Disclaimer • The presentation cannot account for all risks and other factors that may affect results or performance, or changes in your business practice or operating procedures that may be required to realize results or performance, that are projected or implied in the presentation. • The presentation was written without knowledge of any one persons: • Corporate Compliance Policies • Organizational policies and procedures • Identification of Key Stakeholders • There are no warranties of any kind, express or implied, provided in this documentation. This information is provided “as is”. • I am not liable for any damages for use of this document, including, without limitation, consequential, punitive, indirect or direct damages. • The information in this PPT is subject to periodic change and updates. • This presentation includes selected third party data, information and/or reference materials. I do not warrant the accuracy of this information, which is provided “as is”.
OBJECTIVES • For Participants to gain a working knowledge of Evaluation & Management Documentation Guidelines to determine the appropriate level of service for a patient’s visit. This knowledge can be applied in everyday situations while seeing patients in order to correctly report for reimbursement of services. AGENDA • Medical Documentation • Payers Expectations • Medical Necessity • Breaking Down the E/M Service • HPI • Exam 95 vs 97 • Medical Decision Making • New or Established Patient • Modifiers • Non Physician • E/M in 2021 • HCC Coding • Other Considerations • Addendum/Late Entries • Querying the Physician • Signatures and Countersignatures • Common Errors • Resources
Purpose of Medical Documentation • Documentation provides… • Chronological record of patient care • A record to monitor the patient’s response to intervention • A means to communicate among care providers • Tangible evidence of care provider work effort • Adequate documentation… • Facilitates accurate and timely claims review and payment • Permits review of utilization and quality of care data • Provides data for research and education • Provides defense against litigation
Principals of Medical Record Documentation E&M documentation should include: • Chief complaint • Reason for encounter, relevant history • Past and present diagnosis and health risk factors • Physical exam and test results • Assessment, clinical impression, and/or diagnosis • Patient’s progress, response and changes to treatment and/or diagnosis • Plan for care • Rationale for diagnostic or ancillary services • Date and legible identity of observer/provider with acknowledgement (signature or electronic signature)
Cloning (Copy & Paste) We have gone from medical records we can’t read to medical records we don’t trust. Copying and pasting data from one record to another • Advantages • Saves time • Allows for consistency from one part of a record to another HOWEVER, • Disadvantages • Unable to distinguish any difference in notes • EHRs remove handwriting that could be attributed to an author • Copied documentation can represent a false record since documentation may not match • Some Medicare contractors (Palmetto) believe cloned notes fail to establish medical necessity for the visit If it isn’t documented, OR if it is copied it wasn’t done.
Possible Effects of Cloning • Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpaymentsmade. • “Noridian LLC Proprietary March/April 2016”
Save that Record! • Providers required to maintain ordering and referring documentation for seven years from date ofservice • Codification of existing requirements • Record retention is considered part of normal businesspractice • 42 Code of Federal Regulations (CFR) Section 424.516(d)
Contractual Obligation • Payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. • Payers may request some or all of the following information to validate services: • Site of service • Medical necessity and appropriateness of the diagnostic and/or therapeutic services provided • Operative and/or procedural notes • Identity of performing provider
Expectations/General Principals • 1.The medical record should be complete and legible. • 2.The documentation of each patient encounter should include: • reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; • assessment, clinical impression, or diagnosis; • plan for care; and • date and legible identity of the observer. • 3.If not documented, the rationale for ordering diagnostic and other ancillaryservices should be easily inferred. • 4.Past and present diagnoses should be accessible to the treating and/orconsulting physician. • 5.Appropriate health risk factors should be identified. • 6.The patient's progress, response to and changes in treatment, and revision ofdiagnosis should be documented. • 7.The CPT and ICD-9-CM codes reported on the health insurance claim form orbilling statement should be supported by the documentation in the medical record.
Medical Necessity Defined • “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.” • Per Internet Only Manual (IOM) Medicare Claims Processing Manual, • Publication 100-04, Chapter 12, section 30.6.1
Criteria • Consistent with the symptoms and diagnoses or treatment of thepatient’s condition, illness, disease orinjury • In accordance with acceptedprofessional medicalstandards • Not primarily for the convenience of the patient orprovider • Furnished at the most appropriate level that can be safely provided to thepatient
Guidelines: History • History of present illness (HPI) is a chronological description of the development of the patient’s presenting illness. • For new problems: since the first sign and/or symptom • For follow-up visits: from the previous encounter to the present • Described using one or more of eight dimensions or elements • Level of HPI is distinguished by the number of dimensions documented • Quality • Description of problem, symptom, or pain (e.g., dull, itching, constant) • Timing • When problem occurs (e.g., in the morning, after eating, while lying down, etc.) • Context • Instances associated with problem (e.g., when sitting, standing for long periods, etc.) • Location • Where problem, pain, or symptom occurs (e.g., leg, chest, etc.) • Severity • Description of severity (e.g., 1-10 rating, mild, moderate, etc.) • Duration • How long problem has persisted (e.g., one week, since last night, etc.) • Modifying factors • Actions to make better or worse (e.g., pain relievers help dull pain) • Associated signs & symptoms • Other problems associated with when primary problem occurs (e.g., stress causes headache, burning during urination, etc.)
Guidelines: Review of Systems (ROS) • ROS is an inventory of body systems which identify signs and/or symptoms the patient has or once had. There are three levels of ROS: • A problem pertinentROS inquires about the system directly related to the chief complaint (1 system) • An extendedROS inquires about the system directly related to the chief complaint and a limited number of additional systems (2 – 9 systems) • A complete ROS inquires about the system(s) directly related to the chief complaint PLUS all others (at least 10 body systems) Coding tip: It is permissible for the physician to document “all others negative” to achieve a “complete” ROS
Guidelines: Past Medical, Family, and/or Social History (PFSH) There are 2 levels of PFSH: Pertinent (1 element) or Complete (2 or 3 elements) • Past medical history • Injuries, illnesses, treatments, medications, operations, and allergies (includes CURRENT medications and allergies) • Family history • Medical events, hereditary diseases, causes of death (pertinent positives and negatives) for patient’s parents, siblings, other family members and/or children • Social history • Employment, education, military history, marital status, living arrangements, use of drugs, alcohol, tobacco and/or any high risk behaviors/practices
Important Notes About ROS and PFSH • The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. • The provider must indicate that this information was reviewed. • A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded: • The provider can reference the existing ROS and PSFH in the chart and update as necessary. • Note that the provider must personally perform the HPI.
1995 Exam Documentation Guidelines Exams should document EITHER body areas OR organ systems
1997 Exam Documentation Guidelines • 1997 guidelines require bulleted lists • General multi-system exam recognizes 15 organ systems: • Constitutional • Eyes • Ears, nose, mouth, throat • Neck • Respiratory • Cardiovascular • Chest (breasts) • Gastrointestinal (abdomen) • Genitourinary (GU) (male) • GU (female) • Lymphatic • Musculoskeletal • Skin • Neurologic • Psychiatric
Examination Important Points • Both types of examinations may be performed by any physician, regardless of specialty. • Some important points that should be kept in mind when documenting general multi-system and single organ system examinations are: • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. • Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. (A notation of “abnormal” without elaboration is not sufficient.) • 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).
Preventative Medicine • The “Comprehensive” exam required is not synonymous with the “Comprehensive” exam required for E/M services • Counseling, anticipatory guidance and/or risk factor reduction interventions are a part of the periodic preventive medicine service • Immunizations and ancillary studies involving laboratory, radiology, or other procedures are reported separately when performed • Welcome to Medicare Examination - goals of the Initial Preventive Physical Examination (IPPE), also known as the “Welcome to Medicare Preventive Visit,” are health promotion and disease prevention and detection. (G0402) • face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment • Medicare Annual Wellness Exam (G0438 and G0439)
Guidelines MDM • Medical Decision Making (MDM) is one element in determining the level of service. • Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. • A high level of medical decision making does not equate to the highest level of service. • Requirements are identical for 1995 and 1997 guidelines.
Complexity of MDM • Number of possible diagnoses and/or number of management options • Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed • Risk to patient of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options • The documentation should support the medical necessity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making.
Important Points About Complexity of Data Document the review of lab and other tests. • A simple notation of the results such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. • Discussing tests with the physician who performed or interpreted the study should be documented. • Direct visualization and interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented. Document the following: • Summarize the findings- it is not sufficient to state “old records reviewed” • it is sufficient to state that they were not relevant. • Any decision to obtain old medical records • The use of an interpreter • Obtaining history from family members
Risk of Complications, Morbidity, Mortality • Refers to the patient’s level of risk at that visit. • Co-morbid diseases, in and of themselves, are not considered in selecting a level of E&M service unless their presence significantly increases the complexity of the medical decision making. This should be clearly documented.
Prescription Drug Management • Prescription management is a moderate risk management option which includes: • The writing of a new prescription • Most injections given in the office • Reviewing and not changing current medications and dosages • “Blood pressure controlled by current regimen. Renewing prescriptions for metoprolol and irbesartan.” • A decision NOT to prescribe medication • Drugs suspected of causing unacceptable side effects • Drugs that interact with current medication
Documentation Tips for MDM • For a presenting problem with an established diagnosis, the record should reflect whether the problem is: • improved, well-controlled, resolving OR • Inadequately controlled, worsening or failing to change as expected • The review of lab, radiology, and/or other diagnostic test should be documented. • A simple notation, such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. • Alternatively, the review may be documented by initialing and dating the report contained the test results. • The review of old records must be documented and findings or lack of findings should be stated in the record. • Document co-morbidities, underlying diseases that increase risk of presenting illness
Counseling and/or Coordination ofCare • Dominates more than 50% ofencounter • Total length of time of encounter must be documented • Record should describe counseling and/or activities to coordinate care and patient’s response
Consideration of Time • Time is defined as face to facetime • Cannot round up to next level basedon time • All components of code must bemet The use of time or contributing factors (counseling or coordinating care) to set the E/M level: • Documentation of the nature of the counseling or coordination of care • Documentation of the amount of time spent • A statement that more than 50% of the visit was spent performing these activities • It is not required that these services be provided at every or any patient encounter.Example: TT (Total Time) = 40 min. CT (Counseling Time) = 30 min.
Defining New vs Established • New Patient: One who has Not receivedany professional services from any provider of the group practice of the same specialtywithin the past 3 years. • Established Patient: One who has receivedany professional services from any provider of the group practice of the same specialtywithin the past 3 years. • Professional services are face-to-face services: office visits, hospital visits, surgery • Group practices with multiple sites are considered a single practice if they operate under a single tax identification number. • When a substitute physician is covering for another physician under a reciprocal billing arrangement, the patient is classified as if seen by the physician not available. • If a physician leaves a group practice and joins another group, patients that were seen under the original practice are considered established patients.
New - No services received from physician of same specialty who belongs to same grouppractice for threeyears • New - Internal Medicine and FamilyPractice considered differentspecialty • New - Patient seen by same doctor, but not since a three year interval considered newpatient • Established - Patient seen by physician covering oron-call physician considered patient of usual doctor and is not a newpatient • Neither - No distinction is made between new and established patients in the ED.
Modifier 24 • Unrelated E/M service by samephysician during postoperativeperiod • Provided during postoperative period by same physician who performedprocedure • Documentation supports service is not related to postoperative care ofprocedure
Modifier 25 • Significant evaluation and management service by same physician on date of global procedure • If physician indicates service is a significant, separately identifiable E/M service, above and beyond usualpre-op and post-operative work ofprocedure • Usually has a differentdiagnosis, but not required
Modifier 25 with minor surgical procedure • Modifier 25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) may be appended to an E&M service delivered on the same day as a minor surgical procedure if the E&M service is a significant and separate service. • This typically occurs when a physician sees a patient for an evaluation of a condition and decides, as a result of the E&M service, to perform a minor surgical procedure. • Documentation should support the unscheduled nature of the surgical service. • In this case, modifier 25 can be appended to the E&M service, which can be reported in addition to the minor procedure. • Do not use modifier 57 which is only used for major surgeries.
Modifier 25: When to Report? • Unlike major surgeries (those with a 90-day postop period), the office visit is often included with a minor procedure and not separately billable. • CPT states that, “modifier 25 is not used to report an E&M service that resulted in a decision to perform surgery.” In addition, the Medicare Claims Processing Manual, Chapter 12, §40.2A4 states, “where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.” • If the patient does have more than one problem being addressed at the visit, it is appropriate to use different diagnoses on the claim. However, it is not required that two different diagnoses exist. The CPT definition of modifier 25 specifically states, “different diagnoses are not required for reporting of the E&M services on the same date.” • If only one diagnosis exists, The CPT definition says that a separately identifiable service must be provided. If the physician has to cope with more than one occurrence of the same problem but do so in different ways, then the visit and the procedure are billable. • If the only purpose of the exam is preoperative care, or to determine the need to proceed with the procedure, then a claim for an office visit with modifier 25 would not be appropriate. Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf Source: http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
Modifier 25: When not to Report? • Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery. • Do not append modifier 25 if there is only an E&M service performed during the office visit (no procedure done). • Do not use a modifier 25 on any E&M on the day a “Major” (90 day global) procedure is being performed. • Do not append modifier 25 to an E&M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E&M service included. • Patient came in for a scheduled procedure only. Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf Source: http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf Source: http://www.acc.org/tools-and-practice-support/practice-solutions/coding-and-reimbursement/appropriate-use-of-modifier-25
Global surgical package • The global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. • A pre-operative evaluation on the day of or day before surgery • All intra-operative and post-operative services • Follow up services for the rest of the global period Common global periods can be up to 90 days for major surgery, 10 days for minor procedures. Some minor procedures have no global period but Medicare considers E&M services bundled with the procedure.
Modifier 57: Decision for Surgery • CPT Modifier 57 is used when the initial decision to perform a major surgical procedure is made during an E&M service provided the day before or the day of a major surgery (90 day global period). • Modifier 57 should not be used when the E&M service is associated with a minor surgical procedure (defined as having a 0 or 10 day global period). • Modifier 57 should not be used when the E&M service was for the preoperative evaluation.