2What is documentation and why is it important? Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history.Assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring his/her health over time.“If it isn’t documented, it didn’t happen”!
3The Elements of Medical Documentation The reason the patient presented to see the physician/provider.Complete details of the information provided by the patient and by the evaluation of the patient.The results of diagnostic, consultative, and/or therapeutic services provided to the patient.The assessment of the patient conditions.The plan for the care of the patient, including advice from other physician specialists.Other services, procedures and supplies provided to the patient.The time spent with the patient, if counseling or coordinating care was provided.
4The Elements of Medical Documentation… The style and form of medical documentation depends on the provider. However, it is important that any reader of the medical record be able to understand the service rendered and medical necessity for the service.The medical documentation must be legible and understandable for all providers who care for the patient. If the handwriting of the physician cannot be read, Medicare auditors, as well as other payers, consider the service as not billable.
6Evaluating Your Documentation Is the reason for the patient encounter documented in the medical record? Is the Chief Complaint documented by the physician? Is the diagnosis documented to the highest specificity?Does the medical record clearly explain the medical necessity of the level of E&M service, diagnostic and therapeutic procedures, support services and supplies provided?Is the assessment of the patient’s condition apparent in the medical record?Medical record should tell the patient story!
7Other Points to Consider Documentation guidelines in the Evaluation and Management Services Guide also indicate that the documentation should be able to validate where the services were rendered and that the services were medically necessary and appropriate.The ICD-9-CM & CPT codes reported on the UB (facility) & 1500 (professional) should be supported by the documentation in the medical record.
8And a few more Points…The history areas and medical decision making areas frequently suffer from lack of detail. It is common to see the words “Patient here for f/u” as the chief complaint and the HPI. This is insufficient as is “Patient here to establish MD.”With decision making, the notations “continue present meds” and “f/u 3 months” tells nothing of the problem(s), the status of the problem, and the treatment or management of the problem.
10Evaluation & management E&M services refer to visits and consultations furnished by physicians and/or providers.Billing for a patient visit requires the selection of a CPT code that best represents the level of E&M service provided.Five (5) CPT codes that may be selected to bill for office or other outpatient visits for a “new” patient (99201 – 99205) and…Five (5) CPT codes for an “established” patient (99211 – 99215).
11New patient e&m99201 – Usually the presenting problem(s) are self-limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Problem focused historyProblem focused examinationStraightforward medical decision making
12New patient e&m99202 – Usually the presenting problem(s) are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Expanded problem focused historyExpanded problem examinationStraightforward medical decision making
13New patient e&m99203 – Usually the presenting problem(s) are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Detailed historyDetailed examinationMedical decision making of low complexity
14New patient e&m99204 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Comprehensive historyComprehensive examinationMedical decision making of moderate complexity
15New patient e&m99205 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient and/or family. E&M requires the following three key components:Comprehensive historyComprehensive examinationMedical decision making of high complexity
16New vs. establishedTo determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is ‘new’ or already ‘established’.CPT 2012 Revised Definitions:New - “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belong to the same group practice within the past three years”.
17Established – “An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years”.Exception! Patients seen in the Emergency Room do not have the distinction of ‘new’ vs. ‘established’.
18Emergency Room ER providers use following CPT codes: 99281 99282 99283 Problem focused history & examinationStraightforward MDMUsually presenting problem(s) are self limited or minor.99282Expanded problem focused history & examinationLow complexity MDMUsually presenting problem(s) are of low to moderate complexity99283Moderate complexity MDMPresenting problem(s) are of moderate severity
19And a few more… 99284 99285 Detailed history and examination MDM of moderate complexityUsually the presenting problem(s) are of high severity, and require urgent eval by the physician but do not pose an immediate significant threat to life/physiological function99285Comprehensive history & exam and MDM of high complexityHigh severity and pose an immediate significant threat to life/physiological function
20Documentation guidelines General multi-system exam (7 body areas or 12 body systems)Problem Focused = 1Expanded Problem Focused = 2-4Detailed = 5-7Comprehensive = 8 or more
21Documentation guidelines Multi-system exam or one of ten individualized single system examsGet ‘credit’ for documentation of 3 or more chronic conditionsHistory and Medical Decision Making are the same for 1995 & 1997CMS – Use whichever set of results is most in the physicians’ favor.However, you can’t mix & match!
22Documentation of E&M services The three key components of E&M services are:HistoryPhysical ExaminationMedical Decision MakingPlease note that just because the E&M level is dependent on two or three key components, performance & documentation of one component, ie, examination, at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E&M.
23Chief Complaint (CC)Chief Complaint – Each note must always include a chief complaint even if the chief complaint describes that the patient is presenting for follow-up of a previous problem, the reason for the visit must be clear as in “Patient presenting for f/u of uncontrolled hypertension.”Usually stated in the patient’s own words.Sometimes referred to as “presenting problem.”Example: Patient complains of upset stomach, aching joints, or fever.
24Key Components (History) Information that is given by the patient to the physicianThe history consists of 3 partsHistory of Present Illness (HPI)Review of Systems (ROS)Past, Family, Social History (PFSH)Remember! The Chief Complaint and the HPI must be documented by the physician.
25Four types of history Problem Focused Required Brief N/A TYPE OF HISTORYCHIEF COMPLAINTHISTORY OF PRESENT ILLNESSREVIEW OF SYSTEMSPAST, FAMILY, AND/OR SOCIAL HISTORYProblem FocusedRequiredBriefN/AExpanded Problem FocusedProblem PertinentDetailedExtendedPertinentComprehensiveComplete
26Key Components (History) History of Present Illness – Includes information described by the patient about the current condition including:Location – refers to the location of the problem/symptoms – left lower quadrant; left leg; right arm; etc.Severity – severity of the presenting problem – mild, severe; increasing; resolving, etc.Timing – the interval of the pain or suffering – every night; constant; comes and goes; intermittent, etc.Modifying Factors – how is the pain symptom modified – relieved by standing erect; better after taking aspirin; walking makes pain worse; etc.Quality – descriptive adjective – dull; sharp; aching; stinging; throbbing, etc.Duration – how long the patient has had the symptoms – two days; since last visit; since this morning, etc.Context – describes how the symptoms began or occurred – after the auto accident; after eating out at a restaurant; when I sit down; etc.Associated Signs and Symptoms – these are significant signs/symptoms that the patient feels are related to/part of their injury or illness – dizziness with nausea; swelling with injury; double vision with headache, etc.
27History… Alternate HPI Example Documentation of three chronic illnessesMust be related to chief complaintStatus of each condition must be documentedExampleChief Complaint (CC)Follow-up of HTN & Lower Extremity EdemaHPI –(1) Patient states that home BP readings have been 130/80 – 145/85 with Diovan. (2) Patient states legs are not as swollen at end of day. (3) She states that headaches are less frequent and severe. (4) She has also been able to lose some weight and has more energy.Brief HPI consists of 1 to 3 elements of the HPIExtended HPI consists of at least 4 elements of the HPI or the status of at least 3 chronic or inactive conditions
28ROS (review of systems) Review of Systems – Includes the patient’s “inventory” of signs and/or symptoms. These are most often answers to questions asked by the provider in order to establish a working diagnosis. Systems are:Constitutional – weight loss, fever, chills, malaise, etc.Ear, nose throat, and mouth – hearing loss, sinusitis, sore throat, oral cavities, etc.Gastrointestinal – nausea, vomiting, diarrhea, constipation, ulcer, etc.Integumentary – skin rashes, moles, dryness, lumps, pigmentation, etc.Endocrine – polyuria, polydipsia, cold-heat intolerance, diabetes, etc.Genitourinary – hematuria, nocturia, menopause, incontinence, etc.Hematologic/Lymphatic – anemia, bruising, bleeding, lymph node enlargement, etc.Eyes – diplopia, blurred vision, glasses, etc.Cardiovascular – chest pain or pressure, palpitations, murmur, hypertension, etc.Musculoskeletal – arthritis, joint stiffness, swelling, myalgias, gout, etc.Neurologic – dizziness, syncope, seizures, vertigo, weakness, tremor, etc.Allergic/Immunologic – allergies to medicine, food, etc./hepatitis, HIV, etc.Respiratory – cough, wheezing, asthma, etc.Psychiatric – depression, agitation, panic-anxiety, memory disturbance, etc.
29More on ros…The Review of Systems should be pertinent to the presenting problem – All pertinent positive and negatives should be documented. If all systems are reviewed, after the pertinent systems are documented, the statement “all other systems have been reviewed and are negative” will be appropriate for a complete review of systems.If a separate form is used for the Review of Systems, it should be dated and initialed by the provider with pertinent comments noted. This can be referred to by documenting “Review of Systems as noted on face sheet dated __ __ ____ has been reviewed with the following changes”.But be careful in using this statement! It is not necessary to have a complete ROS for a minor problem such as a sprained ankle or sinusitis. Right?
30Three types of ros Problem Pertinent Inquiries about the system directly related to the problem identified in the HPI.The patient’s positive responses and pertinent negatives for the system related to the problem should be documentedIn the following example, one system – the ear- is reviewed:Chief Complaint: EaracheROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness or headache
31Three types of ros Extended/Expanded Problem Inquiries about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.Patient’s positive responses and pertinent negatives for two to nine systems should be documented.In the following example, two systems – cardiovascular and respiratory- are reviewed:Chief Complaint: Follow-up visit in office after cardiac cath. Patient states “I feel great.”ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of the left leg.
32Three types of ros Complete Inquiries about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems.At least 10 organ systems must be reviewed with positive systems or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating “all other systems are negative” is permissible.In the following example, 10 signs & symptoms are reviewed:Chief Complaint: Patient complains of “fainting spell.”ROS:Constitutional: weight stable, + fatigueEyes: + loss of peripheral visionEar, Nose, Mouth, Throat: no complaintsCardiovascular: + palpitations; denies chest pain, calf pain, pressure or edemaRespiratory: + shortness of breath on exertionGastrointestinal: appetite good, denies heartburn, + episodes of nauseaUrinary: denies incontinence, frequency, urgency, nocturiaSkin: + clammy, moist skinNeurological: + fainting; denies numbness, tingling and/or tremorsPsychiatric: denies memory loss or depression. Mood pleasant.
33Past, family & social history (PFSH) May also be documented by “Refer to history on face sheet dated __ __ ____ with the following changes:”Past Medical History – includes adult & childhood illnesses or trauma, vaccinations & screenings, past surgical history, past & current medications, allergies.Family History – includes parents, siblings, children, genetic disease of the family or other family history.Social History – Information about the patient’s habits and circumstances – smoking, alcohol, drug use; sexual orientation, marital status, living arrangements, occupation, education, religion, recent travel.
34What if you can’t get the history from the patient? History is unobtainable:Patient is unconscious, mentally ill, unable to speak, intoxicated, etc.No other source is available.Document the reason why the patient is unable to communicate and also that no other source is available, if applicable.Physician is given credit for PFSH if unable to obtain from the patient.
35Physical exam Key Components of Physical Exam Should be pertinent to the presenting problem, i.e. if an established patient is in for follow-up of allergic rhinitis, a head to toe exam is not necessary.Should never, ever be copied forward from a previous visit.Care should be taken when using a check off form with “Normal” – not just go down the line √ off systems!Some auditors consider “WNL” as “We Never Looked.
36General multi-system exam TYPE OF EXAMINATIONDESCRIPTIONProblem FocusedInclude performance and documentation of 1-5 elements identified by a bullet in 1 or more organ system(s) or body area(s).Expanded Problem FocusedInclude performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).DetailedInclude at least 6 organ systems or body areas. For each system/area selected, performance & documentation of at least 2 elements identified by a bullet is expected. May include performance & documentaiton of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.Comprehensive1997: Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected.1995: 8 organ systems must be examined. If body areas are examines and counted, they must be over and above the 8 organ systems.
371997 documentation guidelines The 10 single organ system examinations are:CardiovascularEar, Nose, Mouth and ThroatEyesGenitourinary (male & female)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicalPsychiatricRespiratorySkin
38Documentation guidelines of exam Specific abnormal and relevant negative findings of the exam of the affected or symptomatic body area(s) or organ system(s) should be documented.A notation of “abnormal” without elaboration is insufficient.Brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).
39Key Components Medical Decision Making Number of diagnosis(es) or management options:All known diagnoses that are being treated or affect treatmentUndiagnosed conditions that are being evaluatedTreatments being used, considered or plannedPlays the ‘primary’ role in determining the correct level of service
40Amount &/or complexity of data to be reviewed If a diagnostic service is ordered, planned, scheduled or performed at the time of the E&M visit, the type of service should be documented.Review of labs or any diagnostic tests should be documented.“WBC elevated” or “chest x-ray unremarkable” is acceptable. The review may be documented by initialing & dating the report that contains the test results.Decision to obtain medical records or history from someone other than the patient must be documented.“Old records reviewed” or “additional history obtained from the family” without further elaboration is not sufficient – no credit should be given.
41Table of riskRisk of significant complications, morbidity, and mortality is based on the risks associated with:Presenting problem(s) or number of diagnoses and/or risk of complications (Chief Complaint)Diagnostic procedures orderedPossible management options
42S O A P – Not the cleaning kind! (S)ubjectiveChief Complaint – Each note must always include a chief complaint.History of Present IllnessReview of SystemsPast Medical, Family and Social History
43S O A P – Format (O)bjective Physical Examination – Second of the three key components for evaluation and management is documented by the provider.Amount and Complexity of DataReview of tests, records, independent review of tracings, specimens, etc.
44S O A P – Format (A)ssessment Number of diagnoses: The following should be considered:All known diagnoses that are being treated or affect treatmentUndiagnosed conditions that are being evaluatedRisk of complications and/or morbidity or mortality
45S O A P – Format (P)lan Treatment Options: Prescription drug managementDiagnostic testsIV FluidsSurgeriesDecision not to resuscitateReturn to OfficeReferral to another physicianPhysical, Occupational, Speech TherapyOver the Counter Drugs
46And then there is “Time” Used in selecting an E&M code only when Counseling and/or Coordination of care represents more than 50% of the time spent face-to-face (outpatient) or bedside and on the floor or unit with the patient or family (inpatient).Both time elements – total length of time for the visit and total length of time involved in Counseling and/or Coordination of care – as well as the nature of the counseling and/or coordination of care must be documented explicitly in the medical record.
47Prolonged servicesCPT codes are used when a physician provides prolonged services involving direct (face-to-face) patient contact beyond the usual service in either the inpatient or outpatient setting.Reported in addition to E&M level.Report the total duration of the face-to- face time spent even if not continuous.
48More on prolonged services Bill the first hour with CPT 99354, 99356Each additional 30 minutes with CPT 99355,Can only be reported ‘once’ per dayLess than 30 minutes is included in the E&M levelExample:Physician performed a visit that met the definition of visit code & the total duration of the direct face-to-face services (including the visit) was 65 minutes.Physician bills E&M and 1 unit of CPT
49Inpatient Initial Hospital Care Subsequent Hospital Care 99221 (low severity – 30 minutes)99222 (moderate severity – 50 minutes)99223 (high severity – 70 minutes)Subsequent Hospital Care99231 (Stable, recovering or improving – 15minutes at bedside)99232 (Responding inadequately/developedminor complication – 25 min)99233 (Unstable/developed significantcomplication or new problem – 35 min)
50Discharge day management Documentation does not always include the total time spent performing the discharge day management functionReview of the medical recordCompletion of discharge summary99238Less than 30 minutes99239More than 30 minutesCPT Default:If time is not documented, then the lesser of the two is billed, i.e.,
51Critical careRequires ‘direct personal management’ from a physician, the absence of which ‘would likely result in sudden, clinically significant or life-threatening deterioration’ of the patient.Examples:Acute allergic reaction(s)GI bleedSubdural/subarachnoid hemorrhageAMIRespiratory distress/failure
52Critical care Critical Care is a ‘time’ driven CPT code. Does not require constant bedside attendance.Reviewing ancillary studiesDiscussions with nursing staff, physicians, family members & documentation of these interventions in the medical recordBillable procedure include (but not limited to):Endotracheal intubationCPRChest tube placementCVP line insertionsEKG interpretation
53More on critical carePhysician(s) MUST document critical care for the encounter in the record.State the time spent providing critical care in minutes:99291 = documented minutes99292 = Each additional 30+ documentedminutesThe HPI & ROS guidelines are not required for Critical Care, however, documentation does need to support medical necessity for the high level of service.
54If it is NOT documented, it did NOT happen! The Golden RuleIf it is NOT documented, it did NOT happen!
55Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. PO Box 486 Pocatello, ID (208) Fax: (360)