Basics of Coding for Compliance Health Systems Compliance Presented by JoAnn Martinez, CPC Compliance Educator
Documentation Best Practice Common Themes ICD-10 that support E/M & Procedure Coding Type and Cause of a Condition As Indicated by Supports Medical Necessity Infectious Agent Causal Organism Linking Due to Secondary to related to Anatomical Site or Anatomical Region Laterality Right, Left, Bilateral Acuity of Disease Mild, Moderate, Severe, Acute, or Acute on Chronic Underlying Conditions Disease Manifestations Drug, Tobacco, ETOH Use Abuse Dependence Episode of Care Initial, Subsequent, Sequelae 2
Episode of Care Initial Encounter = A (7 th Character): Injury or condition while the patient is receiving active treatment for the injury or condition. Ex: Surgical treatment, emergency department encounter, and evaluation and treatment by a new physician Patient is evaluated in the ER for a displaced transverse fracture and the left ulna that cannot be managed at this time. The ER applies immobilization and ice and instructs patient to follow-up with Ortho in the morning. This is an initial encounter S52.222A When orthopedist evaluates the patient and reduces the fracture the next day, the patient is receiving initial active treatment for the fracture. This is the first encounter at which the patient receives definitive care so you would report the S52.222A Change the Scenario: The patient has a greenstick fracture of the shaft of the left ulna, which is definitely managed in the ER with a cast or splint. This is the initial encounter S52.212A Patient is evaluated for injury in the orthopedic office at a later date. This is a subsequent encounter. This is true even if the cast or splint is removed and a new one is applied because the patient already received definitive fracture care in the ER. 3
Episode of care Subsequent Encounter = D (7 th Character) Encounters after the patient has receive active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase Examples: Cast change or removal, removal of external or internal fixation device, medication adjustment, or aftercare and follow up visits following injury treatment 4
Episode of Care Sequela = S (7 th Character) Sequela is used for encounters with complications or conditions that arise as a direct result of an injury, such as a scar formation after a burn. The scars are sequela (late effects) of the burn (injury) Most common sequela is pain. Many patients receive treatments for pain long after an injury has healed Some patients might never have been treated for the injury at all. As time passes the pain becomes intolerable and the patient seeks a pain remedy 5
Evaluation and Management (E&M) Services
What is considered when selecting an E/M code? There are three key components that are considered part of an E/M visit : History Examination Medical decision making Each of these components have specific key points that are considered when selecting a CPT code
The History (HPI) The history component of an E/M visit consists of: Chief Compliant (CC) History of Present Illness (HPI) Review of Systems (ROS) Past medical history, family history and social history (PFSH)
History Components Chief Complaint (CC) The medical record should clearly reflect the chief complaint. Patient is being seen today for Patient returns today for follow-up on...
History of Present Illness--HPI HPI is documentation directly related to the present episode of care. This includes a Sub Category of: 8 elements details describing the current presentation location (where) duration (how long) timing (when) quality (what is it like) severity (i.e. pain scale) modifying factors (what has been done) context (what created symptom) associated signs/symptoms (what else is happening) NOTE: If you are unable to obtain history, document why and any attempts that were made i.e. Unable to obtain history as patient was unconscious upon arrival. Or.. friend attempted to answer questions but was really unsure of information, we were unable to obtain a history as patient was unconscious when he arrived. Of note: Status of 3 chronic conditions may also be counted in lieu of HPI.
Example: History Components History of Present Illness (HPI) Patient states she has been having right wrist (location) discomfort (quality) for 3 months (duration). States she has taken Tylenol to relieve the pain (modifying factors).
History Component Review of Systems(ROS) Review of Systems include: Constitutional (fever, weight loss) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic A complete ROS would include 10 or more systems or documentation of positives or pertinent negatives and a statement of all others negative Do not say ROS negative, you must demonstrate that they were reviewed with the patient
Review of Systems Example: Denies fever (const). Occasional rapid heartbeat(card/vasc). Positive for asthma(resp). All other systems negative.
Past medical history History Component Past History (PFSH) Prior illnesses and injuries, operations, hospitalizations, current medications, allergies, age appropriate immunization, etc. Family history Health status or cause of death of parents, siblings, and children ; Diseases related to the HPI or ROS; Hereditary or high risk diseases Social history Marital Status, living arrangements, current employment, occupational history, use of drugs/alcohol, educational history, (new for 2015) military history, etc. **(all 3 needed for new patients, initial admission, consults)** Complete PFSH - New Patient/ED = all 3 needed Established Patient = 2 out of 3 needed
Selecting the Level of History Example: New problem 3 HPI Expanded Problem 10+ ROS Focused History 1 PFSH
Physician s Hands on The Exam Type and content of exam based on clinical judgment and nature of presenting problem Statement of Abnormal is not sufficient
1995 Exam Elements Cannot mix and match BA and OS The following body areas are recognized: Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity The following organ systems are recognized: Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic
The 4 X 4 Rule = Detailed Exam 4 or more items for 4 or more body areas or organ systems Constitutional 1) BP 2) Temp 3) Pulse 4) Respiration Cardiovascular 1) Regular rate 2) Rhythm 3) Normal S1 4) Normal S2 Respiratory 1) Chest clear to auscultation 2) Non-labored breathing 3) No rhonchi 4) No rales Gastrointestinal 1) Abdomen soft and non-tender 2) Normal bowel sounds 3) No hernia 4) Abdomen flat
Organ Systems 4x4 rule items Organ System Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Elements that describe the Organ System Vital signs vitals:3 of 7 (BP/s-P/pulse/resp/temp/wt/ht), general appearance Exam of pupils (reaction to light) PERRLA External ears; nose inspection; hearing assessment; inspect nasal mucosa, lips, teeth and gums Palpation of heart, auscultation of heart Respiratory effort, percussion of chest, auscultation of lungs Exam of liver and spleen/bowel sounds Male-testicles are descended bilaterally firm, non tender, and without masses or lesions. Female, Introitus is normal, vaginal walls pink and moist without lesions or evidence of trauma. Exam of gait and station; inspection of digits and nails; exam of joints, bones and muscles; notation of misalignment, asymmetry; assessment range of motion and pain; muscle strength and tone Skin Neurologic Inspection of skin and subcutaneous tissue (rashes ect.); palpation of skin and subcutaneous tissue (induration ect.) Test cranial nerves with notation of deficits, exam of deep tendon reflexes notation of pathological reflexes (eg. Babinski); exam of sensation Psychiatric Hematologic/Lymphatic/Immunologic Patient s judgment and insight; orientation to time, place and person; recent and remote memory Palpation of lymph nodes in neck, axillae, groin or other
Body Areas 4x4 rule items Body Area Document Head, including the face Scars, lesions, palpation of face with notation of presence or absence of sinus tenderness Neck Masses, symmetry, tracheal position, crepitus(crackling sensation) & overall appearance Chest, including breasts and axilla Symmetry, nipple discharge Palpation of breasts and axillae (eg, masses or lumps, tenderness) Abdomen Genitalia, groin, buttocks Back Exam with notation of masses or tenderness, hernia presence, presence of hemorrhoids and rectal masses Exam of scrotal contents and penis-male Exam of external genitalia-female Exam of joints spine Each Extremity Inspection and / or palpation of the skin and subcutaneous tissue for both upper and lower extremities (each listed- counts, rt. and lt. arms=2)
Medical Decision Making Divided into three sections: 1. Number of Diagnosis or Treatment Options 2. Amount and Complexity of Data Reviewed 3. Risk of Complications, and/or Morbidity or Mortality
Medical Decision Making Diagnosis and Options Number of Diagnosis or Treatment Options 1 2 2
Medical Decision Making Additional Workup Defined as anything that is being done beyond that encounter at that time Example: a physician sees a patient in his office and needs to send that patient on for further testing
Medical Decision Making Complexity and Data Amount and Complexity of Data Reviewed
Level of Risk Table of Risk (USE THE HIGHEST LEVEL DOCUMENTED) Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected Minimal * One self limited or minor problem, e.g. cold, insect bite *Lab tests requiring venipuncture *CXRs *ECG/EEG, U/A, echo * Rest * Gargles * Elastic bandages * Superficial dressings Low 2 or more self limited or minor problems 1 stable chronic illness Acute uncomplicated illness or injury, e.g. cystitis, sprain * Physiologic tests not under stress, e.g. PFTs * Non CV imaging with contrast, e.g. barium enema * Superficial needle biopsy * Clinical lab test requiring arterial puncture * Skin biopsies * OTC drugs * Minor surgery w/ no identified risk factors * PT, OT IV fluids w/out additives Moder ate * 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment * 2 or more stable chronic illnesses * Undiagnosed new problem with uncertain prognosis, e.g., lump in breast * Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis * Acute complicated injury, e.g. head injury with brief LOC * Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test * Diagnostic endoscopies with no identified risk factors * Deep needle or incisional biopsy * CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath * Obtain fluid from body cavity * Minor surgery with identified risk factors * Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors * Prescription drugs * Therapeutic nuclear medicine * IV fluids w/ additives * Closed tx of fracture or dislocation without manipulation High * 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment * Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI * An abrupt change in neurological status, e.g. seizure * CV imaging studies with contrast with identified risk factors * Cardiac EP test * Diagnostic endoscopies with identified risk factors * Discography *Elective major surgery w/ identified risk factors * Emergency major surgery * Parenteral controlled substances * Drug therapy requiring intensive monitoring for toxicity * Decision not to resuscitate or to de escalate care because of poor prognosis
Final Result for Complexity: Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2 nd circle from the left. Remember that two out of the three elements are required. Final Result for Complexity A Number of diagnosis or treatment options 1 Minimal 2 Limited 3 Multiple B Highest risk Minimal Low Moderate High C Amount and Complexity of data Type of decision making 1 Minimal or low STRAIGHT FORWARD 2 Limited LOW COMPLEX 3 Multiple MODERATE COMPLEX 4 Extensive 4 Extensive HIGH COMPLEX
New Patient vs Established Patient A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. An established patient is an individual who has received professional services from the physician/npp or another physician of the same specialty who belongs to the same group practice within the previous three years.
Modifiers Modifier 25 Defined as Significant and Separately Identifiable Evaluation & Management (E/M) visit performed on the same day as a procedure. The modifier is only used when used in a very specific set of circumstances. Modifier 25 should only be appended only to E/M service codes. Only those instances where a medical visit (E/M) on the same date as a diagnostic or therapeutic procedure is separately identifiable for an unrelated problem should the facility receive separate reimbursement for the evaluation and management service. A modifier 25 appended to the E/M code would be used in these cases to indicate that a medical visit occurring the same day was unrelated to any procedure that was performed.
Modifier 25 Continued Reporting an E/M service with modifier 25 is only appropriate if one of the following conditions have been met: The patient requires evaluation above and beyond what is typically expected as part of the evaluation prior to the procedure. The patient s condition has changed or worsened and the patient needs to be reevaluated. The patient presents with a new, separate problem than what prompted the procedure.
Example of when you would apply a Modifier 25 An established patient visited her physician s office for a procedure to repair a minor laceration on her right foot. (Oh by the way) While the physician sutures the wound, the patient complains of new edema on her left leg and ankle. Instead of rescheduling, the physician examines the patient s left leg and ankle after completing the suturing and documents the extra exam. Bill for the E/M Bill for the Procedure Use a Modifier 25 to get both paid for. The exam for the left leg and ankle edema is completely separate from the repair of the minor laceration and therefore the E/M service can be billed as a separate identifiable service.
Example of when you would not use the Modifier 25 A Medicare patient presented to her physician s office complaining of a painful abscess on her back. The physician took a problem focused history and performed a problem focused exam. He decided to incise and drain the abscess while the patient was still in the office. Bill for the procedure only. Medicare does not pay separately for an E/M service under these circumstances. NO E/M NO Modifier the exam was directly related to the procedure performed nothing new or separate was identified.
Important Points to Remember About Consults and Referrals 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. Defined by CPT, a referral is the process whereby a physician who is providing management for some or all of the patient s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.
Consultations Consultations are requests from another provider for advice or an opinion Documentation of a consultation request must be clearly stated in the note. For example: Ms. Blue is being seen today in consultation at the request of Dr. John Smith for RUQ abdominal pain. A letter addressed to a provider does not support a request for consult A CC: at the bottom of a note does not support a consult request Avoid using the word referred for a consultation
Remember the R s Request and Reason Documentation should explicitly reflect what the patient is being seen for and who requested the service. For example, I was asked by Dr. John Smith to see this patient in consultation for Do not refer to a team or a department ; documentation must reflect the name of the requesting provider. Render and Report The consulting provider should appropriately document the encounter in the medical record and provide a written report to the requesting provider. In a setting where the requesting provider and the consultant share the same record, this communication can be in the EMR; it does not have to be a formal letter. **Please remember if you are the one requesting a consult make sure your note specifically states that **
Documentation of Clinical activities by Medical Staff and House Staff (link listed at the bottom of the slide) The purpose of this policy is to ensure that Medical Staff and House Staff documentation of clinical activities supports and promotes: High-quality clinical care Patient safety and quality improvement Accurate billing for provided services Compliance with regulatory requirements such as Medicare conditions of participation, The Joint Commission (TJC) standards, Liaison Committee on Medical Education (LCME), and Accreditation Council for Graduate Medical Education (ACGME) requirements, and state and federal law 35
OP - Documentation of Clinical Activities by UNMH Medical Staff and House Officers General Documentation Principles Medical Staff and House Staff shall chart legible and completely, and shall authenticate each entry by signature, date, and time. Documentation of routine outpatient clinical encounters shall be completed in a timely manner, preferable immediately following the provision of care, but no later than 72 hours after the outpatient clinical entry and any relevant billing Attending Physicians and other Medical Staff shall document their physical presence during the key portions of a service provided by House Staff in accordance with regulatory billing requirements Documentation of clinical encounters must support the billing of clinical encounters submitted Documentation of clinical activities provided more than 30-days prior is discouraged and requires notification of the Service Chief. 36
IP - Documentation Requirements History and Physical Exam (TJC R.C. 01.03.01): Dictated & signed within 24 hours of admission H & P completed no more than 30 days before, nor later than 24 hours after Inpatient Admission For H & Ps completed within 30 days before Inpatient Admission, an update (addendum) documenting any changes in a patient s condition must be completed within 24 hours after Inpatient Admission or before surgery Operative Report (TJC R.C. 02.01.03): Dictated immediately following the procedure Brief Op Note- Electronically entered immediately after surgery and signed within 24 hours of procedures Discharge Summary: Dictated & signed within 24 hours of patient discharge https://hospitals.health.unm.edu/intranet7/apps/doc_management/index.cfm?project_id=1 Documentationofclinicalactivitiesbymedicalstaffandhouseofficers 37
Where can I find Compliance Resources on Clinical Documentation Guidelines
How Can I Get Help? UNMMG compliance staff are available to help with any questions or concerns that you may have relating to OUTPATIENT coding. You can also request GROUP Provider Education sessions through the Compliance Department. Visit the UNMMG website for compliance help at http://unmmg.health.unm.edu For compliance scheduling, see below: Scheduling please call: Compliance Coordinator Matthew Montoya 505-925-6053 mmmontoya@unmmg.org
How Can I Get Help? Purvi P. Mody ealth Systems Chief Compliance and Internal Audit fficer pmody@salud.unm.edu 05 272-8761 Kay Kennedy, CPC, CPMA ompliance Supervisor 05 272-3384 Kennedy@unmmg.org upports Psychiatry JoAnn Martinez, CPC, Compliance Educator Approved ICD-10 Trainer jomartinez@unmmg.org 505 272-0035 Sandy Colson, CPC, CPC-H, CPMA 505 925-4997 SKColson@unmmg.org Supports Internal Medicine Terry Padilla, CPC 505 272-6070 TPadilla@unmmg.org Supports FM, Neurology, Neurosurgery, Dermatology & OB/GYN Frances Garcia, CPC, CEMC 505 272-4293 fmmadrid@unmmg.org Supports Surgery and Pediatrics Kerry Bryceland, CPC 505 272-2902 Kbryceland@unmmg.org Supports Orthopaedics Auditors
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