Coding and Documentation Training for E/M Services Coding and Documentation - June 2018.pdfcoding decisions and any response to the limited information provided in a question is intended

Coding and Documentation Training for E/M Services

My Background

• My connection to coding and documentation

• My connection to clinical processes

• My connection to ICD-10

• My connection to YOU

Coding & Compliance Initiatives, Inc. 2

Disclaimer

The information provided within this presentation is for educational purposes only and is not intended to be considered legal advice. Opinions and commentary are solely the opinion of the speaker. Many variables affect coding decisions and any response to the limited information provided in a question is intended to provide general information only. All coding must be considered on a case-by-case basis and must be supported by appropriate documentation, medical necessity, hospital bylaws, state regulations, etc. The CPT codes that are utilized in coding are produced and copyrighted by the American Medical Association (AMA).


Agenda• Describe what medical documentation facilitates

• Medical Necessity and General Principles of Documentation

• Evaluation & Management Codes • Three key components of Evaluation and Management

services

• Counseling and Coordination of Care

• New versus established patients/clients


Documentation and Coding


What Documentation Facilitates• Proper and complete documentation plays a crucial function in

patient overall care.

• Can help avoid many future potential problems

• Medical record documentation is used for a multitude of purposes

• Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test. Clinical documents must be accurate, timely and reflect specific services provided to a patient.


Medical Necessity - CMS• Per the Social Security Act 42 U.S.C. § 1395y(a)(1)(A),

“SSA” Medicare only pays for medical items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment.

• National coverage determinations (NCDs) and Local Coverage Determinations (LCDs). Section 522 of the Benefits Improvement and Protection Act (BIPA) defines an LCD as a decision by a Medicare carrier whether to cover a particular service in accordance with the SSA


Medical Necessity - AMA

• “Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is:

• (a) in accordance with generally accepted standards of medical practice;

• (b) clinically appropriate in terms of type, frequency, extent, site and duration; and

• (c) not primarily for the convenience of the patient, physician, or other health care provider.”


Medical Necessity

• National Coverage Determination

• Local Coverage Determination

• Other Payors

• CPT “stays out of it” – does give scenarios in CPT Assistant and other publications but not related to medical necessity


Medical Necessity

• Just because it is medically necessary in a provider’s eyes does not mean it is a covered service!


Medical Necessity and ICD-10

• How does ICD-10 affect Medical Necessity or does it?


Documentation to support Medical Necessity

• Describe the patient and their condition

• Tell the story

• Don’t assume level of knowledge

• Don’t rely on diagnosis documentation in the assessment/impression alone

• Review any payor medical policies –document in terms they use


E/M Codes

• 3 Key Components:• History• Examination• Medical Decision Making

• Contributory Components:• Counseling• Coordination of Care• Nature of the Presenting Problem• Time

13Coding & Compliance Initiatives, Inc.

History


History• Chief complaint- CC/Reason for visit

• History of present illness – HPI

• Review of systems – ROS

• Past, Family, Social history- PFSH


Chief Complaint/Reason for Visit

• A concise statement describing the reason for the encounter.

• A statement describing the symptom, problem, or provided recommended return that is the reason for the encounter


History of Present Illness (HPI)• Location – specific location

• Quality – radiates, achy, sharp

• Severity – moderate; 1-10 on the pain scale

• Duration – time frame (2 days, 6 hours) since yesterday

• Timing – frequency, how long it lasts, when first notices


History of Present Illness (HPI)

• Context – related to a certain activity, occurs at a certain time of the day (i.e. notices anxiety when out in public)

• Modifying factors – aggravating: what makes it worse; alleviating: what makes it better (meditating makes it better, rest helps)

• Associated signs & symptoms –if the patient volunteers the info it is an HPI (if the patient responds to a question it is a ROS)


HPI

• Sally presents with blurry vision and left sided headache for 2 days


HPI

• Sally presents with blurry (quality) vision (chief complaint) and left sided (location) headache for 2 days (duration)

• What about:• Timing

• Quality

• Severity

• Modifying factors

• Associated signs/symptoms


HPI

• Mr. Smith presents today in follow-up and indicates he is doing very well and doesn’t have any complaints.


HPI

• Mr. Smith presents today in follow-up (for what)and indicates he is doing very well and doesn’t have any complaints.

• What about:• Mr. Smith presents today in follow-up of his diabetes. He

indicates he is doing very well and doesn’t have any complaints. He did state that he takes his medications(modifying factor) as prescribed and checks his blood sugars 3 times a week (timing).


Review of Systems

• Constitutional symptoms - fever, weight loss

• Eyes – blurry vision, pain

• Ears, Nose, Mouth, Throat – congested, sore throat

• Cardiovascular – chest pain, edema, palpitations

• Respiratory – coughing, dyspnea, wheezing

• GI – heartburn, nausea, diarrhea, appetite

• GU – nocturia, frequency, lumps, pain


Review of Systems

• Musculoskeletal – aching muscles, pain, swelling joints

• Integumentary - itching, rash, changes in mole• Neurological – numbness, convulsions, dizzy,

headache• Psychiatric – loss of memory, crying, sleep pattern

changes• Endocrine – sweating, thyroid replacement

medication• Hematological / Lymphatic – swollen nodes, bleeding• Allergic / Immunologic – NKDA, allergic to;

immunizations


Past Medical, Family &/or Social History• Past History

• Allergies, current meds, immunization, surgeries, previous illness, age appropriate feedings

• Family History• Health of parents, siblings or children, hereditary diseases that put

the patient at risk (blood relatives)

• Social History• Age appropriate review of past and current activities

• Marital status

• Employment

• Drug, alcohol, and tobacco use

• Education

• Sexual history


Documentation Guidelines• HPI is qualitative

• Trying to describe the reason for the encounter

• ROS is quantitative• An inventory and investigating an organ

• Double Dipping • You may use same piece of information in HPI and ROS

– Only with..

• Further development in the ROS

• You may not use the same piece of information twice in HPI


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Types of History

• Problem Focused - (“focuses” on chief complaint only)

• Chief complaint

• Brief history of present illness/problem

• Expanded Problem Focused - (“expands” beyond the chief complaint only)

• Chief complaint

• Brief history of present illness/problem

• Problem pertinent system review

Coding & Compliance Initiatives, Inc.

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Types of History

• Detailed - (extends beyond chief complaint with “detailed” info regarding additional systems/problems)

• Chief complaint

• Extended History of Present Illness

• ROS Include Number of Additional PERTINENT Systems reviewed

• PMH/FM and/or SH Pertinent to Chief Complaint


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Types of History

• Comprehensive - (Complete review all systems as relate to chief complaint)

• Chief complaint

• Extended HPI

• Complete ROS (total of 10)

• Complete PMH/SH/FM (must be pertinent)


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Types of HistoryType of History Chief Complaint History of

Present IllnessReview of Systems

Past Medical, Family and/or Social History

Problem Focused

X 1 NONE NONE

Expanded Problem Focused

X 1 1 NONE

Detailed X 4 2-9 At least one

Comprehensive X 4 10 or more 2/3 or 3/3


Examination


Physical Examination

• Two sets of guidelines• 1995 vs. 1997

• Is a specialist bound to 1997 guidelines?

• What are the differences?


Physical Examination

• 1995 Exam Guidelines• More subjective than 1997

• Did not define documentation needed for a single system exam

• Not all specialties are represented by a single system exam

• Easier in most cases for providers to meet these requirements

• The difference between Expanded Problem Focused and Detailed Exam never clarified


Problem

Expanded

Detailed

Comprehensive

1995 - Body Areas/Organ

Systems1997 – Bullets

1 1 - 5

2 - 7

2– 7 *with 1 detailed

8 + organ

systems

6 - 11

12 - 17

18 / 9

Multi - Sys Single - Sys

1 - 5

6 - 11

12 +

All Shaded +

1 Unshaded

Eye/Psych = 9

Determining Level of Physical Examination

Body Areas / Organ Systems

This is vague so refer to 1997 “bullets”

Example - 1995

VITALS: Stable, afebrile.GENERAL: NADCARDIOVASCULAR: RRRLUNGS: CTAABDOMEN: Soft, tenderness in right lower quadrant, no guarding

VITALS: Stable, afebrile.GENERAL: NADCARDIOVASCULAR: RRRLUNGS: CTAABDOMEN: Soft, tenderness in right lower quadrant, no guarding, no rebound, bowel sounds in all 4 quadrants, no acute abdomen, no hepatosplenomegaly.


Medical Decision-Making (MDM)


Medical Decision Making (MDM)

• The medical decision-making should drive the visit

• The history and exam should match the severity of the problem(s) and complexity of decision-making


Medical Decision Making (MDM)

• The plan helps create the severity of the patient’s condition and work performed by the provider.

• Tell the story


Medical Decision-Making

Problems Number Points Results

Self-limited or minor (stable, improved or worsening)

Max = 2 1

Established problem (stable or improved) 1

Established problem (worsening) 2

New problem; no additional workup or diagnostic procedures ordered

Max = 1 3

New problem; additional workup planned 4

Enter Total


Enter Total

Medical Decision-MakingAmount and/or Complexity of Data to be Reviewed Points

Review and/or order of clinical tests 1

Review and/or order of tests in the radiology section 1

Review and/or order of tests in the medicine section 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from someone other than the patient

1

Review and summarization of old records and/or obtaining history from someone other than the patient

2

Independent visualization of image, tracing, or specimen itself (not simply a review of the report)

2

Enter Total



Levels of MDM

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Type of

Decision

Making

Number of Dx or

Treatment

Options

Amount and/or

Complexity of

Data to Review

Risk of

Complications

and/or Morbidity

or Mortality

Straight forward Minimal Minimal or None Minimal

Low Complexity Limited Limited Low

Moderate

Complexity

Multiple Multiple Moderate

High Complexity Extensive Extensive High


Acute or Chronic Patient

Acute

Chronic

Level 2No interventions

Go home

Level 4Acute problem with complicating factors

Level 5Acute problem with

threat to life or bodily function

Level 3Chronic stable

problem

Level 3Acute uncomplicated

problem

Level 5Severely exacerbated or threat to life or bodily

function

Level 4Chronic mildly

exacerbated problem or 2/3 chronic stable

Level 2No interventions

Go home


Example• History: Patient presents with abdominal pain. She

states the pain has been there for 2 days and worse when she is up moving around. Low grade fever, no diarrhea, some nausea

• Exam: Vital Signs: Wt. 136, BP 122/84, HR 82, RR 16; General Appearance: pleasant but appears in pain; Abdomen: soft, tender on RLQ, no hepatosplenomegaly; CV: RRR; Resp: clear to auscultation

• Assessment: RLQ pain; Fever• Plan: CMP, CBC with diff; CT abdomen


Example• History: Patient presents with abdominal (location)

pain (cc). She states the pain has been there for 2 days (duration) and worse when she is up moving around (modifying factor). Low grade fever, no diarrhea, some nausea

• Exam: Vital Signs: Wt. 136, BP 122/84, HR 82, RR 16; General Appearance: pleasant but appears in pain; Abdomen: soft, tender on RLQ, no hepatosplenomegaly; CV: RRR; Resp: clear to auscultation

• Assessment: RLQ pain; Fever• Plan: CMP, CBC with diff; CT abdomen


Example• Pt here for f/u on DM and HTN. She is still not taking her

insulin as directed. She has not followed through with her chronic disease mgmt. appts and is tearful during the exam. She feels very hopeless and lost most of the time. She verbalizes the importance of monitoring her glucose and keeping a log as well as taking her insulin as directed. Her blood sugar has been over 300 when she does take it. She complains of numbness in her feet. She has not been compliant with her insulin. She does not check her blood pressure. She tries to take her medicine but indicated she typically takes it 3 days out of the week as she usually forgets. She does not have any chest pain, shortness of breath or leg swelling. She has a h/a once in a while. She continues to smoke.


Example• Pt here for f/u on DM and HTN. She is still not taking her

insulin as directed (modifying factor). She has not followed through with her chronic disease mgmt. appts and is tearful during the exam. She feels very hopeless and lost most of the time (timing). She verbalizes the importance of monitoring her glucose and keeping a log as well as taking her insulin as directed. Her blood sugar has been over 300 (severity) when she does take it. She complains of numbness (quality)in her feet (location). She has not been compliant with her insulin. She does not check her blood pressure. She tries to take her medicine but indicated she typically takes it 3 days out of the week as she usually forgets. She does not have any chest pain(ROS), shortness of breath (ROS)or leg swelling. She has a h/a (ROS) once in a while. She continues to smoke. (social history)


Example• A/P: uncontrolled diabetes – continue Lantus – 15 units subcutaneous in AM –

patient educated on the importance of being compliant with medication and checking blood sugar

• Diabetes with polyneuropathy

• HTN – continue metoprolol tartrate tab 100 mg – 1 tab with food twice a day –stressed the importance of taking medication every day as directed. Limit intake of salt, simple carbs, saturated fats, transfats, cholesterol – eat a well balance diet with lean protein.

• MDD recurrent – increase Prozac 20 mg 1 capsule in morning daily; start Bupropion HCL tab 100 mg ½ tab days 1-10; 1 tab remainder days. Referral to social worker for emotional support, crisis counseling

• Long term insulin

• Smoker – counseled the patient on the importance of quitting smoking. We discussed different medications, Nicorette gum – patient indicated she is not interested in quitting at this time. She states she will try to “cut back.”

• f/u in 1 month


Preventive vs. E/M

• Why are you seeing the patient?

• Preventive:

• Well Adult

• Well Woman

• Well Child

• Medicare AVW, IPPE/Welcome to Medicare, etc.


Selecting E/M Based on Time

• For visits that involves more than 50 percent counseling and/or coordination of care, time can determine the level of coding.

• For example, if a 40-minute office visit with an established patient involved more than 20 minutes of counseling and coordination of care, the visit would be reported with 99215 if everything was documented and medically necessary.


Sufficiently Documenting Encounter Details

• Objective and measurable• I have more pain – more pain than what?• I can lift more weight with my right shoulder

now – how much is more?• I can ambulate to the coke machine – how

far is the coke machine?


Components of Documentation

• Who?• Who is performing the service?• Who is the encounter with?

• What and how many?• What service is being provided? How many?

• Where?• Where is the place of service/location?

• When?• Date and time

• Why?• Medical necessity, diagnosis, rationale• For clinician to think about – why me? Why does this require

my skill set? My licensure?


Other Tips

• Ancillary and diagnostic test results • Document how you utilized them for the

patient’s care. • If normal, indicate normal and what (i.e. continue

same meds, follow-up if not better in xx, etc.)

• What is the patient being assessed for

during the specific visit – don’t just drop in

all the diagnoses. They should be

assessed, relevant and medically necessary

for the specific encounter.


Other Tips

• If you use order sets or macros – make sure

there is information specific to each

beneficiary

• Watch for charting discrepancies• Edema in assessment – exam indicates no

edema


Bullet Proof your EM

• Make the chief complaint a real complaint

• Answer the who, what, when, where, why,

how

• Don’t ignore the ROS

• Use the exam guidelines that work best for

you

• Incorporate the language of the MDM into

your documentation



Contact

• Shellie Sulzberger, LPN, CPC, ICDCT-CM

• 913-768-1212

• [email protected]

• www.ccipro.net


mailto:[email protected]

http://www.ccipro.net/


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• CCI assists our clients improve their documentation quality, coding and billing accuracy, and compliance with health care regulations www.ccipro.net

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Shellie Sulzberger, LPN, CPC, ICDCT-CMMs. Sulzberger is a Licensed Practical Nurse, Certified Professional Coder and ICD-10 Trainer. She received her Bachelors of Science degree in Business Administration from Mid America Nazarene University. Ms. Sulzberger received her nursing license in 1994 and was a practicing clinician at Saint Luke’s Health System for several years before transferring to the internal compliance/audit area. She became credentialed as a Certified Professional Coder in 1996 and assisted the Saint Luke’s Health System with performing medical record chart audits to verify the accuracy of the internal coding and claims processing.

Ms. Sulzberger spent approximately six years as a coding/billing consultant with National accounting and consulting firms (BKD, Grant Thornton) before becoming the President of Coding & Compliance Initiatives, Inc. (CCI) in April 2003. Ms. Sulzberger assists her clients with improving their operational performance in a variety of critical outcome areas, including coding/billing, corporate compliance, charge capture processes, etc. Ms. Sulzberger works with a variety of health care providers including hospitals, physician practices, and rural health clinics in their daily compliance and operational activities.

Ms. Sulzberger presents locally and nationally on coding topics as well as developing specialized training programs to meet the needs of her clients. Shellie recently was credentialed through American Institute of Healthcare Compliance as a Certified ICD-10 Trainer.

Contact Info:Tel: 913-768-1212Or [email protected]


mailto:[email protected]

Documents

Coding and Documentation Training for E/M Services Coding and Documentation - June 2018.pdfcoding decisions and any response to the limited information provided in a question is intended