Documenting & Coding for Compliance Department of Family and Community Medicine October 17, 2012 UNMMG Compliance
Documentation
Documentation Why is it important? Enables the physician and other health care professionals to plan and evaluate the patient s treatment Helps communication among physicians others involved in the patient s care Simplifies claims review and payment Reduces problems related to medical reviews Serves as a legal document to verify the care provided
COUNSELING & COORDINATION OF CARE If counseling and coordination of care constitute more than 50% of the time spent with attending and the patient, the level of service may be selected on time instead of the key components. Documentation must be detailed and clearly reflect the amount of time spent face-to-face by the attending physician or mid-level along with specific details as to what was discussed with the patient. Examples of documentation if selecting the E&M level based on time of counseling and coordination of care: I spent 20 minutes of this 30 minute visit discussing with the patient his diet and educating the patient on proper.. Or I spent more than 50% of this 30 minute visit discussing with the patient the need for surgery. Patient concerned about. **Remember this is face-to-face time with the attending physician or mid-level only this does not include time spent with by resident.
Teaching Physician Documentation Rules The teaching physician must personally document: His or her presence and participation during the encounter A teaching physician must make reference to the resident/fellow (not team or group ) Participation in the management of the patient Reference to the resident/fellow s note Make sure you are forwarding your notes for verification of the teaching physician and so that they can add their attestation. If there is no attestation from the attending the encounter is not billable
Procedures It is critical that documentation supports details of the procedures For minor procedures (<5 minutes) the Teaching Physician has to be present for the entire procedure You may document the Teaching Physicians presence for minor procedure. Example, Dr. ABC was present for the entire procedure.
Timely Documentation Timely documentation helps us to provide quality care to our patients and enables proper coding and billing UNM Clinical Affairs policy states that: Documentation of routine clinical encounters or for inpatient services shall be completed in a timely manner, preferably immediately following the provision of care Don t forget to verify and sign your dictation and make sure it is forwarded to your attending for their verification and signature
Copy & Paste Transcription is only allowed to copy specific areas of a previous note: Past medical history, social history, family history, past surgical history and problem list Be sure that you have reviewed and made corrections as needed Any time you ask for copy and paste in your dictation it goes to a transcription supervisor to review and delays the note If you are typing the note yourself use caution when deciding what to copy and paste Don t copy another provider s progress note, discharge summary, or other information that is not appropriate for the visit Providers are responsible for the content of their documentation, whether the content is original, copies, pasted, imported or reused Documentation should accurately reflect the clinical work performed that day
Medical Students Do not agree with a medical student s documentation Only refer to: Past family history Past medical history Social history Review of systems You must perform and document the rest of the history, the exam and medical decision making portion of the visit Any use of medical student documentation other than what is defined may result in non-billable charges
Coding
What is considered when leveling a visit? 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 Keep in mind that the length of the note does not necessarily determine the level. Key components are taken into consideration just as much as medical necessity.
History 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) Document all relevant HPI, ROS and history
History Components (CC & HPI) Chief Complaint (CC) What the patient is being seen for? Be specific and avoid statements like here for follow-up. Mr. Baca is being seen today for a cough and sore throat. History of Present Illness (HPI) Things like location (where), duration (how long), timing (when), quality (what is it like), context (how) severity (i.e. pain scale), modifying factors (what has been done for it) and associated signs and symptoms (what else is happening) Mr. Baca is complaining of a cough for two days, now developing a sore throat. Patient reports he was with his three year-old grandson over the weekend who was sick. Sore throat pain is 7/10. He has been taking over the counter cough/cold medicine but it has not helped. He has noticed shortness of breath, some fever and is very fatigued.
History Component (ROS) Review of Systems (ROS) 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 An inventory of body systems obtained through a series of questions seeking to identify and/or symptoms that the patient may be experiencing or has experienced ROS helps define the problem, clarify differential diagnosis, identify needed testing, or serves as baseline data on other systems Document those systems with positive or pertinent negatives.
History Component (PFSH) Past medical history Prior illnesses and injuries, operations, hospitalizations, current medications, allergies, age appropriate immunization status, age appropriate feeding/dietary status 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, etc.
Examination Be sure to document your exam as appropriate for each patient Don t examine areas unnecessarily in order to bill for higher levels 1995 or 1997 Guidelines are used to determine the level of a visit (same history and medical decision making components
1995 Exam Elements 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
Medical decision making is the E/M component that describes the aspects of the physicians work involved to formulate a diagnosis and a management plan. Things taken into consideration are: The number of diagnosis and management options (prescriptions, tests ordered, decision for surgery, etc.) Amount/complexity of data (i.e. labs or x-rays reviewed) Risk of complications Medical Decision Making **Note: Medical necessity is not the same as Medical Decision Making. Medical necessity looks at what was reasonable and necessary for the diagnosis or treatment of an illness or injury.
Modifiers The most common modifiers used with an E/M visit are: Modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. (Use with an E/M code when an unscheduled procedure is done at the time of the visit) Modifier GC E/M service that has been performed in part by a resident/fellow under the direction of a teaching physician Modifier GE E/M service that has been performed by a resident without the presence of a teaching physician under the primary care exception (Valid only with E/M codes 99211-99213 or 99201-99203)
What s next? You re kidding, there is more?
How Do I Stay Compliant? By providing good care while billing and documenting accurately By doing only what is medically necessary By documenting what you do By billing only for what you document (if it isn t documented it didn t happen) By understanding and applying coding and compliance conventions for billing and documentation
How Can I Get Help? UNMMG has coders and compliance staff that are available to help with any questions or concerns that you may have You can request an informal one-on-one education session by contacting the UNMMG Compliance Office Contact Terry Padilla or Cassandra Romero directly Visit the UNMMG website for coding and compliance help at http://unmmg.health.unm.edu/
Thank You!