11Revised April 2011Revised April 2011 TUMG Compliance TUMG Compliance
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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
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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
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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.
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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
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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.
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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.
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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
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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
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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?
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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…
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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
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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
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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.
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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
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End of PresentationEnd of Presentation
To Earn Compliance Credit:
Complete and Sign the “Documenting an Outpatient
Visit” QuizFax to: 504-988-7777
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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
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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
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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.
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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?
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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.
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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)
1- History of 1- History of Present IllnessPresent Illness 2 – Exam2 – Exam
3 – Medical 3 – Medical Decision Decision MakingMaking
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?
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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)
1- History of 1- History of Present IllnessPresent Illness 2 – Exam2 – Exam
3 – Medical 3 – Medical Decision Decision MakingMaking
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.
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