessment should discuss progress towards goals Were goals achieved? If not, why? Patient went on vacation Patient fell down the stairs How will the care plan change to adapt to goals that were not met? Easier or harder exercises? More or fewer visits? Referral or new diagnostic test? 24
Short term goals restated: 1. Reduce pain by 10% 2. Increase strength (Is there documented loss of strength?) 3. Increase endurance (How do you measure this?) 4. Increase ability to move affected area (Measurable?) 5. Increase ability to exert force to affected area AND (these are better) 1. Get 5-6 hours of quality sleep (within what time frame?) 2. Stand for more than 20 minutes (Is this from Oswestry?) 3. Sit for more than 20 minutes pain free 4. Walk for more than 1 block pain free 5. Lift more than 20 pounds from off the floor 25
Evaluation & Management Office/Outpatient New Patient 99201 99202 99203 99204 99205 Office/Outpatient Established Patient 99211 99212 99213 99214 99215 *A new patient is one who has not received any professional services from the physician.within the past three years.
Evaluation & Management Three Key Components: History Physical Examination Medical Decision Making Contributing Factors: Nature of Presenting Problem Time Counseling Coordination of Care
Nature of the Presenting Problem Medical necessity is the overarching criterion for payment. 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. -Social Security Act 1862 (a)(1)(a)
Nature of the Presenting Problem A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows: Minimal: A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician s or other qualified health care professional s supervision. Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.
Nature of the Presenting Problem Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected. Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
Nature of the Presenting Problem New Patient E/M 99201 Self-limited or minor 99202 Low to Moderate severity 99203 Moderate severity 99204 Moderate to High severity 99205 Moderate to High severity
The NEW ChiroCode DeskBook is available at ChiroCode.com Most of this presentation is covered in Chapters 4 and 5.
Take-away Document the entire Episode of Care Learn to use the Chain of Medical Necessity Create powerful diagnostic statements Use a solid diagnostic code hierarchy Create meaningful goals Know how to convey Medical Necessity through E/M codes 33