DOCUMENTATION - midwest-site



DOCUMENTATION and CODING

INTRODUCTION

Documentation and coding are directly related to appropriate reimbursement now more than ever before.

• Documentation in the medical record must support the CPT-4 and ICD-9-CM codes submitted on claim forms.

• Documentation in the patient record should:

• Provide continuity of care

• Support the code billed

• Serve as a legal document that verifies care provided

RELATIONSHIP TO FRAUD & ABUSE

• Brief fraud & abuse legislation history

• Health Insurance Portability and Accountability Act of 1996 (HIPAA)

• Created Federal healthcare fraud and abuse trust fund to finance future law enforcement activities.

• Extended the Federal criminal offense to all payer sources (except FEHBP) and granted broader investigative authority to the OIG, FBI and DOJ.

• Established a Beneficiary Incentive Program, which requires Medicare EOB’s for all Medicare services and provides a reward to individuals who report information that leads to the imposition of penalties.

• Expanded Medicare/Medicaid criminal provisions (anti-kickback law).

• Amended the exclusion provisions to require mandatory exclusion for a minimum of 5 years. Extended exclusion to include officers and managing employees of the entity convicted of healthcare fraud regardless of the level of involvement in the fraudulent activity.

• Expanded authority to impose civil monetary penalties to all payer sources (except FEHBP). Increased the maximum fine from $2,000 to $10,000 for each line item or service and assessments from double to triple the amount claimed.

• Penalties

• Federal False Claims Act

• Treble damages of not less than $5,000 nor more than $10,000 per claim plus reasonable costs and attorney fees.

• Not exclusive of other penalties.

• Federal Criminal Statutes

• Mandatory exclusion from government programs for at least 5 years.

• Probable loss of license.

• Civil Penalties Administered by OIG

• Exclusion from government programs.

• Monetary penalties equivalent to the False Claims Act.

• State Laws

• RICO Civil Suit

• Fraud - Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or another.

Examples:

• Billing for services not rendered/not documented

• Kickback arrangements between providers and suppliers

• Up-coding

• Unbundling

• Abuse - Actions that are inconsistent with sound business or medical practices and result in provision of services or care that is not reasonable or necessary.

Examples:

• Over utilization of services

• Excessive fees for services

• Provision of harmful or poor quality care

• Risks/Targets

• Up-coding

• Billing for services not documented

• Professional/courtesy discounts

• Unbundling

• Investigations/Audits can be triggered by:

• Claims data

• Patient complaints

• Employee complaints

• Information shared from investigation of other providers

• Information shared from investigations by other agencies/payers

DOCUMENTATION

• E&M services are related to the intensity and complexity of the care provided during the patient encounter.

• Types & definitions of E&M visits:

• New patient – A patient who has not received professional services from the physician or any member of the same group practice who is of the same specialty within the past three years. In addition, TMM adheres to the Medicare guidelines for IN, IL, and KY that specify that encounters must be face-to-face. (Interpretation of an X-ray or EKG does not constitute a face-to-face encounter.)

• Established patient – A patient who has received professional services from the physician or any member of the same group practice who is of the same specialty within the past three years. (A covering physician must classify the encounter as it would have been by the patient’s attending physician.)

• Problem-oriented - An encounter that is primarily care for a chief complaint or requires care for an acute or chronic condition. The condition requires performance of the three key components of a problem-oriented E&M service: history, examination and decision-making.

• Preventive - An encounter that is primarily for a physical exam, pap or well-child visit. An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive evaluation which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

• Split - An encounter that is initially for a preventive service where an significant problem/abnormality is encountered in the process of performing the preventive evaluation and requires additional work in performance of the key components of a problem-oriented E&M service.

• Key components of E&M Services:

• History

• Chief Complaint – A concise statement describing the problem, symptoms, condition, diagnosis or other factors that constitute the reason for the encounter, usually stated in the patient’s words.

• History of Present Illness – A chronological description of the development of the present illness from the first sign and/or symptom to the present. Includes location quality severity, timing context, modifying factors and associated signs and symptoms related to the problem.

• Review of Systems - An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms, which the patient may be experiencing or has experienced.

• Past Medical History - Review of the patient’s past experiences with illnesses, injuries and treatments. Information should include surgeries, major illnesses and injuries, hospitalizations, current medications, allergies, immunizations and dietary habits.

• Social History - Information related to tobacco, alcohol or drug use, occupation, education, marital status and other pertinent social information.

• Family History - Review of medical events in the patient’s family that includes significant information about the health/death of parent, siblings and children, specific diseases related to the patient’s current complaint and hereditary diseases.

• Examination

• The examination performed and documented is dependent upon clinical judgement, the patient’s history and the nature of the presenting problems.

• General Multi-System Exam documents one to eighteen elements of fourteen possible systems or organs. These systems/organs include constitutional, eyes, ENMT, neck, respiratory, cardiovascular, chest/breast, GI/abdomen, lymphatic, skin, GU, musculoskeletal, neurologic and psychiatric. (Most frequently used in Family Practice.)

• Single Organ/System Exam documents information from examination of a single body organ or system. These include cardiovascular, ENMT, eyes, GU, hematologic/lymph/immunologic, musculoskeletal, neurological, psychiatric, respiratory and skin. (Most frequently used by specialists.)

• Medical Decision Making

• The complexity of establishing a diagnosis and/or selecting a management option.

• The level is determined by factors including the number of possible diagnoses and management options, the amount and complexity of data and risk of significant complications, morbidity and/or mortality.

E&M CODE KEY COMPONENTS

|KEY COMPONENTS |ELEMENTS/BULLETS |POSSIBLE LEVELS |

|HISTORY |CC – Description of symptoms |Problem Focused |

| |HPI – Location, quality, severity, duration, | |

| |timing, context, moderating factors, associated | |

| |signs and symptoms | |

| |ROS – Constitutional, eyes, ENMT, cardiovascular, |Expanded Problem Focused |

| |respiratory, GI, GU, musculoskeletal, | |

| |integumentary, lymphatic, allergy/immunologic | |

| |PFSH – past illnesses, surgeries, injuries, | |

| |treatment, family medical events, hereditary | |

| |diseases, past and current social |Detailed |

| |factors/activities | |

| | | |

| | | |

| | | |

| | |Comprehensive |

|EXAM |BODY AREAS – Head/face, neck, chest/breast/axilla, |Problem Focused |

| |abdomen, genitalia/groin/buttocks, back/spine, each| |

| |extremity | |

| |ORGAN SYSTEMS – eyes, ENMT, cardiovascular, GU, |Expanded Problem Focused |

| |neurologic, lymphatic, respiratory, | |

| |musculoskeletal, psychiatric, GI, immunologic, | |

| |hematologic, skin |Detailed |

| | | |

| | | |

| | |Comprehensive |

|DECISION MAKING |# Diagnoses/Management Options |Straightforward |

| |Amount/Complexity of Data | |

| |Risk of Complication, Morbidity/Mortality |Low Complexity |

| | | |

| | |Moderate Complexity |

| | | |

| | |High Complexity |

CODE LEVEL ELEMENT REQUIREMENTS

|LEVEL |HISTORY |EXAM |DECISION MAKING |

|Problem Focused |CC |1 – 5 bullets from 1 or more body systems|Straightforward |

| |1 – 3 elements from HPI | |(Options, Data & Risk =|

| | | |Minimal) |

|Expanded Problem Focused |CC |6 – 11 bullets from 1 or more body |Low Complexity |

| |1 – 3 elements from HPI |systems |(Options & Data = Limited; Risk = |

| |1 element from ROS | |Low) |

|Detailed |CC |12 – 17 bullets from 2 or more body |Moderate Complexity |

| |4 elements from HPI |systems |(Options = Multiple; Data & Risk |

| |2 elements from ROS | |= Moderate) |

| |Past, Family OR Social History | | |

|Comprehensive |CC |2 or more bullets from EACH of 9 body |High Complexity |

| |4 elements from HPI |systems or areas |(Options & Data = Extensive; Risk|

| |10 elements from ROS | |= High) |

| |Past, Family AND Social History | | |

• New patient level determination

• Requires 3 of the 3 areas meet or exceed the code level submitted.

• Established patient level determination requirements

• Requires 2 of 3 areas meet or exceed the code level submitted.

Patient ID: Date of Service: Reviewer: Date of Review:

Code Billed: __________________________________Code Documented: ______________________________

Diagnosis Code Billed:______________________Diagnosis Code Documented:________________________

___Medicare Signature on File ___MSP Form Present ___Medicaid/Medicare Waiver Present

_______________________________________________________________________________________________

A.HISTORY______________________________________________________________________

| Problem Focused | Expanded | Detailed | Comprehensive |

|Chief Complaint |Chief Complaint |Chief Complaint |Chief Complaint |

|1-3 elements about HPI |1-3 elements about HPI |4 elements about HPI |4 elements about HPI |

| |Review of 1 system |Review of 2 systems |Review of 10 systems |

| | |Personal, Family or Social Hx |Personal, Family and Social Hx. |

|History Of Present Illness | Location | Duration | Timing | Associated S&S | Status of 3 Chronic or | PF E |

| |Quality |Severity |Context (cause) |Modifying factors |Inactive Illnesses |D C |

|Past, Family, Social History |Past Personal |Family |Social | |

| |Current Medications |Health status/ cause of death of parents, |Employment / Occupational Hx |PF |

| |Allergies |siblings &/or children |Sexual history/GYN history |E |

| |Prior Illnesses/Surgeries |Specific diseases related to chief complaint |Drug, alcohol, tobacco use |D |

| |Prior hospitalization |present illness or ROS |Marital status |C |

| |Immunizations | |Education | |

| |Other | |Other | |

B.MULTI-SYSTEM EXAM________________________________________________________________

| Problem Focused | Expanded | Detailed | Comprehensive |

|1-5 bullets from 1 or more systems |6-11 bullets from 1 or more systems |12-17 bullets from 2 or more systems / |2 or more bullets from EACH of 9 systems / |

| | |areas |areas |

|System/Body Area |Elements of Exam | |System/Body Area |Elements of Exam |

|Constitutional | General appearance of Patient | |Genitourinary |Males |

| | Measurement of any 3 vital signs | | | Exam of scrotal contents (spermato-/hydrocele, mass, tender) |

|Eyes | Inspection of conjunctiva, sclera & lids | | | Exam of the penis |

| | Exam of pupils & irises | | | Digital rectal exam of prostate (size, symmetry, nodule,tender) |

| | Ophthalmoscopic exam (optic disc, C/D ratio, post segs) | | |Females |

|Ears, Nose, | External inspection of ears & nose | | |Pelvic exam w/ or w/o collection of pap smear, including: |

|Mouth, Throat |Otoscopic exam of auditory canals & TM’s | | |Exam of external genitalia & vagina (cysto-/rectocele) |

| | Assessment of hearing | | | Exam of urethra (mass, tenderness, scarring) |

| | Inspection of nasal mucosa, septum, turbinates | | | Exam of bladder (mass, fullness, tenderness) |

| | Inspection of lips, teeth & gums | | | Exam of cervix (appearance, lesions, discharge) |

| |Exam of oropharynx (tongue, tonsils, mucosa, palates) | | |Exam of uterus (size, position, mobility, tenderness, support) |

| | | | | Exam of adnexa / parametria (mass, tender, organomegaly) |

|Neck | Exam of neck (masses, symmetry, trach position, crepitus) | |Musculoskeletal | Exam of gait & station |

| |Exam of thyroid (enlargement, tenderness, mass) | | |Inspection &/or palpation of digits & nails |

|Respiratory | Assessment of respiratory effort | | | (clubbing, cyanosis, infection) |

| | Percussion of chest (dullness, flatness, hyperresonance) | | |Examination of joints, bones, and muscles of |

| | Palpation of chest (tactile, fremitus) | | |one or more of the following six areas: |

| | Auscultation of chest(breath/adventious sounds, rubs) | | | - Head & neck; - Spine, ribs, & pelvis ; |

|Cardiovascular | Palpation of heart (location, size, thrills) | | | - R. upper extremity; - L. upper extremity, |

| | Auscultation of heart (note abnormal sounds) | | | - R. lower extremity; - L. lower extremity |

| | Exam of carotid arteries (bruits, pulse amplitude) | | |The examination of a given area includes: |

| | Exam of abdominal aorta (size, bruits) | | | Inspection &/or palpation (note asymmetry, tenderness, |

| | Exam of femoral arteries (pulse, amplitude, bruits) | | | crepitation, defects, effusion, masses) |

| | Exam of pedal pulses (pulse, amplitude) | | | Assessment of ROM (note pain, crepitation, contracture) |

| | Exam of extremities for edema, varicosities | | | Assess stability (note dislocation, subluxation, laxity) |

|Chest | Inspection of breasts (symmetry, nipple discharge) | | |Assess muscle strength & tone (note atrophy, etc.) |

|(Breasts) | Palpation of breasts & axillae (masses, tenderness) | | | |

|Gastrointestinal | Exam of abdomen (note mass, tenderness, sounds) | |Neurologic | Test cranial nerves (note deficits) |

|(Abdomen) | Exam of liver & spleen | | | Exam of deep tendon reflexes (Note pathological reflexes) |

| | Exam for presence or absence of hernia | | | Examination of sensation (by touch, pin, vibration, etc.) |

| | Exam of anus, perineum, rectum(sphincter tone, mass) | |Psychiatric | Description of patient’s judgment & insight |

| |Stool sample for occult blood | | |Brief description of mental status including: |

|Lymphatic |Palpation of lymph nodes in two or more areas: | | | Orientation to time, place & person |

| | Neck Axillae Groin Other | | | Recent & remote memory |

|Skin | Inspection of skin, sub-Q tissue (lesions, rash,ulcers) | | | Mood & affect (depression, anxiety, agitation) |

| | Palpation of skin, sub-Q tissue (indurated, mass, tight) | | | |

Medical Decision Making

|A. Number of Diagnoses or Treatment Options | | | |B. Amount/Complexity of Data Reviewed | |

|Self limited or minor (Stable, improved or | | 1 |(Max = 2) |Order &/or review clinical lab tests | 1 |

|worsening) | | | | | |

|Established problem (Stable, improved) | | 1 | |Order &/or review tests from radiology section | 1 |

|Established problem (Worsening) | | 2 | |Order &/or review tests from medicine section | 1 |

| | | | |(EKG, EMG, allergy tests, audiometry) | |

|New problem (No additional work-up planned) | | 3 | |Discussion of test results with performing provider | 1 |

|New problem (Additional work-up planned) | | 4 | |Decision to obtain old records/Obtain history from other than patient/Discuss| 2 |

| | | | |case with other provider | |

| | | | |Independent visualization of image, tracing or report | 2 |

|TOTAL | | | |TOTAL | |

|C. Complication Risk Factor(s)|(Select highest assigned to any category) | | |

|Level of Risk |Presenting Problem |Dx Procedures Ordered |Management Options Selected |

|Minimal |One self-limited or minor problem |Lab tests, X-rays, EKG, EEG |None required, rest, superficial dressings |

|Low |Multiple self-limited or minor problems |Physiologic tests w/o stress |OTC remedy |

| |One stable chronic illness |Imaging studies w/contrast |Minor surgery w/o risk factor |

| |Acute, uncomplicated illness or injury |Superficial needle biopsy |PT, OT or ST |

| | |Skin biopsy |IV fluids w/o additive |

| | |Arterial blood draw | |

|Moderate |One or more chronic illness with exacerbation, |Stress tests |Minor surgery w/identified risk |

| |progression or treatment side effects |Endoscopies w/o risk factors |Elective major surgery w/o identified risk |

| |Two or more chronic stable illnesses |Cardiovascular imaging study w/o |Prescription drug management |

| |Undiagnosed new problem with uncertain prognosis |identified risk factor |Therapeutic radiology |

| |Acute complicated injury |Deep needle or incisional bx |IV fluids w/additives |

| |Acute illness with systemic symptoms |Centesis of body cavity fluid |Closed treatment of skeletal injury |

|High |One or more chronic illnesses w/severe exacerbation, |Cardiovascular imaging study w/identified|Elective mahor surgery w/identified risk |

| |progression or treatment side effects |risk |Emergency major surgery |

| |Acute or chronic illness or injury that may pose a |Cardiac electrophysiological tests |Parenteral controlled substance |

| |threat to life or bodily functions |Endoscopy w/identified risk factors |Drug therapy requiring intensive monitoring |

| |Abrupt change to mental status | | |

|TABULATION OF MEDICAL DECISION MALKING | | | | |

|A. Diagnoses/Management Options |Minimal (< 1) |Limited (2) |Multiple (3) |Extensive (> 4) |

|B. Amount/Complexity of Data |Minimal/Low ( 4) |

|C. Highest Risk (From any category) |Minimal |Low |Moderate |High |

| MEDICAL DECISION MAKING |Straightforward |Low Complexity |Moderate Complexity |High Complexity |

|(Highest 2 of 3 areas.) | | | | |

INITIAL NEW PATIENT OFFICE VISIT (Requires 3 out of 3 to be met or exceeded)

| |CODE |HISTORY |EXAM |DECISION MAKING |TIME |

|Level I |99201 |Problem Focused |Problem focused |Straightforward |10 |

|Level II |99202 |Expanded problem focused |Expanded problem focused |Straightforward |20 |

|Level III |99203 |Detailed |Detailed |Low complexity |30 |

|Level IV |99204 |Comprehensive |Comprehensive |Moderate complexity |45 |

|Level V |99205 |Comprehensive |Comprehensive |High complexity |60 |

ESTABLISHED PATIENT VISITS (Requires 2 out of 3 to be met or exceeded)

| |CODE |HISTORY |EXAM |DECISION MAKING |TIME |

|Level I |99211 |Nurse Visit |Nurse visit |Nurse visit |10 |

|Level II |99212 |Problem Focused |Problem focused |Straightforward |20 |

|Level III |99213 |Expanded problem focused |Expanded problem focused |Low complexity |30 |

|Level IV |99214 |Detailed |Detailed |Moderate complexity |45 |

|Level V |99215 |Comprehensive |Comprehensive |High complexity |60 |

OFFICE CONSULTATIONS - NEW OR ESTABLISHED PATIENTS (3 out of 3 to be met or exceeded)

| |CODE |HISTORY |EXAM |DECISION MAKING |TIME |

|Level I |99241 |Problem Focused |Problem focused |Straightforward |10 |

|Level II |99242 |Expanded problem focused |Expanded problem focused |Straightforward |20 |

|Level III |99243 |Detailed |Detailed |Low complexity |30 |

|Level IV |99244 |Comprehensive |Comprehensive |Moderate complexity |45 |

|Level V |99245 |Comprehensive |Comprehensive |High complexity |60 |

CONFIRMATORY CONSULTATIONS (2nd Or 3rd Opinions)

NEW OR ESTABLISHED PATIENT ( 3 out of 3 to be met or exceeded)

| |CODE |HISTORY |EXAM |DECISION MAKING |

|Level I |99271 |Problem Focused |Problem focused |Straightforward |

|Level II |99272 |Expanded problem focused |Expanded problem focused |Straightforward |

|Level III |99273 |Detailed |Detailed |Low complexity |

|Level IV |99274 |Comprehensive |Comprehensive |Moderate complexity |

|Level V |99275 |Comprehensive |Comprehensive |High complexity |

Note: May be requested by the patient, another physician or other entity. The physician using this code is expected to provide an opinion or advice only. These codes may be used in any setting.

Common Mistakes

• New physician coding errors

• Up coding due to large volume of new patient visits requiring 3 of 3 areas meet or exceed the level billed.

• Tend to bill new patient visits using requirements for established patient code levels.

• Established physician coding errors

• Under coding due to large volume of established patient visits requiring only 2 of 3 areas meet or exceed the level billed.

• Tend to bill established patient visits using requirements for new patient code levels.

• Preventive services

• Under-utilized due to general confusion and past habits.

• Tend to bill as problem oriented or split even when there is no significant additional work involved.

• Split billing (well care/sick care)

• Over-utilized due to general confusion and past habits.

• Tend to split bill any visit that is for preventive care in a patient that has at least one other diagnosis, whether it requires significant additional work.

V. Questions

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