Documentation for Providers

1. Documentation for Providers Office of Corporate Compliance

2. Objectives • Why Document? • E/M Documentation Guidelines • History of Present Illness • Physicial Examination • Medical Decision Making • Documentation Examples

3. Documentation Based on CMS Criteria • The presentation materials are based on CMS guidance with respect to regulations and rules associated with billing or submission of claims to government payers. • Other payer manuals may be consulted for specific regulations and rules.

4. Why Document? • Evaluation, treatment and monitoring • Communication and continuity of care • Accurate and timely claims review and payment • Appropriate utilization review and quality of care • Collection of data for research and teaching 1995 Documentation Guidelines

5. Principles of Documentation • Be complete and legible • Include chief complaint (CC), reason for encounter, assessment, plan of care, date and identity of observer • Indicate rationale for ordering diagnostic and/or ancillary services • Indicate past and present diagnoses • Indicate appropriate health risk factors • Show patient’s progress or lack thereof • Support service/procedure and diagnosis(es) 1995 Documentation Guidelines

6. Evaluation and Management Services Documentation Guidelines Category and Type

7. Categories of E/M Services • Each E/M service category has special instructions for use • Office/Other Outpatient • Hospital Inpatient • Consultations • Hospital Observation • Emergency Department • Critical Care • Neonatal Intensive Care • Nursing Facility • Domiciliary, Rest Home or Custodial Care • Home • Case Management • Preventive Medicine • Newborn Care • Special Services AMA 2004 CPT Manual

8. Type of E/M Service AMA 2004 CPT Manual

9. Components • Chief Complaint • Key Components • History • Physical Examination • Medical Decision Making • Contributory Components • Nature of presenting problem or illness • Counseling • Coordination of care • Time AMA 2004 CPT Manual

10. Chief Complaint (CC) • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words. 1995 Documentation Guidelines

11. Key Components History – History of Present Illness Review of Systems Past, Family & Social History

12. History of Present Illness (HPI) • The HPI is a chronological description of the development of the patient’s illness from the 1st sign and/or symptom to the present. • Current E/M guidelines identify 8 dimensions typically used to provide further elaboration about the patient’s condition. 1995 Documentation Guidelines

13. Dimensions of the HPI AMA 2004 CPT Manual

14. Documentation Example of HPI • 45 year old female patient complains of intermittent sharp pain in her left hip after falling from a ladder today. Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain.

15. 45 year old female patient complains of intermittentsharp pain in her left hip after falling from a ladder today. Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain. Location = Hip Duration = today Timing = intermittent Severity = 9 (scale 1-10) Quality = sharp pain Context = falling from ladder Modify Factor = aspirin Associated S&S = numbness in leg Evaluation of Example HPI

16. Documentation Tips on HPI • HPI must be documented by the billing physician • HPI, ROS &/or PFSH need not be located in separate sections of the MR note • Example: Statement “The patient denies nausea” located in the HPI section may be used in ROS • CMS does not recognize documentation of a single element in both the HPI and ROS sections CMS Documentation Guidance

17. Review of Systems (ROS) • The ROS is an inventory of body systems obtained through a series of questions asked by the physician seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. 1995 Documentation Guidelines

18. Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Systems Included 1995 Documentation Guidelines

19. Documentation Example of ROS • Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.

20. Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative. Neurological = loss of consciousness Gastrointestinal = no bowel/bladder problems All other neg Evaluation of Sample ROS

21. Documentation Tips for ROS • ROS may be documented by ancillary staff or by patient • Physician must review, date and sign • Document pertinent positive &/or negative findings • Any positive findings must be documented individually • “Noncontributory” alone is not acceptable documentation • If the patient is unable to give history & care-giver or family member is not available, document reason patient is unable to respond • Example: patient unconscious, intubated, poor historian CMS Documentation Guidance

22. Past, Family, & Social History (PFSH) • The PFSH consists of a review of one or more of the following three areas of the patient’s history: • Past History (P) • Family History (F) • Social History (S) • The PFSH is considered to be interval history for subsequent inpatient visits. • Interval history - any new history information obtained since the last “physician-patient” encounter AMA 2004 CPT Manual

23. Past, Family and Social History (PFSH) AMA 2004 CPT Manual

24. Documentation Example of PFSH Currently not taking medication, was hospitalized in 1994 for tibia fracture. Does not smoke and lives with husband in Motown. Family history for fracture is negative.

25. Currently not taking medication, was hospitalized in 1994 for tibia fracture. Does not smoke and lives with husband in Motown. Family history for fracture is negative. Past = no Meds, hospitalization Social = no smoke, lives with husband Family = negative Evaluation of Example PFSH

26. Documentation Tips for PFSH • PFSH may be documented by ancillary staff or by patient • Physician must review, date and sign • “Non-contributory” alone is not sufficient for billing purposes CMS Documentation Guidance

27. E/M Level Selection from Example

28. Key Component Physical Examination 1995 Documentation Guidelines as published in 1995 by American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS)

29. Organ Systems Constitutional Eyes Ears, nose, mouth, and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic /Immunologic Body Areas Head, including face Neck Chest, including breast and axillae Abdomen Genitalia / Groin / Buttocks Back, including spine Each Extremity 1995 Physical Examination 1995 Documentation Guidelines

30. 1995 Level Selection 1995 Documentation Guidelines

31. Documentation Example of PE T 98, BP 138/68, well groomed Lungs clear Heart RRR, S1 S2 Abd soft +BS Ext 4+ edema Skin intact

32. T 98, BP 138/68, well groomed Lungs clear Heart RRR, S1 S2 Skin intact Abd soft +BS Ext 4+ edema Organ Systems: Const Respir Cardio Skin Body Areas: Abd Ext Evaluation of PE

33. Documentation Tips for PE • Notation of “abnormal” without elaboration is insufficient documentation • A brief statement or notation indicating “negative” or “normal” is sufficient for findings within normal limits • Under 1995 DGs, comprehensive PE must consist of evaluation of 8 or more of the 12 organ systems 1995 Documentation Guidelines

34. Medical Decision Making Number of Diagnoses Amount/Complexity of Data Risk

35. Medical Decision Making (MDM) • MDM refers to the complexity of establishing a diagnosis and/or selecting a management option. • MDM is the function of 3 variables • Number of diagnoses &/or management options • Amount &/or complexity of data that must be obtained, reviewed &/or analyzed • Risk of significant complications, morbidity &/or mortality 1995 Documentation Guidelines

36. Number of Diagnosis Management Options 1995 Documentation Guidelines

37. Amount and/or Complexity of Data • Documentation should include: • Diagnostic service: • Ordered, planned, scheduled or performed • Review of tests results • Simple notation or initialing & dating • Decision to obtain old records or addl History • Relevant findings from review of old records • Discussion of results with performing physician • Direct visualization and interpretation 1995 Documentation Guidelines

38. Risk of Complications, Morbidity and/or Mortality • Refers to patient’s level of risk at the visit • Sources of risk • Presenting problem • Diagnostic procedures ordered • Management options selected • Illustrated by clinical examples in “Table of Risk” 1995 Documentation Guidelines

39. Documented Example of MDM A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.

40. A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain. Number of dx/tx options = new problem with addl workup Amt/complexity of data = ordered MRI Risk = prescription management Evaluation of MDM

41. Documentation Tips for MDM • Established diagnoses should indicate: Stable, well-controlled, worsening, failing to improve • Independent review of diagnostic test should document: visualization of image, tracing or specimen • Review of old records, document findings or lack of findings • Document co-morbidities, underlying diseases that increase risk of presenting illness

42. Selection of E/M Level - Example • History section • Detailed • Physical Examination • Detailed • Medical Decision Making • Moderate

43. Selection of E/M Level Code Documentation Guidelines

44. Contributory Components Counseling and Coordination of Care Time

45. Counseling and Coordination of Care • Discussion with patient and/or family with regards to: • Diagnostic results, impressions, and/or recommended studies; • Prognosis; • Risks and benefits of management or treatment options; • Instructions and/or follow up; • Importance of compliance with chosen treatment or management options; • Risk factor reduction; and/or • Patient and family education. AMA 2004 CPT Manual

46. Documenting for Time • When counseling/coordination of care requires more than 50% of visit: • Document • Total time of visit • Time spent providing counseling/coordination • May document minutes or percentage of time; i.e., 51% or 20 minutes of the 35 minute visit • Nature and extent of counseling/coordination of care • Time must be face-to-face for clinic visit or floor time for inpatient visit

47. Consultation Code Selection

48. Definition of Consultation • “…a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” • Payment for consultation is often significantly higher than other E/M service • AMA Principles of CPT Coding, Second Edition

49. Consultation: Requires a physician request for an opinion or advice. Request and reason for consult must be documented. Evidence of opinion and/or advice communicated back to requesting physician. UPIN is required. Referral: Is a transfer of care for treatment of a specified problem. Is for a known problem. Physician plans to manage the patient’s care and treatment. No report to referring physician is required. Consultation vs. Referral

50. A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of an unknown or uncertain problem is requested by another physician or appropriate source. The written or verbal request for a consultation must be documented in the medical record. The consulting physician may initiate diagnostic or therapeutic services at the consultation or subsequent visit. The consulting physician’s opinion and any services ordered or performed must be: a) Documented in the medical record; and b) Communicated by written report to the requesting physician or other appropriate source. Four Elements That Distinguish A Consultation