Transcript COMPLIANCE
DOCUMENTATION REQUIREMENTS E/M Codes Targeted Codes 99214 : established patient, outpt. visit – presenting problems are usually moderate to high severity 99212: established patient, outpt. Visit – presenting problems usually self limited or minor 99233: subsequent hospital care – usually patient is unstable, developed a significant complication or a significant new problem 99231: subsequent hospital care – usually a stable, recovering, or improving patient Codes accounting for the errors What codes should have been used Principles of Documentation: • MR should be complete & legible • Documentation for each patient encounter should include: – – – – – – – – Reason for encounter & relevant history Physical exam & findings Prior diagnostic test results Assessment Clinical impression or diagnosis Plan for care Date Legible identity of the observer Principles of Documentation Cont. • If not documented, the rationale for ordering diagnostic & ancillary services should be easily inferred • Past & present diagnosis should be accessible to the treating/consulting physician • Appropriate risk factors should be identified • Pt’s progress, response to & changes in treatment & diagnosis revision should be documented • CPT & ICD-9 codes on claim must be supported by MR documentation Evaluation and Management Codes -Developed jointly by HCFA & the AMA How to stay on the good side of HCFA MEDICAL NECESSITY – Inpatient : Does the diagnosis code support the medical need for the service performed? If not, does the documentation in the record support the necessity? – Outpatient : Level of Visit Codes The 7 Components: KEY 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time E & M Determination Level History Examination Med. Decision Making I Prob. Focused Problem Focused Straightforward II Expanded Prob. Focused Expanded Problem Focused Straightforward III Detailed Detailed Low Complexity IV Comprehensive Comprehensive Moderate Complexity V Comprehensive Comprehensive High Complexity The 7 Components: KEY 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time Documentation of History: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive History elements (some or all): chief complaint, CC history of present illness, HPI review of systems, ROS past, family and/or social history, PFSH ROS & PFSH obtained Earlier w/o any change: • Do not have to re-record if there is evidence that a physician had reviewed & updated the previous one • How to documented the review: – Describe any new information, – not that there has been no change, or – note the date & location of the earlier entry DG 1 •ROS & PFSH may be recorded by ancillary staff or by the patient - physician must supplement or confirm the information received for documentation • If not able to obtain information - note in chart the patient’s condition & the circumstances that preclude obtaining a history DG 2 & 3 HPI Elements 1) location Brief: 1-3 2) quality 3) severity Extended: 4) duration at least 4 or the status of at least 3 chronic or 5) timing inactive conditions 6) context 7) modifying factors 8) associated signs & symptoms DG 4 & 5 ROS Elements • • • • • • • constitutional symptoms • • eyes ears, nose, mouth, throat • • cardiovascular • respiratory • gastrointestinal • genitourinary musculoskeletal integumentary neurological psychiatric endocrine hematologic/lymphatic allergic/immunologic ROS Definitions • PROBLEM PERTINENT - inquires about the system directly related to the problem in HPI • EXTENDED - directly related system + 2 - 9 systems documented • COMPLETE - directly related system + all additional body systems DG 6, 7 & 8 PFSH • Pertinent - review of history areas directly related to problem in HPI • Complete - review of 2 or all 3, depending on the category on E&M code (required for comprehensive assessments) DG 9 PFSH requirements for: Initial Patients Est. Patients • requires 1 item from the 3 areas • requires 1 item from the 2 areas • applies to outpt/office, consults, observation pts, nursing home assessments, domiciliary care, home care • applies to outpt/office, ER services, domiciliary care, home care DG 10 & 11 Level of Service Determination Expanded Problem History Prob. Detailed Comprehensive Focused Focused Brief Brief Extended Extended HPI ROS N/A Problem Pertinent Extended Complete PFSH N/A Detailed Pertinent Complete * Must have all 3 in column or choose lowest The 7 Components: KEY 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time Documentation of Examination: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive Exam Types: cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skin Documentation Guidelines: • Elements w/ mult. components require documentation of at least 1 component • “abnormal” can be used for exams of the affected or symptomatic body area • abnormal/unexpected finding in asymptomatic areas should be described • “negative” or “normal” is sufficient for unaffected or asymptomatic areas General Multi-System Exams: PROBLEM FOCUSED: 1-5 elements in 1 body areas/systems EXPANDED PROBLEM FOCUSED: 6 elements in 1 body areas/systems DETAILED: 2 elements in 6 ore more body areas/systems (or 12 elements in 2 areas) COMPREHENSIVE: allelements in selected areas, 9 body areas/systems Single Organ Exams: PROBLEM FOCUSED: 1-5 elements in any box EXPANDED PROBLEM FOCUSED: 6 elements in any box DETAILED: 12 elements in any box (eye & psychiatric 9 elements) COMPREHENSIVE: allelements ( document every element in bold boxes & at least 1 in normal boxes) The 7 Components: KEY 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time Documentation of Medical Decision Making: Level of service is based on 4 types: 1) straight - forward 2) low complexity 3) moderate complexity 4) high complexity -complexity of establishing a diagnosis and/or selecting a management option Complexity factors…. • Pt’s # of diagnoses • the amount and/or complexity of MR, tests, & other information that must be obtained, reviewed, & analyzed • risk of significant complications, morbidity/mortality as well as comorbidities associated with the presenting problem(s) DG for # of Diagnoses or Mgmt. Options…. • Established dx. - state if improved/well controlled/ resolving or worsening/failing to change as expected • new diagnosis - stated in form of differential dx. possible/probable/rule out • initiation or changes in treatment • to whom or where referrals or consults are made or from whom the advice is requested DG for amount & complexity of data to review…. • Types of service ordered at the time of encounter • reviewed results, initial & date report w/ the results • any further history or information obtained from MR, patient, etc. • relevant findings from above • results of discussions w/ physicians associated w/ reviewed results • direct visualization or independent interpretation of tests/films interpreted by another physician Risk DG... • Any factor that would increase the risk of complications, morbidity, mortality • procedures planned at that time • specific procedure performed at time of encounter • need for an urgent procedure to be done Table of Risk Level of Risk minimal low Presenting Problem Diagnostic Procedure Ordered Management Options Selected • one self limited •Lab tests w/ venipuncture or minor problem •Chest x-rays •EKG/EEG •Urinalysis •Ultrasound •KOH Prep • rest •Gargles •Elastic bandages •Superficial dressings • 2 or more self limited problems • 1 stable chronic illness •Acute complicated illness • over the counter drugs •Minor surgery w/ no identified risk factors •PT or OT •IV fluids w/o additives •Physiologic tests not under stress •Non-cardiovascular imaging studies w/ contrast •Superficial needle biopsies •Clinical lab test •Skin biopsies Table of Risk Level of Risk Presenting Problem Moderate • one or more Diagnostic Procedure Ordered •Physiologic test under chronic illness w/ stress mild exacerbation •Diagnostic endoscopies • 2 or more stable w/ no identified risk chronic illnesses factors • undiagnosed new •Deep needle or problem w/ incisional biopsy uncertain •Cardiovascular imaging prognosis studies w/ contrast & no •Acute illness w/ identified risk factors systemic •Obtain fluid from body symptoms cavity •Acute complicated injury Management Options Selected • minor surgery w/ identified risk factors •Elective major surgery w/ no identified risk factors •Prescription drug management • Therapeutic Nuclear Med. •IV fluids w/ additives •Closed treatment of fracture or dislocation w/o manipulation Table of Risk Level of Risk Presenting Problem Diagnostic Procedure Ordered Management Options Selected High • one or more chronic illness w/ severe exacerbation • acute/chronic illness/injury that pose a threat to life or bodily function • Diagnostic endoscopies w/ identified risk factors •Cardiovascular imaging studies w/ contrast & identified risk factors •Cardiac electrophysiological tests •Discography • Emergency major surgery •Elective major surgery w/ identified risk factors •Parental controlled substances •Drug therapy requiring intensive monitoring for toxicity •Decision not to resuscitate Medical Decision Making Determination Type of Decision Making # of dx. or mgmt options Data Reviewed Risks Straight Forward Low Moderate High Minimal Limited Multiple Extensive Minimal Limited Moderate Extensive Minimal Low extensive High * 2 of 3 elements must be met or exceeded E & M Determination Initial Patients must have 3 of 3 Level History Examination Med. Decision Making I 99201 Prob. Focused Problem Focused Straightforward II 99202 Expanded Prob. Focused Expanded Problem Focused Straightforward III 99203 Detailed Detailed Low Complexity IV 99204 Comprehensive Comprehensive Moderate Complexity V 99205 Comprehensive Comprehensive High Complexity E & M Determination Initial Patients must have 3 of 3 Level History Examination Med. Decision Making I 99201 Prob. Focused Problem Focused Straightforward II 99202 Expanded Prob. Focused Expanded Problem Focused Straightforward III 99203 Detailed Detailed Low Complexity IV 99204 Comprehensive Comprehensive Moderate Complexity V 99205 Comprehensive Comprehensive High Complexity NEW PATIENTS 99201-99205 One who has NOT received any professional services from the physician or any other physician of the same specialty who belongs to the same group practice within the past 3 years. 36 E & M Determination Established Patients must have 2 of 3 Level History Examination Med. Decision Making I 99211 Prob. Focused Problem Focused Straightforward II 99212 Expanded Prob. Focused Expanded Problem Focused Straightforward III 99213 Detailed Detailed Low Complexity IV 99214 Comprehensive Comprehensive Moderate Complexity V 99215 Comprehensive Comprehensive High Complexity ESTABLISHED PATIENTS 99211-99215 One who HAS received professional services from the physician of the same specilaity who belongs to the same group practice within the last 3 years. 38 EST. PT Billing - 99211 Can be billed by the nursing staff when a chief complaint exists. Normally Required Care: Blood pressure, weight, reactions to current meds, additional services not usually provided by a physician NOT: finger sticks & injections *physician must be on the premises 39 Observation Care 99218-99220 Report encounters by the supervising MD Characteristics of Observation Pts: • not been admitted as an inpatient • may be physically detained in ER • clinical condition is being observed • additional time needed to clarify condition • to determine if hospitalization is needed 40 Observation to Inpatient• MD admits pt to both w/in 24 hours – bill as initial hospital visit • Do NOT bill for an initial hospital visit & initial obs. code • Can NOT bill for an obs. discharge mgmt when admitting to inpt. 41 Global Surgical Period • Fee includes obs payment • Must use modifiers with the CPT code to receive payment • –57 indicates that the decision for surgery was made while the patient was in obs. • -24 denotes observation services are unrelated to the surgery • -79 subsequent surgical procedure • -25 separately identifiable service 42 MODIFIER -25 Indicates that E/M codes reported on the same bill are for significant and separately identifiable services 43 One last thing… If using a template to dictate your note DON’T FORGET to state that it was “normal” or “negative”