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Welcome to PMI’sWebinar Presentation

Brought to you by:Practice Management Institute®

pmiMD.com

On the topic:

Clinical Documentation Requirements for Primary Care

Meet the Presenter…

Doug ArringtonCMC, CHC, CHRC, CPC, COC,

CPMAFaculty

Practice Management Institute

Clinical Documentation –Primary Care

Doug Arrington, DNP(c), MSN, FNP, CMC, CPC, COC, CPMA,

CHC, CHRC

Faculty – PMI

References • AHIMA – Clinical Documentation for ICD-10 CM and PCS -

http://www.ahima.org/education/onlineed/Programs/cdi• ICD-10 CM Coding for IM, Primary Care, Peds and OB/GYN -

http://betterhealth.mckesson.com/wp-content/uploads/MED3000-ICD-10-slide-deck-3-14-13.pdf• ICD-10 Clinical Concepts for Family Practice -

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsFamilyPractice1.pdf

• ICD-10 CM Official Guidelines for Coding and Reporting FY 2016 -https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf

• ICD-10 Clinical Concepts for Pediatrics -https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsPediatrics1.pdf

• ICD-10 Clinical Concepts for Internal Medicine -https://www.acponline.org/running_practice/payment_coding/coding/icd10-clinical-concepts-nternal-medicine.pdf

• ICD-10 CM Crosswalks in the primary care setting: assessing reliability of the GEMs and reimbursement mapping -http://jamia.oxfordjournals.org/content/jaminfo/early/2015/02/07/jamia.ocu028.full.pdf

• Thompson, T. (n.d.). The good, the bad, and the Ugly ICD-10 CM -http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Management/finances-coding/The-Good-the-Bad-coding-webinar-April-16.pdf

• Note: None have copyright or TM – okay to copy and use in your practice

Practice Management Institute www.pmiMD.com

Webinar/Audio Conference September 15, 2015

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Objectives

• Documentation of acuity and severity of illness• Meaningful Use• Enough information for the coder to apply the

correct code• Identify the anatomical specificity required clinical

documentation for certain primary care diagnoses, and procedures

• Outline the chronic diagnosis for primary care providers, and outline the detailed in documenting chronic disease illness, manifestation, complications, cause, and effect

Guiding Principles of I-10 Clinical Documentation

• “Documentation for ICD-10 is an unnecessary burden.” – The number and type of new concepts required

for ICD-10 are not foreign to clinicians

– The focus of documentation is good patient care

– Patients deserve to have accurate and complete documentation of their conditions

– If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we?



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Basic Clinical Documentation Includes:

• Reason for encounter or chief compliant• • Relevant history of the illness (timeline since

last visit for all follow ups)• Physical examination findings • Diagnostic test results – since last visit• Assessment – for visit – not entire problem

list – only items addressed in the HPI• Clinical impression or diagnosis – only items

in HPI• Medical Plan of Care – items in HPI



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Documentation for Severity and Risk (MDM)

• Comorbidities• Manifestations• Etiology/Causation• Complications (cause

and effect)• Anatomical location –

detailed• Sequelae• Functional state• Trimesters/Weeks

gestations

• Phase/stage of illness or disease

• Complication Codes• Lymph involvement• Lateralization &

localization• Procedure – detailed• Implants, devices,

biologics and medications

• Clinical Scales – Coma Score

Good Documentation Includes

• Rationale for ordering diagnostics and ancillary services

• Health risk factors identified

• Patient’s progress

• Patient’s response to treatment/non compliance identified

• Revisions of diagnosis documented based on clinical results

• All codes reported on the claim form must be supported in the medical record – if it has not been documented – it has not been done.



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What I learned In______

• Type of condition

• Onset – when did it first start

• Etiology/Cause– Infectious agent

– Physical agent

– Internal failure

– Congenital


• Anatomical location– Structure of problem

• Proximal, distal, medial, lateral, central peripheral, superior, inferior, anterior, posterior

– Laterality• Right or left, bilateral or unilateral

– Severity• Mild, moderate, or severe

– Other factors• Smoking, geographic location, occupation, high risk

behaviors,



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• Time parameters– Intermittent, recurring, acute/chronic

• Complications or Comorbidities– Diabetes with neuropathic joint

– Intracranial Injury

• Manifestations– Paralysis, Loss of consciousness


• Healing levels– Routine, delayed, malunion, non-union

• Findings or symptoms– Fever, hypoglycemia/hyperglycemia– Wheezing, murmur, hyperactive bowel sounds

• External cause– MVA, injury, assault, work related, self harm

• Encounter Type– Initial, subsequent, sequela, routine exam,

administrative,



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Poorly Coded or Poorly Documented – definition

• Coding (Documentation) that does not fully define important parameters of the patient condition, [or not documented] that could otherwise be defined given information available to the clinician and/or the coder.

• However, if it has not been documented – it cannot be coded

• Coders are not clinicians – they do not/can not interpret lab reports, diagnostic studies, nor are they magicians – reading between the lines

Documentation is Always Consistent

• One time mention of diagnosis/problem is not enough for coding

• Treated diagnosis are always:– Inpatient

• Assessed through the patient stay – DAILY

– Outpatient• Assessed every visit until it is resolved or stabilized

(chronic disease) – then on a regular basis to ensure that it remains stable

– Never coded from the problem list!!!



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Body Site Examples

• Musculoskeletal/Orthopedic– Laterality, specific bone and bone portion

• Pulmonary– Lobe specific, laterality

• Digestive– Solid organ and digestive tract specific to the

body part, laterality, portions• For patients with resection, ligation, repairs,

insertions, place of devices and stents– Location, laterality, number, chamber, vessels,

valves(s), nerve or nerve plexus

Episode of Care – 7th extender placement

• Initial encounter

• Subsequent encounter

• Sequela

• Please note that a “X” place is used for all codes less than 6 characters

• Fracture– Initial, subsequent,

sequela

– Closed

– Open

– Delayed healing

– Nonunion

– Malunion

– Displaced

– Nondisplaced



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Complications of CareDocumentation Requires an

CAUSE & EFFECT Relationship• Type 2 DM with Diabetic nephropathy

• Anemia due to chemotherapy

• Anemia due to acute/chronic blood loss

Documentation

Before, During and After I-10



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Documentation Before – 1889

Documentation – still on paper chart



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EMR – Happily Ever After

Primary Care – Documentation

• Type

• Site(s)

• Exam Findings

• How bad is it?

• What other disease/condition is making it better or worse?



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Primary Care Documentation

• Hypertension– Benign or malignant is no longer an issue

– Must document• Type – essential or secondary

• Relationship with CKD, DM, CVD or pulmonary

• Comorbidities' – CHF


• Congestive Heart Failure– Acuity – acute, chronic, acute on chronic– Type – systolic, diastolic

• Atherosclerotic heart disease w/wo angina– Cause – assumed to be atherosclerosis – unless

noted otherwise– Stability or unstable– Vessel(s) if known– Bypass graft involvement – autologous or

biological



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• Arrhythmias– Location – atrial, ventricle, sub ventricular,

etc.

– Flutter, fib, av block (type), long QT, SSS

– Acuity – acute or chronic

– Cause – HTN, ETOH, dig, other medication


• Arthritis– Type

• Localized, general, primary, secondary, osteoid, subtype

• Location, affected bones, joints, laterality

• Other conditions – describe all related underlying diseases or conditions



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• Injuries– Episode of care – initial, subsequent, sequelae

– Site – specific location including laterality

– Etiology – how did it happen? Would you believe?

– Place of occurrence – where did it happen?

– Intent – accidental, assault, self-harm, unknown

– Status – work, civilian, military, school related, other (church)


• Asthma– Cause – exercise, cough variant, r/t smoking,

chemical exposure, environment

– Severity – mild, moderate, severe

– Other factors – acute, chronic, intermittent, persistent, status asmaticus, acute exacerbation, acute on chronic, ozone days



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• Diabetes– Type – I, II, drug/chemical induced,

gestational, due to other condition – CF

– Complication – what other body organ/systems are affect by – i.e., foot ulcer

– Treatment – D/E, oral medications, insulin, combination


• Hypoglycemia or hyperglycemia– Possible to code wo using DM– Document H/H glycaemia and specify if due

to a procedure or other known cause –transient in nature or watchful waiting

• Abdominal pain and tenderness– Location – quadrant, periumbilical, epigastric,

etc.– Pain or tenderness type – colic, rebound,

generalized, localized



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• Acute respiratory failure– Type – acute, chronic, acute and chronic

– W/wo hypoxia, hypercapnia

• Anemia– Type – Iron def, hereditary hemolytic,

acquired, aplastic, etc.

– Causation – blood loss, due to – and state the condition


• Hyperlipidemia– Type – pure, mixed, hyperchylomicronemia, etc.

• Hypothyroidism– Type – congenital, acquired

– Causation – post surgical, iodine, etc.

• UTI– Site – cystitis, urethritis, etc.

– W/wo hematuria

– Identify causative agent, if known



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• Pneumonia– Type – bacterial, fungal, parasitic, mycoses,

aspiration – etc.– Viral pneumonias and influenza, simple to

complex– Location – lobe(s)– Causing agent– Complications – sepsis, shock, respirator

failure, complication of care – hospital acquired


• Herpes Simplex– Type

– Location

– Severity

– Disseminated

– Associated diagnoses/conditions



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• Purpura– Type

– Thrombocytopenic

– R/t other conditions i.e., immune, congenital

– Capillary fragility

– Pseudo hemophilia

– Comorbidities


• Obesity– Type

– Excess caloric intake

– W alveolar hypoventilation

– Drug induced – document drug

– Syndrome – PCOS – document

– BMI

– Other related comorbidities



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Depression

• Episode– Single or recurrent

– Severity – mild, moderate, severe – w/wo psychotic features

– Remission – partial or full

Otitis Media

• Incidence – acute, chronic, recurrent• Laterality• Type – serous, allergic, mucoid, etc.• Rupture w/wo• Infectious agent, if known• Exposure to tobacco smoke• Comorbidity(ies)• Tubes – w/wo



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• Cellulitis– Site – anatomic

– Laterality

– Cellulitis of limb – right, left, upper, lower,

– Measurement

– Internal/external – mouth, other orifices'

– Associated conditions/disorders

Gout

• Type – drug induce, idiopathic, primary, secondary, w renal impairment – identify

• Acuity – acute, chronic – w/wo tophus, attack, flare

• Other contributing factors



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• Newborn– Delivery type

– Maternal Hx

– Gestational age, weight, length

– Acquired conditions –

– Congenital

– Physical exam – document presence of everything – this for some may be the first baseline exam

Burns

• Type – corrosion, thermal

• Site – body & laterality

• Degree – first, second, third degree

• Percentage – TBSA rule of nine’s

• 3rd. Degree specify

• cause



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• Under dosing– Medication – taken less frequently than

prescribed or not using the medication at all.

– If reduction in the dosage results in relapse/exacerbation the medical condition must also be documented

External Cause

• How – fall, mva, accident

• Where – home, work, school

• Activity – skiing, ironing, gardening

• Status – civilian, military, volunteer,

• No national requirement for reporting external cause (provider 1500)

• Worker’s comp may require



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• History – personal and family of– Malignant neoplasm – specify type– Congenital malformation/deformation – specify

type– Allergies – type– Chemotherapy– Radiation therapy– Surgical history– Medical history – chronic problems– Mental health problems


• Risk Factors– Genetic carrier – CF, hemophilia, Scell

– Susceptibility to – Ca – type, endocrine disease

– Environmental exposures

– Work exposures

– Comorbidity – what added risk factor’s are their (DM and depression)



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• Retained Foreign Body– Glass, metal, radioactive, tooth, tampon, gun shot

pellet, road rash – gravel

• Contact with/exposure to– HIV– Anthrax– Varicella– Mold (type)– Second hand smoke– Other


• Reproductive Services– Contraceptive type(s) history of

– Procreative management

– Pregnancy test

– Pregnancy state (incidental)

– Supervision of pregnancy

– Antenatal screening



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• BME– 19 or less– 20.0 – 20.9– …..– 60.0 – 69.9– 70+– Associated conditions– Pediatric BMI (2 – 20)

• Less than 5th percentile for age• Fifth percentile to less than 85th percentile for age• 85th percentile to less than 95th percentile for age• Greater than or equal to 95th percentile for age


• Mechanical device complication– Body system

– Device type

– Complication – breakdown, displacement, leakage, infection, hemorrhage, pain, embolism, fibrosis, anything else?

– Episode – initial, subsequent, sequela

– Document primary medical condition and or comorbidities



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• Complications of care– Affected body system – specific

– Condition – specific

– Condition is a/an complication or expected outcome

– Complication occurred – intraoperative or postoperative

– Associated medical condition(s)


• Socioeconomic/psychosocial – Education/literacy– Employment– Occupation exposure – type– Housing– Social environment– Upbringing– Support system– Family circumstances– Anything else?



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Questions?

Thank you for your attendance!

Get your questions answered on PMI’s Discussion Forum: http://www.pmimd.com/pmiForums/rules.asp

Contact information: Doug Arrington [email protected]



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