Disclaimer

11Revised April 2011Revised April 2011 TUMG Compliance TUMG Compliance

DisclaimerDisclaimerThis presentation is intended only for use by This presentation is intended only for use by Tulane University faculty, staff, and students. Tulane University faculty, staff, and students.

No copy or use of this presentation should occur No copy or use of this presentation should occur without the permission of Tulane University. without the permission of Tulane University.

Tulane University retains all intellectual property Tulane University retains all intellectual property interests associated with the presentation. interests associated with the presentation.

Tulane University makes no claim, promise, or Tulane University makes no claim, promise, or guarantee of any kind about the accuracy, guarantee of any kind about the accuracy,

completeness, or adequacy of the content of the completeness, or adequacy of the content of the presentation and expressly disclaims liability for presentation and expressly disclaims liability for

errors and omissions in such content.errors and omissions in such content.

Revised April 2011Revised April 2011 TUMG Compliance TUMG Compliance 22

Documenting an Documenting an Outpatient VisitOutpatient Visit

Overview of Basic Principles

Before viewing, print the file: Documenting an Outpatient Visit

which contains a handout and a quiz


Read Before ProceedingRead Before ProceedingPhysicians and Staff may earn one compliance

credit by viewing this presentation, completing the assessment, and faxing the assessment to the

HIPAA Compliance Office: 504-988-7777

This presentation may be viewed for compliance credit only once in a fiscal year

(July 1 - June 30).

To check to see how many compliance credits you have and to see which training sessions you have

completed, contact the University Privacy and Contracting Office at 504-988-7721


It is the policy of TUMG to provide healthcare It is the policy of TUMG to provide healthcare services that are in compliance with all state services that are in compliance with all state

and federal laws governing its operations and and federal laws governing its operations and consistent with the highest standards of consistent with the highest standards of

business and professional ethics. Education for business and professional ethics. Education for all TUMG physicians is an essential step in all TUMG physicians is an essential step in

ensuring the ongoing success of compliance ensuring the ongoing success of compliance efforts.efforts.


This is the first of a 6-part series focused on

documenting outpatient services. Part 1: Overview Part 1: Overview of Basic Principlesof Basic PrinciplesPart 2: Documenting Part 2: Documenting a Historya HistoryPart 3: Documenting Part 3: Documenting an Examan Exam

Part 4: Documenting Medical Part 4: Documenting Medical Decision Making Decision Making Part 5: Time-Based CodesPart 5: Time-Based CodesPart 6: Linking to Resident Part 6: Linking to Resident NotesNotes


TUMG Physicians are responsible TUMG Physicians are responsible for documenting their outpatient for documenting their outpatient visits and selecting the level of visits and selecting the level of

service to be billed to the carrier.service to be billed to the carrier.


Purpose of PresentationPurpose of Presentation

To provide information regarding documenting and To provide information regarding documenting and selecting a level of service for outpatient visitsselecting a level of service for outpatient visits

To provide links to source documents that will To provide links to source documents that will assist physicians in the understanding and assist physicians in the understanding and application of documentation guidelines.application of documentation guidelines.


The WYSI-WYG PrincipleThe WYSI-WYG Principle(WYSI-WYG)(WYSI-WYG)

The WYSIWYG principle defines the relationship between documentation and level of service

WWhat hat YYou ou SSee ee IIs s WWhat hat YYou ou GGetetCorollary:Corollary:

If it isn’t written, If it isn’t written,

it didn’t happen, and it didn’t happen, and

it can’t be billedit can’t be billed


Physician:I know the service is a

99204

Physician Note

Chief Complaint

Expanded History

Detailed Exam

Moderate Decision Making

An understanding of Evaluation and Management Guidelines, paired with the WYSI-WYG Principle, greatly reduces the

potential for Level of Service – Documentation Mismatches

Reviewer/Coder: I see a 99202


Outpatient Visit EssentialsOutpatient Visit Essentials

1)1) Documentation that supports the level of Documentation that supports the level of service billedservice billed

Does the note contain all the elements required for Does the note contain all the elements required for the level of service selected?the level of service selected?

2) Clearly established Medical Necessity2) Clearly established Medical Necessity

Does the note provide a clear reason for the visit, Does the note provide a clear reason for the visit, and are the assessment and plan clearly related to and are the assessment and plan clearly related to the reason for the visit?the reason for the visit?


Physician Note

Chief Complaint

History

Exam

Medical Decision Making

To avoid “underdocumenting,” the physician’s note must reflect all the elements of History,

Exam and Medical Decision Making performed for each outpatient encounter.

Decision Making

Exam

History

It’s a matter of writing and/or dictating…


To insure that documentation supports To insure that documentation supports the level of service:the level of service:

Understand and apply General Principles of Medical Understand and apply General Principles of Medical Record documentationRecord documentation

Understand and apply Evaluation and Management Understand and apply Evaluation and Management documentation guidelines documentation guidelines click here: (jump to slide 18)click here: (jump to slide 18)

Link to other supporting documentation (resident Link to other supporting documentation (resident notes, staff notes, patient questionnaires)notes, staff notes, patient questionnaires)

Links to Documentation Resources (click on the link to open)

1995 General Principles of Medical Record Documentation

1997 General Principles of Medical Record Documentation

Linking to resident notes and teaching physician guidelines


To insure that Medical Necessity is To insure that Medical Necessity is established a note should containestablished a note should contain

A clearly stated chief complaint click hereA clearly stated chief complaint click here A clearly stated diagnosis(es) or, in absence of a A clearly stated diagnosis(es) or, in absence of a

diagnosis, signs and symptoms diagnosis, signs and symptoms A clearly stated or easily inferred rationale for A clearly stated or easily inferred rationale for

ordering diagnostic or other ancillary servicesordering diagnostic or other ancillary services

WORD OF CAUTION:

The only instance where information can be inferred is for ordering diagnostic or other ancillary services.

The chief complaint and the diagnosis cannot be inferred; they must be clearly documented


Auditors are not psychicsAuditors are not psychicsI sense a complete

review of systems…but the crystal ball is

cloudy regarding a chief complaint and

the exam…

Note

Medical Record Reviewers or Coders do not fill in gaps in a note.

Each outpatient visit must stand alone. Reviewers will not look back at prior notes to support a level of service.


Need More Information?Need More Information?The TUMG Compliance Educator / Audit Specialist is The TUMG Compliance Educator / Audit Specialist is available to any physician/section/department that would available to any physician/section/department that would like further information on outpatient documentation like further information on outpatient documentation

guidelines or other compliance topicsguidelines or other compliance topics..

Contact:Contact:Sue Straumanis, CPC, CHCSue Straumanis, CPC, CHC

[email protected]@tulane.edu

Phone: 504-988-6807Phone: 504-988-6807


End of PresentationEnd of Presentation

To Earn Compliance Credit:

Complete and Sign the “Documenting an Outpatient

Visit” QuizFax to: 504-988-7777


Chief ComplaintChief Complaint

““The Chief Complaint is a The Chief Complaint is a concise statement concise statement describing the symptom, describing the symptom, problem, condition, problem, condition, diagnosis, physician-diagnosis, physician-recommended return, or recommended return, or other factor that is other factor that is reason for the encounter” reason for the encounter” This is usually stated in This is usually stated in the patient’s own words.the patient’s own words.Source: Source: Medicare Physician Guide: A Medicare Physician Guide: A Resource for Residents, Practicing Resource for Residents, Practicing Physicians, and Other Healthcare Physicians, and Other Healthcare Professionals. 11Professionals. 11thth Edition – Oct. Edition – Oct. 2009, pg. 102.2009, pg. 102.

Corollary: The Chief Corollary: The Chief complaint cannot be complaint cannot be inferred.inferred.

Click here to return to main presentationClick here to return to main presentation


Basics of E/M Coding – 6 slidesBasics of E/M Coding – 6 slidesThe Meet or Exceed PrincipleThe Meet or Exceed Principle

New Patients OR Initial New Patients OR Initial ConsultsConsults, the Physician , the Physician must must MEET or EXCEEDMEET or EXCEED documentation requirements documentation requirements for three of for three of threethree E/M E/M ComponentsComponents

HistoryHistory ExamExam Medical Decision Medical Decision

MakingMaking

Established Patients OR Established Patients OR Follow-Up ConsultsFollow-Up Consults, the , the Physician must Physician must MEET or MEET or EXCEEDEXCEED documentation documentation requirements for requirements for twotwo of of three E/M Components. three E/M Components.

History/Medical History/Medical Decision MakingDecision Making

Exam/Medical Exam/Medical Decision MakingDecision Making

There are six slides in this section of the presentation– at slide 6 there is a link to return to the main presentation


A word about Established Patient A word about Established Patient documentation documentation

Although Established Patient/Follow-Up Consult E/M level of Although Established Patient/Follow-Up Consult E/M level of service is based on two of three E/M components, that does not service is based on two of three E/M components, that does not mean that the physician should not document elements of all mean that the physician should not document elements of all three E/M components if the information is germane to the three E/M components if the information is germane to the treatment of the patient. treatment of the patient.

Medical Decision Making must always be one of the two Medical Decision Making must always be one of the two components when determining level of service to ensure components when determining level of service to ensure medical necessity is being met.medical necessity is being met.


New Patients – Selecting A Level of ServiceNew Patients – Selecting A Level of ServiceE/M Code and E/M Code and Visit Time (in Visit Time (in

minutes)minutes)

1- History of 1- History of Present IllnessPresent Illness 2 – Exam2 – Exam

3 – Medical 3 – Medical Decision Decision MakingMaking

99201-1099201-10

99241-1599241-15Problem-Problem-focusedfocused

Problem-Problem-focusedfocused

Straight Straight forwardforward

99202-2099202-20

99242-3099242-30ExpandedExpanded ExpandedExpanded Straight-Straight-

forwardforward

99203-3099203-30

99243-4099243-40DetailedDetailed DetailedDetailed LowLow

99204-4599204-45

99244-6099244-60ComprehensiveComprehensive ComprehensiveComprehensive ModerateModerate

99205-6099205-60

99245-8099245-80ComprehensiveComprehensive ComprehensiveComprehensive HighHigh

A physician note documents a detailed History, expanded Exam and Moderate Medical Decision Making. What New Patient code or Consult code is supported by the documentation?


New Patients – Selecting A Level of ServiceNew Patients – Selecting A Level of ServiceE/M Code and E/M Code and Visit Time (in Visit Time (in

minutes)minutes)

1- History of 1- History of Present IllnessPresent Illness

2 – Exam2 – Exam 3 – Medical 3 – Medical Decision Decision MakingMaking

99201-1099201-10

99241-1599241-15

Problem-focusedProblem-focused Problem-focusedProblem-focused Straight forwardStraight forward

99202-2099202-20

99242-3099242-30

ExpandedExpanded ExpandedExpanded Straight-forwardStraight-forward

99203-3099203-30

99243-4099243-40

DetailedDetailed DetailedDetailed LowLow

99204-4599204-45

99244-6099244-60

ComprehensiveComprehensive ComprehensiveComprehensive ModerateModerate

99205-6099205-60

99245-8099245-80

ComprehensiveComprehensive ComprehensiveComprehensive HighHigh

With new patients or consults, the LOWEST of the three E/M key components documents determines the level of service. In this case, a 99202 or 99242.


Established Patients – Selecting A Level of ServiceEstablished Patients – Selecting A Level of Service

E/M Code and E/M Code and Visit Time (in Visit Time (in

minutes)minutes)



99211-1099211-10 N/AN/A N/AN/A N/AN/A

99212-2099212-20 Problem-Problem-FocusedFocused

Problem-Problem-FocusedFocused Straight-forwardStraight-forward

99213-1599213-15 Exp. Problem-Exp. Problem-FocusedFocused

Exp. Problem-Exp. Problem-FocusedFocused LowLow

99214-2599214-25 DetailedDetailed DetailedDetailed ModerateModerate

99215-4099215-40 ComprehensiveComprehensive ComprehensiveComprehensive HighHigh

A physician note documents a detailed History, expanded Exam and Moderate Medical Decision Making. What established patient code is supported by the documentation?


Established Patients – Selecting A Level of ServiceEstablished Patients – Selecting A Level of Service

E/M Code and E/M Code and Visit Time (in Visit Time (in

minutes)minutes)



99211-1099211-10 N/AN/A N/AN/A N/AN/A

99212-2099212-20 Problem-Problem-FocusedFocused

Problem-Problem-FocusedFocused Straight-forwardStraight-forward

99213-1599213-15 Exp. Problem-Exp. Problem-FocusedFocused

Exp. Problem- Exp. Problem- FocusedFocused

LowLow

99214-2599214-25 DetailedDetailed DetailedDetailed ModerateModerate

99215-4099215-40 ComprehensiveComprehensive ComprehensiveComprehensive HighHigh

With established patients, the LOWEST of the two highest E/M key components documented determines the level of service. In this case, documentation supports a level 99214.

*Click here to return to main presentation*

Documents

Disclaimer