A Guide to Compliance at New York City s Health and Hospitals Corporation Resident Orientation 1
General Principles of Documentation 2
7 General Principles of Documentation 1. Medical record should be complete and legible 2. Each encounter should include Reason for encounter and relevant history, physical examination findings, and prior test results Assessment, clinical impression, or diagnosis Plan for care Date and legible identity of observer 3. Rationale for ordering diagnostic tests and ancillary services should be easily inferred if not documented 3
Teaching Physician Supervision For all services you provide, you MUST ensure that your attending physician documents the following in the medical record: They were physically present for the critical and key portions of the examination They participated in the management of the patient. 4
7 General Principles of Documentation 4. Past and present diagnoses accessible to treating and/or consulting physician 5. Appropriate health risk factors identified 6. Patient s progress, response to and changes in treatment, and revision of diagnosis documented 7. CPT and ICD codes reported on health insurance claim form or billing statement supported by documentation in medical record 5
E&M Coding: Medical Decision Making Number of Amount and/or Risk of Type of Medical Diagnoses/ Complexity of Complications, Decision Making Management Data to be Morbidity, and/or Options Reviewed Mortality Minimal Minimal or None Minimal Straightforward Limited Limited Low Low Complexity Multiple Moderate Moderate Moderate Complexity Extensive Extensive High High Complexity 6
Evaluation & Management Services Basic cognitive service to assess the patient s status and establish a plan of care Can occur in any setting: office, hospital, home, nursing home, etc. There are different levels of service based upon the work involved. It is a face to face service. 7
E&M Established Patient Codes Procedure History Examination Medical Decision Code Making 99211 N/A N/A N/A 99212 Problem Focused Problem Focused Straightforward 99213 Expanded Problem Expanded Problem Low Complexity Focused Focused 99214 Detailed Detailed Moderate Complexity 99215 Comprehensive Comprehensive High Complexity 8
Evaluation & Management Services New Patient A patient who has not been seen by the physician (or a physician in the same specialty in the same group) in the past three years. Established Patient A patient who has received professional services from a physician in the same specialty or same group within the past three years. New Pt. Code Level Established Pt. Code 99201 Level 1 99211 99202 Level 2 99212 99203 Level 3 99213 99204 Level 4 99214 99205 Level 5 99215 9
Evaluation and Management Levels Procedure History Examination Medical Decision Code Making Level 1 Problem Focused Problem Focused Straightforward Level 2 Expanded Expanded Straightforward Problem Focused Problem Focused Level 3 Detailed Detailed Low Complexity Level 4 Comprehensive Comprehensive Moderate Complexity Level 5 Comprehensive Comprehensive High Complexity 10
E&M Coding: Examination GENERAL MULTI SYSTEM EXAMINATION Level of Examination Problem Focused Expanded Problem Focused Detailed Comprehensive Perform and Document 1 5 elements identified by a bullet in 1 or more organ system(s) or body area(s) At least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s) At least 2 elements identified by a bullet from at least 6 organ systems or body areas or at least 12 elements identified by a bullet in 2 or more organ systems or body areas All elements identified by a bullet in at least 9 organ systems or body areas; for each system/area, at least 2 elements identified by a bullet 11
E&M Coding: History History of Past Review of Systems Past / Family or Level of History Illness (HPI) (ROS) Social History (PFSH) Brief N/A N/A Problem Focused (1 3 elements) Brief Problem Pertinent N/A Expanded Problem (1 3 elements) Focused Extended Extended Pertinent Detailed (4 or more elements) Extended Complete Complete Comprehensive (4 or more elements) Elements: ROS: PFHS areas: location, quality, constitutional, eyes, ears past history severity, duration, nose, mouth, throat, family history timing, context, cardiovascular, respiratory, social history modifying factors, gastrointestinal, gastroassociated signs urinary, musculoskeletal and symptoms integumentary, neurological, psychiatric, endocrine, hematologic/ lymphatic, allergic/ immunologic 12
E&M Coding: Examination SINGLE ORGAN SYSTEM EXAMINATION Level of Examination Problem Focused Expanded Problem Focused Detailed Comprehensive Perform and Document 1 5 elements identified by bullet in box with either shaded or unshaded border At least 6 elements identified by bullet in box with either shaded or unshaded border At least 12 elements identified by bullet in box with either shaded or unshaded border (except eye and psychiatric examinations) Perform all elements identified by bullet in box with either shaded or unshaded border; document every element in each box with shaded border and at least 1 element in box with unshaded border 13