CPT Coding &Clinical Documentation Training Module

1. CPT Coding &Clinical Documentation Training Module Department of Billing & Collections

2. Objectives • Review Centers for Medicare and Medicaid Service (CMS) documentation guidelines for outpatient-inpatient evaluation and management services. • Identify the components and rules for choosing the levels of Evaluation and Management services.

3. Principles of Medical Record Documentation • The medical record documentation must support the level of service billed. • Services not documented = not done • Should support the medical necessity of the service provided • Notes must be complete and legible

4. Medical Record DocumentationShould include: • Reason for the encounter (Chief Complaint) is always required. • Relevant history • Physical exam findings and prior diagnostic test results • Assessment, clinical impression or diagnosis • Plan of care • Date and legible identity of observer

5. Evaluation & Management Codes CPT Codes • Initial Observation Care: 99218-99220 • Discharge Observation Care: 99217 • Same Day Observation Care: 99234-99236 • Initial Hospital Care:99221-99223 • Subsequent Hospital Care: 99231-99233. • Discharge Hospital Care: 99238-99239.

6. Seven Components of an E&M Code • History • Physical Examination • Medical Decision Making Contributory Components: • Time • Counseling • Coordination of Care • Nature of Presenting Problem 3 Key Components

7. Chief Complaint (CC) The reason the patient is being seen today Examples: • 35 y/o male presents today w/ headache • 65 y/o female presents w/ chest pain • Patient is here for follow up of his CHF • Patient is here for follow up of Hypertension • Not sufficient with just a statement patient is here for follow up If the CC is not documented no history level can be counted for the visit

8. History of Present Illness (HPI)The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptomto the present. The following 8 elements are recognized: HPI Elements: • Location • Quality • Severity • Duration • Timing • Context • Modifying Factor • Associated signs and symptoms Requires 4 or more HPI elements for the comprehensive level

9. Elements of HPI • Location • where the problem is occurring. • Often the same as the chief complaint • Duration • How long the patient has had the problem. • Includes the specific and non-specific descriptors (hours, couple of days, one month ago). • Severity • How bad is the condition or disease

10. Elements of HPI • Quality • Descriptive terms that further define the condition • Context • Circumstances under which the condition occurred or occurs • Timing • Time of the day or other associated timing • Modifying Factors • The things the patient has done • Associated Signs and Symptoms • Additional problems that may be related to the chief complaint

11. Review of Systems (ROS) An inventory of body systems obtained through a series of questions to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following 14 systems are recognized:

12. Constitutional symptoms (e.g. fever weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (including breasts) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Review of Systems

13. Review of Systems (ROS)Three levels of ROS: • Problem Pertinent (1 system) • Extended (2-9 systems) • Complete (at least 10 systems) • Problem pertinent ROS identified, through a series of questions, inquiries about the system. • Extended ROS must identify the positive responses and pertinent negatives for at least (2) and not more than (9) systems. • Complete ROS (10 organ systems must be reviewed) The attending physician may use “all other systems negative” when (2) pertinent positives and/or negatives are documented. In absence of such a notation, all systems must be documented. If unable to obtain, document why, If the patient is unable to communicate due to mental state or language barrier “ROS unavailable due to…” must be noted for full credit.

14. Past, Family and Social History (PFSH) Past-Describes the patient’s past experiences: Examples: past illnesses, injuries, dietary status, operations. Family- Medical events in the patient’s family Examples: Hereditary/high risk diseases of siblings/parents. Social- Describes age appropriate past and current activities Examples: living arrangements, marital status, drug or tobacco use.

15. Patient Unable to Give History • Some patients can’t provide history • Unconscious • Intubated • Mentally ill • Certain illnesses (e.g., Alzheimer's, AMS) • Intoxication • Document any know information from other source. (e.g., EMTs or family) • Document reason why patient is unable to give history.

16. Physical Examinations • Problem Focused – A limited examination of the affected body area or organ system • Expanded Problem Focused- A limited examination of the affected body area or organ system and other symptomatic or related organ system • Detailed- An extended examination of the affected body area (s) and other symptomatic or related organ systems • Comprehensive- The medical records for a general multi-system examination should include findings of 8 or more of the 12 organ systems

17. Organ System (s) 12 Constitutional Eyes Ears, nose, throat, mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neurological Hematologic/lympathic Psychiatric Skin Body Area (s) 10 Head, including the face Neck Chest , including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Examination Components

18. Documenting the Physical Exam • Nothing “negative” or “normal” is sufficient to document normal findings in unaffected areas • Note specific abnormal & relevant negative findings of the examination of the affected or symptomatic body area (s) or organ system (s) should be documented • Describe abnormal or unexpected findings of body areas or organ system

19. Medical Decision Making • Medical Decision Making is the physician’s knowledge and skill in diagnosing and treating the patient’s condition. • Made up of three additional elements • Number of diagnoses or treatment options • Amount and complexity of data reviewed • Risk of complications, morbidity, and mortality

20. Medical Decision Making (MDM) Four levels: • Straightforward • Low complexity • Moderate complexity • High complexity Two of the three areas: Dx. Options, amount of data and risk establish the MDM level

21. Number of Diagnoses or Management • Assessment, clinical impression or diagnosis • Initiation of, or changes in, treatment. • Referrals made, consultations requested or advice sought

22. Complexity of Presenting Problems • Problem self-limited or minor • Problems that would resolve without medical care • Problem is stable or improving • Stable for chronic illnesses that are controlled • Improved for acute illnesses that are getting better. • Problem is worsening • Chronic illnesses that are uncontrolled or poorly controlled or that are progressing

23. Amount and/or Complexity ofData to be Reviewed • Type of diagnostic service ordered, planned, scheduled or performed. • Review of lab, radiology and/or other diagnostic tests. • Decision to obtain old records or additional history from family, caretaker or other source. • Relevant findings from the review of old records • Independent visualization of image, tracing or specimen itself

24. Risk • Risk associated with the presenting problem. • Risk associated with any diagnostic tests ordered or performed • Risk associated with any treatment option selected

26. Contributory Components Documenting Time: • In cases where counseling and/or coordination of care dominates more than 50% of the physician/patient and / or family encounter, time is considered the key or controlling factor to qualify for a particular level of the E&M service. • If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter should be documented and recorded, the documentation should describe the nature of the counseling and/or activities to coordinate care.

27. Counseling & Coordination of Care Counseling is a discussion with the patient and/or family concerning one or more of the following areas: • Diagnostic results, impressions, and/or recommended diagnostic studies • Prognosis, risks and benefits of management (treatment) options, instructions for management and/or follow-up • Risk factor reduction; and patient family education

28. Consultations99241-99245 99251-99255 • A consultation is a type of service provided by a physician whose opinion of advice regarding evaluation and/or management of a specific problem is requested by another physician or another appropriate source. • Consultation service is rendered. • The written opinion or advice is send back (reply) to the requesting provider. • Diagnostic and/or therapeutic services may be initiated during course of consult. • The three “R”s (request, render, reply • All consultation codes will be deleted as 01/01/2010.

29. Inpatient Documentation • Initial hospital admission • Documentation and Dictation of History and Physical (HPI, ROS, PFSH, Exam and Medical Decision). • Subsequent hospital visits • Documentation includes SOAP format • Discharge day management • Time based, includes appropriate final examination, discussion of the hospital stay and preparation of discharge records, prescriptions and referral forms.

30. Observation Care Documentation • Initial Observation Care • Documentation “observation status” (HPI, ROS, PFSH, Exam and MDM) Discharge Observation Care Time based, includes appropriate final examination, discussion of the hospital stay and preparation of discharge records, prescriptions, referral forms.

31. Status Change OP - IP • After the 23 hour observation window is up, the clinical nurse from hospital will request the “change in status” to outpatient- inpatient. • After this change is made by the attending physician, patient is admitted to hospital and the previous observation codes 99218-99220 will change to inpatient codes 99221-99223, add subsequent 99231-99233 and discharge 99238.

32. Observation or Inpatient Care • When a Patient is admitted and discharge from observation or inpatient status on the same date, the services should be reported with codes 99234-99236 as appropriate.

33. Sources • E/M Documentation Guidelines • www.cms.hhs.gov/medlearn/emdoc.asp • Current Procedural Terminology CPT 2009