Code Assignment & Validation Evaluation & Management Services Presenter Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMC Disclaimer This presentation is for general education purposes only. The information contained in these materials and presented during the lecture or in response to your questions is not intended to be, and is not, legal advice. The laws and regulations at issue in this lecture may be open to interpretation. This information may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of BNN. No part of this presentation may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from BNN. 2
Objectives To provide you with an overview of: Evaluation and management (E/M) code assignment Review the elements of an E/M code Review the rules associated with E/M code selection Principles of medical record documentation requirements Review documentation basics Review coding documentation guidelines Identifying & validating appropriate code assignment Review details for the medical record review process Medical record risk and documentation improvement opportunities 3 Documentation Rules: Where do they come from? CPT book language and code descriptors CMS Documentation Guidelines 1995 and 1997 versions available Additional clarification in the CPT Assistant Articles Medicare Internet-Only Manuals CMS NCCI Manual Payer rules, transmittals, software edits 4
8 Interpretations of the CMS DGs 5 What do Payers want from Documentation? Reasonable proof that services provided are consistent with coverage policies for enrollees including: Site of service Medical necessity of all services provided Services provided have been accurately reported 6
Documentation Rules Not that simple anymore Unable to just document what is wrong with a patient and what they want to do Physicians fail audits in some cases due to 1-2 missing words How many rules could there be? 7 Documentation Principles/Requirements of E/M Services The medical record must be complete & legible Each encounter should include: Chief Complaint Patient History Findings of Physical Exam Available Results (previous diagnostic tests) Assessment of Patient Status Clinical Impression or Diagnosis Plan for Care Identification of Observer & Date 8
Documentation Principles/Requirements Signature requirements per CMS CR#6698 MLN Matters SE#1419 Services provided must be authenticated by the author. Stamp signatures are NOT accepted. Acceptable methods: Electronic signature Handwritten signature Signature Log Signature Attestation Statement: certain form/format is not required; however, MACs have published their own samples 9 Remember Medicare has advised that the overarching criterion for code selection should be medical necessity: It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. (CMS Manual System, Pub 100-4, Ch. 12, Sub Sec 30.6.1A) Documentation in History, Exam & Medical Decision Making should consistently support medical necessity. 10
Example #1 Patient with well-controlled diabetes comes in c/o stubbed toe. Patient completes history questionnaire at the office. Using the questionnaire, Comprehensive history is obtained (4 HPI, 10 ROS, 3 PFSH) along with a comprehensive exam (8 OS). Assessment: Contusion toe and stable Diabetes. Patient is instructed to elevate foot, use ice prn and OTC Motrin 200mg. Watch for swelling or circulation issues. Return if worsening. Option #1: 99215 based on comprehensive history and exam Option #2: 99213 based on low MDM and either comprehensive history or exam 11 Example #2 Patient presents with abdominal pain. A comprehensive history and exam are documented. Assessment is gastritis; labs were ordered and patient advised to take over the counter medication for pain relief and drink plenty of fluids. Return prn or if not better. Option #1: 99213 based on low MDM Option #2: 99215 based on comprehensive history and exam 12
Documentation Principles/Requirements MDM can vary from visit to visit, although the diagnosis may be the same, the treatment plan(s) can change The fact that a patient has an underlying condition or chronic problem is only significant if it impacts the encounter on that day (and is documented that it was assessed) 13 Test Yourself True or False Additional diagnoses from a problem list can be added to the assessment to help support an E/M level of service. 14
Test Yourself True or False A comprehensive exam is required for all patients. 15 Test Yourself True or False Non-covered preventive visits may be billed as an E/M level of service to ensure payment. 16
Selecting the E/M Service Identify the category or subcategory of service E.g., Category - Office or Other Outpatient Services, Subcategory - New Patient Review the instructions for the category or subcategory Review the level of E/M service descriptors Determine the level of History documented Determine the extent of the Exam Determine the complexity of MDM Select the appropriate E/M service 17 Which Codes Require What? New vs Established? New has not received any face-to-face professional services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty/subspecialty within the group practice, within the last three years Established has received face-to-face services in the last three years 2 of 3 (examples)» Office or other outpatient services (established patient)» Subsequent hospital» Nursing facility care» Subsequent observation care 3 of 3 (examples)» Office or other outpatient services (new patient)» Emergency department» Initial observation care» Initial hospital care» Consultation Services» Admit & Discharge on Same Day (inpatient & observation) 18
Documentation Principles/Requirements The Key Components History (conversation) Problem Focused Expanded Problem Focused Detailed Comprehensive Examination (hands-on) Problem Focused Expanded Problem Focused Detailed Comprehensive Medical Decision Making (thought process) Straightforward Low Moderate High 19 Contributory Factors Counseling Coordination of Care Nature of Presenting Problem Can the level of service billed support the medical necessity of the diagnosis? Time - Plays a role in Counseling and/or Coordination of Care 20
E/M Coding Requirements CHIEF COMPLAINT (CC): Chief reason for seeing the patient. HISTORY: 4 levels determined by the amount of the following documented History of Present Illness (HPI) Review of Systems (ROS) Past, family and/or social history (PFSH) EXAMINATION: 4 levels determined by the number of Body Areas or Organ Systems examined MEDICAL DECISION MAKING: 4 levels determined by the acuity/complexity of patient s condition # of Diagnosis/ Management Options Amount & Complexity of Data Risk 21 History Chief Compliant (CC) A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient s own words History of Present Illness (HPI) Further defines and clarifies the chief complaint; expands the chief complaint and supports medical necessity and provides information to clarify presenting problem Review of System (ROS) Inventory of body systems obtained through questions to identify signs and/or symptoms the patient is experiencing - what the patient is telling the provider Past, family and/or social history (PFSH) Review of the patient s past medical history (illnesses, injuries, surgeries); family history and age-related social history 22
Chief Complaint - Nature of Presenting Problem Each visit record MUST include the reason the patient is being seen (nature of the presenting problem) If seen in follow-up to what? If seen for medication management medication management for what condition(s)? Failure to document a chief complaint may lead to an unbillable service Helps support medical necessity Where can the chief complaint be documented? Sometimes the chief complaint may change from what the patient says to the nurse, to the information they provide to the provider - make sure any differing information is addressed. 23 Examples Unacceptable does not describe reason for visit Follow Up Follow Up Meds Could be better Medication Management for Low Back Pain 6 month follow up (for what) + Diabetes + Hypertension Good Documentation 6 month follow-up lipids Monthly follow-up chronic pain of neck and back 6 year well child check Left wrist pain 25
Example CC: Patient here for f/u diabetes Bad: HPI: Patient c/o fever and cough x 3 days ROS: No SOB or other cold symptoms Exam: ENT: TMs clear, pharynx red. Lungs clear. A&P: URI. Continue OTC meds. Return if worsening Better: HPI: Patient following diet. Blood sugars at home had been stable but have been slightly elevated. C/O fever and cough x 3 days. A&P: Diabetes, stable. Continue meds. URI. Continue OTC meds. Return if worsening 25 History of Present Illness (HPI) 26
History of Present Illness (HPI) The HPI is a chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present. The HPI further defines and clarifies the chief complaint, expands upon the chief complaint and supports medical necessity, provides information to clarify the presenting problem. Generally well documented when visit is for acute problem need the information to diagnose. 27 Elements of the HPI Location Quality Severity Timing Duration Context Modifying Factors Associated Signs/Symptoms Brief = 1-3 elements 99242 99201-99202 99212-99213 Extended = 4+ elements or update 3+ chronic illnesses 99243-99245 99203-99205 99214-99215 28
Status of 3+ Chronic Conditions It is not enough to list just the chronic conditions. The fact that the patient has chronic conditions and is on medication does not satisfy the documentation guidelines. Documentation needs to be in the history portion of the note - not in the Assessment/Plan. Remember that the history documentation should be the verbal interaction between the provider and the patient without professional interpretation. Since Sept 10, 2013 can be used with either guidelines ( 95 or 97) ROS and PFSH should also be documented. 29 Chronic Conditions Example Bad: Patient presents today for follow-up of Diabetes, HTN and Hypercholesterolemia. Continues to take meds. Better: Patient here today for f/u of Diabetes, HTN and Hypercholesterolemia. States that blood sugars have been in the normal range and she continues on Insulin. Her blood pressure has been 110/70 on average and she has had no further complaints of headaches or blurred vision. She continues to follow her low cholesterol diet and states she has lost 3 lbs. 30
Test Yourself True or False The following Nursing Initial Screening may be accepted and counted as appropriate documentation of HPI Nursing Initial Screening: Pt has a new rash on her arm she would like checked. Some rough spots, red and itchy. Pt noticed rash 5 days ago and getting worse. Provider Notes: Reviewed and agree with above history of present illness. 31 CMS E/M Services Guide The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 32
NGS Frequently Asked E/M Questions https://www.ngsmedicare.com 18. I have heard that four or five years ago NGS issued some sort of correspondence which stated that the history of present illness can only be documented by the provider. I have not been able to find this on the NGS website but have seen it referenced by Yale, among others. Can you verify this? Answer: There are two elements of history that can be elicited and documented by someone other than the provider: the Review of Systems (ROS) and the Past, Family and Social History (PFSH). A staff member or medical student may elicit this information from the patient, but the provider is obliged to review it, amend it if necessary, and indicate in writing that he/she has done so. The provider is responsible for eliciting and documenting the History of the Present Illness (HPI), since this requires defined clinical skill. That said, the provider may utilize the services of a Scribe in documenting the HPI, as with any other element of an E&M service. 33 Review of Systems (ROS) 34
Review of Systems (ROS) ROS is an inventory of body systems obtained through a series of questions from the provider seeking to identify signs and/or symptoms which the patient may be currently experiencing. ROS is not a list of past medical conditions (i.e. asthma, diabetes, arthritis) ROS can be confused with exam elements - remember that the ROS is what the patient is telling the provider (subjective), not what the provider examines (objective) 35 Elements of the ROS Constitutional Genitourinary Eyes Psychiatric ENT Integumentary Cardiovascular Neurological Respiratory Allergic/Immunologic Musculoskeletal Endocrine Gastrointestinal Hematologic/Lymphatic None 99241 99201 99212 Problem Pertinent = 1 System 99242 99202 99213 Extended = 2-9 Systems 99243 99203 99214 Complete = 10+ Systems 99244 99245 99204 99205 99215 36
ROS - All Others Negative The guidelines state: for services that require a complete ROS, at least 10 organ systems must be reviewed with positive and/or pertinent negative responses individually documented. For the remaining systems a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented Must document positive or pertinent negatives as related to the chief complaint Must be medically necessary For your practice, what does all others mean? 37 Hot Button Area Double dipping - What is it and can it be done? The intent of the Documentation Guidelines was not to make the provider restate themselves. Information can be counted more than once as long as it is elaborated on. CC: Pain in arm HPI: Pain in right arm Remember that the guidelines do not state how the note has to be documented. Information can be contained throughout the note. (HX Section) 38
Document Pertinent Positives &/or Negatives Watch for Contradictions 39 Past, Family, Social History (PFSH) 40
Past, Family & Social History (PFSH) Past History Allergies, Current Medications, Immunizations, Previous Trauma, Surgeries, Previous Illnesses/Hospitalizations. Family History Health of Parents, Siblings, Children. Family Members w/ diseases related to the chief complaint. Social History Age appropriate review of past and current activities, marital status and/or living conditions, employment, military status, occupational history, education, use of drugs, alcohol, tobacco. NOTE: For categories of subsequent hospital care and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH. 41 Past, Family & Social History (PFSH) None 99241-99242 99201-99202 99212-99213 Complete (2 of 3) 99215 Pertinent (1 of any) 99243 99203 99214 Complete (3 of 3) 99244 99245 99204 99205 42
ROS vs Past History ROS vs. Past History The ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient has or may be experiencing - again, should be related to the chief complaint. Allergy - ROS vs. Past History Counted as ROS if related to the chief complaint or current signs/symptoms. Documentation that the patient has no allergies or NKDA is Past History information if the patient has no related complaints. A list of diagnoses that the patient has is not a ROS but rather Past history. Examples: Patient has Diabetes, Hypertension, COPD Patient c/o increased thirst prior to taking her insulin for her Diabetes and her COPD seems to be worse with increased SOB 43 Documentation Guidelines (DG) - (Per CMS) ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting that there has been no change in the information; and Noting the date and location of the earlier ROS and/or PFSH. 44
Documentation Guidelines (DG) - (Per CMS) The ROS and/or PFSH may be recorded by the ancillary staff or on a form completed by the patient (e.g. an ROS Intake Form). To document that the physician reviewed the ROS and/or PFSH information, there must be a notation supplementing or confirming that the information was recorded by someone else. The provider of the service must document the chief complaint (CC) and history of present illness (HPI) 45 Documentation Guidelines (DG) - (Per CMS) Non-contributory Can be interpreted as not medically necessary - try to stay away from this terminology 46
Documentation Guidelines (DG) - (Per CMS) If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes the provider from obtaining a history. 47 Determining the History Score: To qualify for a given type of history all of the elements must be met or exceeded E/M Level LEVEL HPI ROS PFSH 99241 99201 99212 Problem Focused Brief (1-3 HPI) N/A N/A 99242 99202 99213 99243 99203 99214 99244-99245 99204-99205 99215 Expanded Problem Focused Detailed Comprehensive Brief (1-3 HPI) Extended (4 or more HPI) Extended (4 or more HPI) Problem Pertinent (1 ROS) Extended (2-9 ROS) Complete (10+ ROS) N/A Pertinent (1 PFSH) Complete (Est: 2 PFSH) (New: 3 PFSH) 48
EXAM - 1995 vs 1997 Guidelines 49 EXAM - 1995 vs 1997 Guidelines 1995 Guidelines Expanded problem focused vs detailed No guidelines Be consistent 1997 Guidelines General Multi-System vs Specialty Exams Both are accepted for now. Currently, there are no proposed guidelines in the pipeline. What are the differences? 1995 Guidelines are more generic Body Area (BA): Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine Organ System (OS): Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psyche, Respiratory, Skin 1997 Guidelines are very specific and use bullets Numeric requirements Parenthetical examples are for clarification and really means or 50
1995 Exam Guidelines (NGS) Body Area (BA) Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine Organ System (OS) Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin Problem Focused (99241, 99202, 99212) 1 BA/OS Expanded Problem Focused (99242, 99202, 99213) 2-7 BA s/os s - limited Detailed (99243, 99203, 99214) 2-7 BA s/os s - extended (or 2 or more, at least 1 in detail) Comprehensive (99244-99245, 99204-99205, 99215) 8+OS s (only OS s count toward a Comprehensive exam) OR Complete exam of a single organ system 51 1995: Note When using the 1995 Guidelines, the documentation of vital signs or general appearance of the patient will give credit for the constitutional organ system. The constitutional organ system is not used as one of the systems that can be documented in detail to give credit for a detailed exam as the documentation should be specifically related to the chief complaint. 52
1995 Detailed Exam (NGS E/M Documentation Training Tool) 2-7 areas or systems expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon 53 1997 Exam Guidelines Two types of examinations: General Multi-System Exam - body areas and organ systems Single Organ System Exam - more extensive exam of a specific organ system 10 single organ system exams Cardiovascular Musculoskeletal ENT Neurological Eye Psychiatric Genitourinary Respiratory Hematologic/Lymph Skin 54
1997 Guidelines - General Multi-System Exam Body Area (BA) Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine Organ System (OS) Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin Problem Focused (99241, 99201, 99212) 1-5 bulleted items Expanded Problem Focused (99242, 99202, 99213) 6-11 bulleted items in one or more organ system or body area Detailed (99243, 99203, 99214) 12-17 bulleted items; 2 bulleted items in 6 systems or areas or 12 bulleted items in at least 2 areas or systems Comprehensive (99244-99245, 99204-99205, 99215) 18+ bulleted items; 2 bulleted items in at least 9 organ systems or document every element in each box with a shaded border and at least one element in each box with an un-shaded border. 55 Exam DG Specific abnormal/relevant negative findings of the affected body area/organ system should be documented. A notation of abnormal without elaboration is not sufficient. Describe abnormal or unexpected findings in asymptomatic areas/systems. Briefly note negative or normal to document normal findings in unaffected areas/systems. 56
Hot Button Areas - Exam There is a difference between the 1995 and 1997 guidelines. Review the exam elements for both sets of guidelines and decide which is best for your group/specialty. ROS vs. Exam - cannot count as both (ROS is the talk, Exam is the walk). Having patient give their height and/or weight is not exam. Vitals are the measurement of. 57 Medical Decision Making Number of Diagnoses or Treatment Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Determining the MDM Score (SF, Low, Mod, High) 58
Medical Decision Making (MDM) Elements The thought process of the physician Complete documentation of thought process including issues being ruled out will support medical necessity and higher levels of service billed. Refers to the complexity of establishing the diagnosis and developing a treatment plan based on the following: Number of Diagnoses and/or Management Options Amount and/or Complexity of Data Reviewed Risk of Complications, Morbidity or Mortality 59 Types of Medical Decision Making Four levels recognized: Straightforward Low complexity Moderate complexity High complexity 60
Medical Decision Making (MDM) Elements Number of Diagnoses or Management Options Amount or Complexity of Data Reviewed Risk of Complications, Morbidity or Mortality 2 of the 3 elements of Medical Decision Making must be met or exceeded 61 MDM Number of Diagnoses/Management Options Number of Diagnoses or Management Options Considered The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the 62 physician.
MDM Number of Diagnoses/Management Options For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plan and/or further evaluation. Only conditions that are assessed and impact the encounter are determining factors when selecting the level of visit (i.e., chronic conditions, comorbidities) 63 MDM Number of Diagnoses/Management Options Bad example: 64
MDM Number of Diagnoses/Management Options Bad example: 65 MDM Number of Diagnoses/Management Options Better example: 66
MDM Number of Diagnoses/Management Options For a presenting problem with an established diagnosis the record should reflect whether the problem is: Improved, well controlled, resolving or resolved Inadequately controlled, worsening, or failing to change as expected For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis or as possible, probable, or rule out (R/O) diagnosis: Outpatient diagnoses coding rule: Use signs & symptoms for your final diagnosis instead of a possible dx. 67 Quantifying Diagnosis and Management Option Number of Diagnoses and Management Options Points Self Limiting or Minor Problems - Stable, Improved or Worsening (Maximum of 2) 1 Established Problem - Stable Improved 1 Established Problem - Worsening 2 New Problem - No Additional Work-up Planned (Maximum of 1) 3 New Problem - Additional Work-up Planned 4 Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive 68
Self Limited Problem Self limited/minor vs. new problem There is no definition in the CMS E/M Guidelines Examples include a cold, an insect bite and tinea corporis. CPT Manual E/M Services Guidelines, Nature of Presenting Problem defines a "self-limited or minor" problem as one that runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status or has a good prognosis with management/ compliance." 69 NGS E/M FAQ Additional Work-up 17. How does NGS interpret additional work up? Answer: NGS does not differentiate between diagnostic tests done on the same date of service as the encounter, and those scheduled following the encounter. Either would be considered additional workup planned." 70
Quantifying Amount of Complexity of Data Reviewed Amount & Complexity of Data Points Ordered and/or reviewed clinical lab test (1 point max) (CPT 80000) 1 Ordered and/or reviewed radiology test (1 point max) (CPT 70000) 1 Ordered and/or reviewed test in the CPT Medicine Section (1 point max) (CPT 1 90000) Discussed the test results with performing or interpreting physician (1 point max) 1 Decision to obtain old records or additional HX from someone other than patient, 1 e.g., family, caretaker, previous physician (1 point max) Reviewed and summarized old records or and/or obtained history from someone 2 other than patient and/or discussion case with another health care provider (2 points max) Independent visualization of image, tracing or specimen (2 points max) 2 Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive 71 Quantifying Amount of Complexity of Data Reviewed Independent visualization and direct view of image - is this worth 1 or 2 points? Guidelines state the direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented General feeling is that it depends on who is billing for the interpretation. If the same provider (group) is also billing for the interpretation then only 1 point is awarded; however if the provider (group) is not billing for the interpretation, then 2 points will be awarded. 72
Quantifying Risk Table indicates three areas of risk: Risk of the presenting problem(s) Risk of Diagnostic procedure(s) ordered Risk of Management option(s) Documentation Guidelines state: Highest Level of Risk in any category determines overall risk 73 Table of Risk Risk Level Min (1) Low (2) Mod (3) High (4) Presenting Problem(s) or Diagnostic Procedure or Management Options One self-limited or minor problem, eg cold, insect bite, tinea corporis Venipuncture CXR,EKG,EEG Urinalysis, KOH US Two or more self-limited or minor problems PFT One stable chronic illness, eg well controlled Non-cardiac imaging Acute uncomplicated illness or injury, eg cystitis, simple sprain (full recovery w/o studies functional impairment is expected) Superficial needle biopsies Arterial puncture Skin biopsies One or more chronic illnesses with mild exacerbation, or side effects of tx Stress tests Two or more stable chronic illnesses Endoscopies w/o risk Undiagnosed new problem with uncertain prognosis, eg, lump in breast factors Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Deep/incisional biopsies Acute complicated injury, eg, head injury with brief loss of consciousness (or Card cath w/o risk increased probability of prolonged impairment) Obtain cavity fluid from body cavity, eg, lumbar puncture, Thoracentesis, culdocentesis One or more chronic illnesses with severe exacerbation, progression, or side effects from tx Acute/chronic illness/injury that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe RA, psychiatric illness w/potential threat to self or others, peritonitis, acute renal failure (or high probability of severe, prolonged impairment) An abrupt change in neurologic status, eg, seizure, TIA, weakness or sensory loss Cardiac catheter w/risk EPS studies Endoscopies w/risk Discography Rest Gargle Elastic bandages Superficial dressings OTC drugs Minor surgery w/o risk PT OT IV fluids w/o additives Minor surgery w/risk Elective major surgery w/o risk Prescription drug management Therapeutic nuclear meds IV fluids w/additives Closed reduction of fracture or dislocation Elective major surgery w/risk Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity DNR decision or to de-escalate care because of poor prognosis 74
MDM: Risk of Significant Complications, Morbidity, &/or Mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. 75 Determining MDM Corresponding E/M Code Level of MDM # of Diagnosis or Mgmt Options Amount or Complexity of Data Reviewed Risk of Complications, Morbidity, or Mortality 99241-99242 99201-99202 99212 Straightforward Minimal (1) Minimal or None (0-1) Minimal (1) 99243 99203 99213 Low Complexity Limited (2) Limited (2) Low (2) 99244 99204 99214 Moderate Complexity Multiple (3) Moderate (3) Moderate (3) 99245 99205 99215 High Complexity Extensive (4) Extensive (4) High (4) Reminder: Two of the three elements in the table must be met or exceeded 76
Medical Necessity Supported in the documentation of: Chief Complaint/presenting problem why the patient presents for services Relevant exam components pertinent to chief complaint and flow to medical decision making Medical decision making establishing a working diagnosis and corresponding treatment plan that addresses the chief complaint 77 Validation Process Purpose, Scope, Approach 78
Purpose, Scope, Approach Purpose To prevent possible legal & financial implications To maintain/promote Compliance Detection Correction Prevention Verification Comparison 79 Purpose, Scope, Approach Scope Determine whether you will perform a retrospective vs prospective review Determine the number of charts per provider Recommended: 10 20 encounters Determine a reasonable time frame you will select from Determine your focus Example: E/M full claim review, focused review Select charts Random: Select every 5 th or 10 th chart Targeted: only 99214s & 99215s 80
Purpose, Scope, Approach Approach Present results in a professional and educational manner Provide providers the opportunity to review and study the results Review and discuss results with provider one-on-one Approach your meeting with the provider as a learning opportunity for both of you Discuss documentation improvement opportunities 81 Purpose, Scope, Approach Monitor and Track Results Work at correcting problems identified Establish an on-going reporting and feedback system Record error rates and trends in documentation Example: not documenting a thorough history or not recording a valid chief complaint, invalid signatures Document and respond to systematic issues/concerns uncovered during the review or your discussions Address over coding to minimize potential pay back Address under coding to maximize potential payments 82
Remember Accept the Fact that No Tool Can Replace A Provider In Determining Medical Necessity Communicate Timely Concisely In terms in which providers can relate 83 In the World of Electronic Health Record EHR Concerns - Functionality, Templating, Cloning, etc. 84
Coding Aspects of the EHRs Is an electronic health record (EHR) a great way to capture coding information? How does your EHR capture coding information? Does your EHR code for you? Is it accurate? 85 Is an EHR a great way to capture coding information? Yes, information is legible, easily accessible, regardless of documentation location; information is recorded for years to come. No, nothing is fool proof. If providers do not use the system as intended, it may become a compliance issue Vendors/IT are not always familiar with rules/regulations 86
How does your EHR Capture Coding Information? History and Exam are relatively easy to abstract from EHRs Text boxes Check off boxes Free text Areas of weaknesses in most EHRs are the most subjective areas of the SOAP: History of present illness Medical decision making How is Medical Decision Making quantified? 87 Does your EHR code for you? Is it Accurate? Which Guidelines are used - 1995 vs. 1997? Do you have the ability to modify the requirements? Does the EHR program suggest changing documentation to support the higher levels of code? 88
EHR Coding Functionality Providers need to understand the concepts of coding to use an EHR to its fullest coding capabilities Elimination of non-compliant coding functionality 89 Medical Necessity Challenges» Unlike EHRs, paper records provide an overall sense of an authentic entry:» Diagnosis may help if the qualifying descriptors are present (e.g., critical nature of the patient s condition, life-threatening)» Data ordered and treatment options give a reasonable insight into the provider s impression of the acuity of the patient s illness. Example:» Return prn indicative of a low MDM» Hospitalization, surgery and complex evaluations indicate 90 moderate to high MDM
What is Cloning? NGS Policy Education https://ngsmedicare.com Documentation is considered cloned when it is worded exactly like or similar to previous entries It can also occur when the documentation is exactly the same from patient to patient: All diabetic patients start to look alike (no individuality); or Every patient visit looks alike (difficult to differentiate one visit from another) 91 NGS Policy Education https://ngsmedicare.com Whether the documentation was the result of an Electronic Health Record, or the use of a pre-printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Cloning may be the most worrisome aspect of an EHR 92
EHR Review Approach to Identify Cloning Obtain 5-10 charts per provider; at least 3-4 from same patient, in sequence Interpret patterns in documentation to identify potential cloning Note concerns for quality and liability 93 Cloning / Templating 94
Overview / Introduction to Scribes 95 Guidelines for Scribe Providers using the services of a scribe must adhere to the E/M Documentation Guidelines, but in addition: Medical record must indicate the name of the person who is acting as a scribe for Dr. X Provider is expected to deliver the service and is still responsible for the medical record Provider must authenticate the medical record confirming that the note is accurate 96
Overview / Introduction to Incident-to Billing 97 Incident-to Billing Medicare Internet-Only Manual (IOM) 100-02 Chapter 15, Section 60 CMS allows services of certain nonphysician practitioners to be billed as incident-to a physician s professional services NGS: Under Medicare Part B, incident-to provisions apply in an office setting only. There is no incident-to billing in a facility under Part B. (Only POS=11) 98
Incident-to Billing Requirements The following requirements are associated with "incident to" billing as defined by Medicare: Physician-initiated course of treatment and continued active participation in the course of treatment and management Direct supervision: physician is physically present in the same office suite Both practitioners are employed by the same entity Billed under the physician who is in the office that day, not necessarily the physician who initiated the plan of care Incident-to billing does not apply to new patients or 99 established patients with new problems E/M Documentation The Impact of ICD-10-CM 100
ICD-10-CM Sample Summary of Results Determination Definition # of Claims % Outpatient Claims Agree Additional code(s) supported Incorrect code(s) * No coding changes (up to 9 codes reviewed) * Agree with claim or coding summary * Medical record documentation supported additional ICD-10-CM code(s); or * Reporting of additional ICD-10-CM code(s) was required based on the official coding guidelines. * Medical record documentation supported different ICD-10-CM code(s) compared to the code(s) reported * Documentation to support a diagnosis code was not provided 112 40 % 44 16 % 87 30 % Both: * Additional code(s) supported and * Incorrect code(s) reported Total # of claims 283 40 14 % 101 ICD-10-CM Simple Documentation Tips When Applicable, remember to document: Acuity Acute, Chronic, Acute on Chronic Severity Mild, Moderate, Severe Laterality Right, Left, Bilateral Cause & Effect Due to, With, Secondary to, Complicated by, Caused by, etc. Anatomic Site Specificity 102
Reference for Guidance Centers for Medicare and Medicaid Services (CMS) Billing Rules Bundling Edits http://www.cms.hhs.gov/ National Government Services (NGS) Local MAC https://www.ngsmedicare.com/ 103 104
Contact Information Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMC Manager sallaire@bnncpa.com BAKER NEWMAN NOYES LLC Toll Free: 1-800-244-7444 Fax: 207-774-1793 105