Coding and Documentation Compliance Training

1. Coding and Documentation Compliance Training Emergency Medicine Physicians UNC Chapel Hill School of Medicine

2. Purpose of this course • To assure appropriate billing through knowledge of guiding principles • To build confidence in documenting evaluation and management (E&M) services for accurate coding and reimbursement

3. Compliance Office’s Role • Develop and assure adherence to faculty practice’s Compliance Plan • Faculty, resident, nurse practitioner and staff education • Medical record reviews (primarily physician-directed billing) • Responses to audit requests from external agencies • Investigate and resolve potential breaches in the Compliance Plan • Research compliance-related issues

4. Billing Professional Services • Every billed service is assigned codes used for reimbursement, statistics, research and other purposes • The complexity of the patient condition, as documented in the physician note, drives the level of evaluation and management service delivered, recorded and billed.

5. Billing Professional Services • A UNC Physicians & Associates coder assigns codes for Emergency Medicine physicians based on the content of their notes. • With the exception of the review of systems and past, family and social history, the medical student’s documentation may not be used or referenced in the physician note.

6. Coding Systems • Diagnosis • International Classification of Diseases (ICD-9CM) • World Health Organization • Procedure • Current Procedure Terminology (CPT) • American Medical Association • Supplemental supply and procedure codes • Healthcare Common Procedure Coding System (HCPCS) • Federal government—but used by many payers

7. Medical necessity • Only services that are medically necessary are billable • Necessity for the work performed must be established in the physician’s note

8. Reimbursement • Based upon the effort required to treat the individual at the time of presentation • Five levels of evaluation and management (E&M) services are designated for emergency department use

9. E&M Services AllowablesEmergency Department Codes

10. E&M Services AllowablesCritical Care Codes

11. E&M code is determined by • Demonstration of medical necessity • Documentation of decision making complexity • Detail of history and physical exam included in the note

12. Critical care • When injury or illness acutely impairs one or more vital organ systems such that there is a probability of imminent or life-threatening deterioration • Document system failure and the decision-making required to assess, manipulate and support vital system functions • Record the amount of time spent providing critical care to the patient

13. Five Emergency Department visit levels • Medical decision making documentation is the key to selection of the code level • Understanding how decision making is evaluated will help improve your documentation

14. Medical Decision Making (MDM)Recording complexity and effort Based on 2 of these 3 components: (detailed on the following 3 pages) • Number of diagnostic and/or management options • Amount and complexity of data • Risk of the illness, injury or treatment

15. Recording your medical decision making

16. Medical Decision Making1.Diagnostic & Management Options 1 point • Self-limited, minor • Established problem, stable or improved • Established problem worsening • New problem, no additional workup planned • New problem, additional workup planned 1 pt. ea 2 pts. ea 3 points 4 ea Total (maximum of 4 points)

17. Medical Decision Making2.Amount and Complexity of Data 1 point for each type • Review/order of 1)clinical lab 2) radiologic study 3)non-invasive diagnostic study • Discussion of diagnostic study w/interpreting physician • Independent review of diagnostic study • Decision to obtain old records or get data from source other than patient • Review/summary old med records or gathering data from source other than patient 1 point 2 points 1 point 2 points Total (maximum of 4 points)

18. Medical Decision Making3.Risk Choose highest bulleted item from any of the following three areas (see risk table, next page) to determine level of risk due to: • Presenting problem • Diagnostic procedures • Management options

19. 3.Table of Risk (To print: right click, choose “print,” then “current slide”)

20. Medical Decision MakingConsiderations • The existence of co-morbidities and underlying diseases is not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision making. • If it does, document it. Don’t merely list it as an existing condition.

21. Medical Decision MakingConsiderations • Risk of the presenting problem is based on the risk related to the disease process anticipated between the present encounter and the recommended next inpatient or outpatient service by a physician

22. MDM Calculation

23. MDM Calculation

24. Documentation requirements The detail recorded in the history and exam generally follows the complexity of the case. It is required that both the history and exam meet at least these requirements.

25. Documenting the history and exam

26. The Four Levels of History & Exam History Components

27. The History History of Present Illness • Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated signs & symptoms Brief = 1-3 elements, Extended = 4+ or review of 3 chronic or inactive conditions Review of Systems • Constitutional symptoms • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin/breast) • Neurological • Psychiatric • Endocrine • Hematologic/lymphatic • Allergic/immunologic Pertinent = <2 Extended = 2-9 Complete = 10-14 or “all others negative” Past, Family and Social History Social • Living arrangements • Marital status • Sexual history • Occupational history • Use of drugs/tobacco/alcohol • Extent of education • Current employment • Other • Past • Current Medications • Prior illnesses/injuries • Dietary status • Operations/hospitalizations • Allergies • Immunizations Pertinent = 1 of 3 areas Complete = 3 of 3 (2 of 3 for estab.) • Family • Health status/cause of death of parent, sibling, children • Diseases related to chief complaint, HPI, ROS • Hereditary or high risk diseases

28. The History • Anyone, including students or the patient himself, may collect the review of systems and past, family and social history, however, the physician note must refer to reviewing those aspects of history to establish the use of those elements in the care of the patient. • The physician must personally document the history of the present illness even if it appears in other providers’ notes.

29. The Physical Exam • A general multi-system examination or a single organ system may be performed by any physician regardless of specialty. • The type (general multi-system or single organ system) and content of examination are selected by the examining physician. • Note specific abnormal & relevant negative findings of the affected or symptomatic area(s)--“abnormal” is insufficient. • Describe abnormal or unexpected findings of asymptomatic areas or systems. • Noting “negative” or “normal” is sufficient to document normal findings in unaffected areas.

30. Examples of presentations at various levels 99281 • patient with several uncomplicated insect bites. • a 20-year-old student who presents with a painful sunburn with blister formation on the back. • a well-appearing 8-year-old who has a fever, diarrhea and abdominal cramps, is tolerating oral fluids and is not vomiting • a sexually active female complaining of vaginal discharge who is afebrile and denies experiencing abdominal or back pain 99282 99283 99283

31. Examples of presentations at various levels 99284 • an elderly female who has fallen and is now complaining of pain in her right hip and is unable to walk. • a patient with flank pain and hematuria • a patient with a new onset of rapid heart rate requiring IV drugs • a patient who presents with a sudden onset of "the worst headache of her life," and complains of a stiff neck, nausea, and inability to concentrate 99284 99285 99285

32. Medicare Teaching Physician Regulations

33. The Medicare program’s perspective on residents • Resident services to Medicare beneficiaries are paid to the hospital through Part A based on the proportionate share of Medicare at the teaching hospital • Teaching physicians are paid by Part B Medicare on a fee-for-service basis only when they provide a personal, face-to-face service in addition to the resident

34. Proper Teaching Physician (TP) Documentation for Medicare • The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed. • Documentation by a resident or any other party of the presence and participation of the TP is not sufficient (except in cases of some procedures in which the teaching physician is present for the entire time--never for ED visit services) • Documentation may be dictated and typed, hand-written or computer-generated.

35. Medicare requires attestation of teaching physician involvement For Emergency Department evaluation and management services: • That the teaching physician performed the service or was physically present during the key or critical portions of all three components: history, exam and decision making; and • The participation of the teaching physician in the management of the patient.

36. Examples of Acceptable Teaching Physician Notes • "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care." • "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note.

37. Examples of Unacceptable Teaching Physician Notes • "Seen and agree." followed by legible countersignature or identity; • "Patient seen and evaluated." followed by legible countersignature or identity; and • A legible countersignature or identity alone.

38. Procedures • Minor procedures of <5 minutes • TP must be present the entire time • Surgical procedures • TP must be present for the key portions and state those portions in the attestation • In operating suite available to return • Two overlapping procedures • Key portions must happen at different times • Must be available to return to either or designate another TP

39. Time-based services • Time-based procedures may be billed to Medicare on teaching physician time only. Record the actual amount of time in the note. • Critical care • Prolonged services • Payers other than Medicare may be billed for resident time performing time-based services if the amount of time is documented

40. North Carolina Medicaid Teaching Physician Regulations

41. NC Medicaid teaching physician (TP) requirements • TP must be "immediately available" to the resident and patient by telephone or pager at the least • For procedures, the TP must use "direct supervision" (available in the office suite) • The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the patient's condition. • Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

42. Where To Get Help • www.med.unc.edu/compliance/ • UNC P&A Professional Charges Coders for Emergency Medicine • Cindy Wyrick, CPC, 966-9051 • Rhonda Peck, CPC, 962-8391 • Jana Rakes, CPC, 843-6096 • Deresa Stroud, CPC, 843-3135 • School of Medicine Compliance Office 843-8638 • Heather Scott, CPC, Compliance Officer • Keishonna Carter, CPC, Compliance Review Analyst • Nirmal Gulati, CPC, Compliance Auditor • Lateefah Ruff, CPC, Office Assistant • Confidential Help Line 800-362-2921 for reporting potential compliance problems • The AMA’s Current Procedural Terminology (CPT) Manual