Clari fying Requirements And Providing Tools For Success

Speaker: Marisa Clauson, CPC

E&M AUDITING

The first step in understanding medical record documentation is becoming knowledgeable of the Evaluation and Management guidelines by which Physicians and Advanced Practice Professionals must document their services.

DOCUMENTATION REQUIREMENTS

“Medical necessity of a service is the overarching criterionfor payment in addition to the individual requirements of aCPT code. It would not be medically necessary orappropriate to bill a higher level of evaluation andmanagement service when a lower level of service iswarranted. The volume of documentation should not be theprimary influence upon which a specific level of service isbilled. Documentation should support the level of servicereported.”Per Internet Only Manual (IOM) Medicare Claims ProcessingManual, Publication 100-04, Chapter 12, section 30.6.1

MEDICAL NECESSITY

The record should be complete and legible.Each documented encounter should include:

• The reason for the encounter, relevant history, physical exam findings and prior diagnostic test results.

• The plan of care• Date and legible identify of the provider• If not specifically documented, the rationale for ordering diagnostic and

other ancillary services should be easily inferred.• Past and present diagnosis should be accessible• Appropriate risk factors should be identified.• The patient’s progress, response to and changes in treatment should be

documented.

GENERAL PRINCIPLES

Centers for Medicare & Medicaid Services (CMS) contractors have been monitoring supporting documentation of E/M services, and have noticed among EHR users a high volume of records with identical documentation across services. In other words, information from previous encounters is brought forward without updating, which brings into question the validity of the entire service.

CLONED DOCUMENTATION IS INAPPROPRIATE

Medicare contractors consider records cloned when: Each entry in medical record is worded exactly like or

similar to the previous entries. Medical documentation is exactly the same from patient to

patient. Cloning often occurs on claims for procedures that have

specific sets of coverage criteria and is most often found as pre-printed, template-type and/or electronic health record notes.

Medicare contractor position: “Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services”.

What makes this visit different/medically necessary from the previous visit, when both are recorded exactly the same?

CLONED DOCUMENTATION-CONTD.

Many providers feel that the 1995 guidelines meet their needs more effectively as the documentation requirements aren’t as cumbersome and specific. That being said, the documentation will be less detailed then if the provider were using the 1997 guidelines.

Providers can choose to use either the 1997 or the 1995 guidelines, whichever is more advantageous to the provider.

It's hard to say that one set of rules is "better" because each version has advantages and disadvantages. You must choose to use one or the other. It is NOT ACCEPTABLE to mix and match elements from both sets of rules within the same note.

1995 VS. 1997 DOCUMENTATION GUIDELINES

The level of service billed is based on the following three key elements:

History Exam Medical Decision Making

Other contributory components would be:

Counseling Coordination of care (with other providers) Nature of presenting problem Time (must be documented in record if used for level of

service)

EVALUATION & MANAGEMENT SERVICES

Every medical record must document a chief complaint (reason for visit).

Usually stated in the patients wordsExample: Four year old boy complaining of bilateral

ear pain, sore throat and fever.Any note not containing a chief complaint will not

meet any level of History as it is required for all E&M service levels.

The chief complaint does not have to be separately documented from the HPI.

HISTORY: CHIEF COMPLAINT

If the visit is strictly for follow up, the condition being followed must be

documented.

Inappropriate example: Patient here for follow up

Appropriate Example: Patient is here for follow up

regarding diabetes management.

CHIEF COMPLAINT

The HPI describes the patients current illness from the first sign and/or symptom to present or from the previous encounter to the present.

The HPI must be documented by the provider. There are a total of 8 elements that can be used to

describe the HPI.Effective Sept. 30, 2013, when billing Medicare, you

may combine the 1997 extended HPI elements along with the 1995 exam guidelines. (Status of 3 or more chronic conditions)

HISTORY OF PRESENT ILLNESS (HPI)

Location- Where the symptom is occurring

Quality- Describing the symptom or

pain

Severity- Rating or

describing the symptom or

pain

Duration- How long has the

pain or symptom been present

Timing- When the symptom

occurs

Context- Instances that

can be associated with the symptom.

Modifying Factors-

Actions done to make symptom better or worse

HPI ELEMENTS

There are two levels of HPI:

• Brief ( 1 to 3 elements)• Extended (4 or more elements)

Example: Patient complaining of left knee (location) pain for three days (duration).

Example: Patient complaining of sharp (quality) left knee (location) pain for three days (duration), worsens with weight bearing (context).

HPI ELEMENTS, CONT.

Positive or negative responses to questions that are asked of the patient.

The ROS can be documented by the patient on a questionnaire or by medical staff.

If the provider references this document, he/she would need to document it in the medical record. The provider would also need to date and sign the document to show that it was referenced.

REVIEW OF SYSTEMS (ROS)

A total of 14 systems 1) Constitutional Symptoms (usual weight, recent weight

changes, fever, weakness, fatigue)2) Eyes (Visual disturbance, glaucoma, cataracts, pain,

redness)3) Ears, Nose, Mouth, Throat (Hearing, discharge, tinnitus,

dizziness, pain, head cold, soreness, redness, hoarseness, difficulty swallowing)

4) Cardiovascular (Chest pain, rheumatic fever, tachycardia, palpitation, elevated blood pressure, edema, faintness, varicose veins)

5) Respiratory (Chest pain, wheezing, cough, dyspnea, bronchitis)

6) Gastrointestinal (Appetite, thirst, nausea,, hematemesis, rectal bleeding, diarrhea, constipation)

REVIEW OF SYSTEMS

7) Genitourinary (Urinary Frequency, pain, nocturia, hematuria, incontinence, menstruation changes, symptoms of menopause)

8) Musculoskeletal (Joint of muscle pain, stiffness, cramps, swelling, l imitation in motor activity)

9) Integumentary (Rashes, eruptions, dryness, jaundice, changes in skin, hair or nails)

10) Neurological (Headaches, faintness, blackouts, seizures, tingling, tremors, memory loss, involuntary movements)

11) Psychiatric (Personality type, nervousness, mood, insomnia, nightmares, depression)

12) Endocrine (Thyroid trouble, heat or cold intolerance, excessive sweating, thirst, hunger or urination)

13) Hematologic/Lymphatic (Anemia, easy bruising or bleeding, jaundice, transfusions)

14) Allergy/Immunologic (Difficulty breathing, anaphylaxis, swelling, sneezing, runny nose or itchy eyes in response to food, medication or airborne allergens)

REVIEW OF SYSTEMS (CONT.)

Problem Pertinent (Inquires about the system directly related to the problem identified in the

HPI) - 1 system

THREE LEVELS OF REVIEW OF SYSTEMS

PFSH - PAST, FAMILY & SOCIAL HISTORY

History Type Chief Complaint

HPI ROS PFSH

Problem Focused

Chief Complaint

Brief (1-3) None None

Expanded Problem Focused

Chief Complaint

Brief (1-3) Problem Pertinent

None

Detailed Chief Complaint

4+ 2-9 Pertinent (1)

Comprehensive Chief Complaint

4+ Complete (10+)

Complete (3)Est. (2)

WHAT IS YOUR HISTORY LEVEL?

All three elements in the table must be met to qualify for a given type of history.

DO NOT count a given element more than once in determining a type of history. For example, an element counted in the HPI may not be counted again as an element of the ROS.

Review of system MUST be medically necessary for chief complaint. If patient presents for a ankle sprain you should not be checking the Genitourinary system!

10 year old boy presents today complaining of right wrist pain. He indicates that he was skate boarding yesterday and fell. Feels sharp pain when he grabs at objects. Mom indicates that Tylenol does seem to help a little.

Review of system: Patient states wrist hurts with movement.

No PFSH documented.

WHAT LEVEL OF HISTORY IS THIS??

4 HPI Documented1. Location- Right Wrist pain2. Duration- Fell yesterday3. Quality- Sharp pain4. Modifying Factors- Tylenol helps a little

1 Review of Systems 5. Musculoskeletal

No Past, Family or Social HistoryHistory= Expanded Problem Focused

CODE MY LEVEL OF HISTORY….

1) Constitutional (Vital signs, general appearance)2) Eyes3) Ears, nose throat & mouth ( When auditing, verify all 3

areas are documented to give credit)4) Cardiovascular5) Respiratory6) Gastrointestinal7) Genitourinary8) Musculoskeletal9) Skin10)Neurologic11)Psychiatric12)Hematologic, lymphatic, immunologic

EXAM SYSTEMS

Based on four types of exams, using 1995 Guidelines

1) Problem Focused- A limited examination of the affected body area or organ system

2) Expanded Problem Focused- A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)

3) Detailed- An extended examination of the affected body(s) and other symptomatic or related organ system(s)

4) Comprehensive- A general multi-System examination or complete examination of a single organ system(s)

LEVELS OF E&M SERVICES

An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based upon clinical judgment, the patient’s history, and nature of the presenting problem(s).

The 1995 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: general multi-system examination and single organ examination.

1997 Guidelines - A general multi-system examination involves the examination of one or more organ systems or body areas, as depicted in the chart on the next slide.

EXAMINATION

TYPE OF EXAMINATION DESCRIPTION

Problem Focused Include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s).

Expanded Problem Focused Include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).

Detailed Include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas.

Comprehensive Include at least eight organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by bullet is expected.*

1997 Guidelines:

A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below

A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below.

Type of Examination DescriptionProblem Focused Include performance and documentation of one to five

elements identified by a bullet, whether in a box with a shaded or unshaded border

Expanded Problem Focused

Include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.

Detailed Examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border. Eye and psychiatric examinations include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border

Comprehensive Include performance of all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected

•Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is not sufficient.•Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. •A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

Some important points that should be kept in mind

when documenting general multi-

system and single organ system

examinations (in both the 1995 and

the 1997 documentation guidelines) are:

WHAT LEVEL IS YOUR EXAM?

Documentation of an Encounter Dominated by Counseling and/or Coordination of Care

When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit t ime in the hospital, or NF), time is considered the key or controll ing factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, the total length of t ime of the encounter should be documented and the record should describe the counseling and/or activit ies to coordinate care.

The Level I and Level I I CPT® books, which are available from the American Medical Association, l ist average time guidelines for a variety of E/M services. These t imes include work done before, during, and after the encounter. The specific t imes expressed in the code descriptors are averages and, therefore, represent a range of t imes that may be higher or lower depending on actual cl inical circumstances.

COUNSELING

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors: The number of possible diagnoses and/or the number

of management options that must be considered; The amount and/or complexity of medical records,

diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

MEDICAL DECISION MAKING

The chart below depicts the elements for each level of medical decision making. To qualify for a given type of

medical decision making, two of the three elements must either be met or exceeded.

TYPE OF DECISION MAKING

# OF DIAGNOSIS OR MANAGEMENT OPTIONS

AMOUNT AND/ OR COMPLEXITY OF DATA TO BE REVIEWED

RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

Straightforward

Minimal Minimal or None

Minimal

Low Complexity

Limited Limited Low

Moderate Complexity

Multiple Multiple Moderate

High Complexity

Extensive Extensive High

The number of possible diagnoses and/or the number of management options that must be considered is based on:

The number and types of problems addressed during the encounter;

The complexity of establishing a diagnosis; and The management decisions that are made by the physician

In general, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.

NUMBER OF DIAGNOSES AND/OR MANAGEMENT OPTIONS

• For each encounter, an assessment, clinical impression, or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation:

• For a presenting problem with an established diagnosis, the record should reflect whether the problem is: • - Improved, well controlled, resolving, or resolved; or • - Inadequately controlled, worsening, or failing to change as expected.

• For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

• The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

• If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom advice is requested

IMPORTANT POINTS TO REMEMBER

The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed.

Indications of the amount and/or complexity of data being reviewed include:

A decision to obtain and review old medical records and/or obtain history from sources other than the patient (increases the amount and complexity of data to be reviewed);

Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test (indicates the complexity of data to be reviewed); and

The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed).

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

Some important points that should be kept in mind when documenting amount and/or

complexity of data to be reviewed include:

•If a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service should be documented. •The review of laboratory, radiology, and/or other diagnostic tests should be documented. A simple notation such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. The review may alternatively be documented by initialing and dating the report that contains the test results. •A decision to obtain old records or obtain additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented.

Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented. If there is no relevant information beyond that already obtained, this fact should be documented. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.

Discussion about results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.

The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.

COMPLEXITY OF DATA, CONT.

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories:

• Presenting problem(s); • Diagnostic procedure(s); and • Possible management options.

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter.

RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

The assessment of risk of selecting

diagnostic procedures and management

options is based on the risk during and

immediately following any procedures or treatment. The

highest level of risk in any one category

determines the overall risk.

The level of risk of significant complications, morbidity, and/or mortality can be: •Minimal; •Low; •Moderate; or •High

MEDICAL DECISION MAKING

Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented;

If a surgical or invasive diagnostic procedure is ordered, planned, performed or scheduled at the time of the E/M encounter, the type of procedure should be documented;

The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied

SOME IMPORTANT POINTS THAT SHOULD BE KEPT IN MIND WHEN DOCUMENTING LEVEL OF RISK ARE:

Risk of Significant Complications, Morbidity, and/or Mortality, cont.

The table on the next couple of pages may be used to assist in determining whether the level of risk of

significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute

measures of risk.

No face-to-face professional services received from the physician or another physician of the same specialty and sub-specialty who belongs to same group practice for three years

Internal Medicine and Family Practice are considered different specialty

Patient seen by physician covering or on-call physician considered patient of usual doctor and is not a new patient

NEW VS ESTABLISHED PTS

E&M

Medical Decision Making

ExamHistory

PUTTING IT TOGETHER

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

(Evaluation and Management Services Guide)

“The Art of E&M Auditing” by Intelicode

Per Internet Only Manual (IOM) Medicare Claims Processing

Manual, Publication 100-04, Chapter 12, section 30.6.1

REFERENCES