1. Clinical Documentation Tips Reflection of Acuity & Medical Necessity
“I Bill for It”

2. Objectives
Understand the elements of synergies in clinical documentation impacting physicians and hospitals
Understand relationship between specificity in documentation and patient acuity
Learn how patient acuity and comorbid conditions drives medical necessity and E & M assignment
Appreciate the “pitfalls” and “traps” of documentation that contribute to denials and downcoding of E & M

3. History of Present Illness
HPI is chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
Focus upon present illness!
Limit elements of past history for documentation in the Past Family Social History section of the History

4. HPI HPI → 8 elements Location Quality Severity Duration Timing Context
Modifying factors
Associated signs and symptoms

5. HPI that are really “HPI’s”
Mrs. Jones, a 75 year old patient presented to the Emergency Room with abdominal pain lower left quadrant of three days duration, suddenly worse last night, with associated shortness of breath, took Maalox, didn’t help. Pain described as at 10 on a pains scale of 10. Pain now 7 out of 10 after receiving Morphine in the ER.

6. Right to the Point NO
Fluff

7. Right to the Point
HPI- The patient presented from the Personal Care Home with a two day history of worsening shortness of breath and nonproductive cough. She started using oxygen at home but this got progressively worse , particularly when ambulating, and she came to the Emergency Room this morning and was found to be in acute respiratory distress.

8. Right to the Point
She was evaluated and found to have acute hypoxemic respiratory failure, congestive heart failure with possible pneumonia. She was stabilized somewhat in the Emergency Room but is still short of breath, more so that at her usual baseline. She is being admitted for further evaluation and treatment.

9. Assessment & Plan
This is a 75 year old-female with 1) Acute congestive heart failure, acute left ventricular systolic dysfunction with probable chronic left ventricular systolic dysfunction. We are going to admit her, give her fluid restrictions, intravenous Lasix for diuresis and pulmonary toilet. Will monitor closely.

10. Assessment & Plan
1) Chronic obstructive pulmonary disease exacerbation with acute on chronic respiratory failure and hypoxia and hypercapnia and acute respiratory acidosis. We are going to give her oxygen and pulmonary toilet with Duoneb treatment. Will diurese her as noted above. Will cover empirically for infection with Avelox, 400 mg, IV daily. Monitor closely and call in pulmonology service and cardiology service if clinical conditions worsen.

11. Assessment & Plan Continued
3) Diabetes mellitus, Type II controlled, and will continue her on Lantus and start her regular insulin sliding scale and monitor
4) Hypertension, will continue current medications and monitor
History of breast cancer. Status post lumpectomy, apparently stable.
5) History of long QT syndrome. She does have an implantable defibrillator. Will rule out MI per protocol and monitor closely
(Total time for H & P examination one hour)
Would be helpful to relate MI rule out to HPI of acute respiratory distress, linking symptoms or provisional diagnoses to the diagnostic tests ordered

12. The Driver

13. Role of HPI HPI drivers:
Extent of PFSH, ROS and physical exam performed
Medical necessity for amount work performed and documented
Medical necessity for E & M assignment
Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements.

14. Speaking of Medical Necessity
Federal law requires that all expenses paid by Medicare, including expenses for Evaluation and Management services, are medically reasonable and necessary.
1862(a)(1)(a) of the Social Security Act, Title XVIII
No payment can be made for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Applies to physician and hospital

15. Synergy of Clinical Documentation
Physician Responsible for patient designation assignment
Inpatient versus Outpatient Service
The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting.
Chapter 1 section 10 of Medicare Benefit Policy Manual

16. Documentation of Acuity
Factors to be considered when making the decision to admit include such things as:
The severity of the signs and symptoms exhibited by the patient;
The medical predictability of something adverse happening to the patient;
The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
The availability of diagnostic procedures at the time when and at the location where the patient presents.

17. Business Synergy Medical Necessity Hospital & Physician Assessment HPI
Plan
Medical Necessity
Hospital & Physician

18. Medical Necessity
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.
It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.
Less Complex diagnoses potentially warrant a lower level of E & M

19. Signs, Symptoms & Nonspecific Diagnoses
Medical Complexity
Signs, Symptoms & Nonspecific Diagnoses
Specific Diagnoses
Chest Pain/Acute Coronary Syndrome
Hypoxemia/Acute Respiratory Distress
Nausea and Vomiting
CHF
Postobstructive Pneumonia with right lower lobe cancer inoperable
Non ST MI with unstable angina
Acute hypoxemic respiratory failure
Food poisoning with severe dehydration
Acute on chronic systolic left sided heart failure
Suspected gram-negative pneumonia in a patient with known inoperable RLL cancer

20. Medical Necessity
Medical necessity of E/M services is generally expressed in two ways: frequency of services and intensity of service (CPT level).
Medicare’s determination of medical necessity is separate from its determination that the E/M service was rendered as billed.

21. Medical Necessity
Medicare determines medical necessity largely through the experience and judgment of clinician coders along with the limited tools provided in CPT and by CMS.
At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs

22. Elements of Medical Necessity
Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work:
Number, acuity and severity/duration of diagnoses/ problems addressed through history, physical and medical decision-making.

23. Common Documentation Deficiency
Progress Note
9/13 10:10 AM- Patient had no new complaints, stable overnight. VS stable, Labs WNL.
Assessment and Plan: Continue Present Management
Deficiency
Not Clear Face-to-Face Encounter
Absence of Diagnoses
No Billable E & M service

24. Elements of Medical Necessity
The context of the encounter among all other services previously rendered for the same problem
Complexity of documented comorbidities that clearly influenced physician work.
Physical scope encompassed by the problems (number of physical systems affected by the problems).

25. Complexity Does Matter
Less Complex
More Complex
Acute respiratory distress
CHF
CHF worsening
COPD exacerbation
COPD exacerbation with hypoxemia
Acute respiratory failure
Acute systolic CHF
Acute on chronic systolic CHF
Acute respiratory failure with COPD exac
COPD exacerbation with chronic respiratory failure
More complex diagnoses represent higher complexity of medical decision making

26. Complexity Does Matter
Less Complex
More Complex
Acute renal insufficiency
Chronic hypoxemia
Cardiac arrhythmia
Acute renal failure
Chronic renal failure
Hypoalbuminemia
Acute renal failure
Chronic respiratory failure
Atrial fibrillation
Acute tubular necrosis/acute interstitial nephritis
Chronic renal failure stage IV
Protein calorie malnutrition

27. Medical Decision Making
Exchange of clinically reasonable and necessary information and the use of this information in the clinical management of the patient

28. Decision Point

29. Medical Decision Making
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
The number of possible diagnoses and/or the number of management options that must be considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and
The risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
Number of possible diagnoses versus symptoms. Provisional diagnoses do count toward medical decision making, symptoms do not count toward medical decision making

30. Medical Decision Making
MDM consists of 4 levels
Straight Forward Complexity
Low Complexity
Moderate Complexity
High Complexity
General Rule of Thumb is inpatient encounter should equate to Moderate or High Complexity

31. Amount & Complexity of Data
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed.
A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed

32. Number of Diagnoses & Management Options
The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
HPI provides a roadmap for the amount of work performed including PE, establishment of medical necessity for ordering tests, amount of work performed, and medical decision making

33. Documentation Tips
DG: For each encounter, an assessment, clinical impression, or diagnosis should (must)be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.
For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.
Notice reference to diagnosis and not sign or symptom, clinical impression and assessment represent diagnoses vs. sign or symptom

34. Documentation Tips
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible,” "probable,” or "rule out” (R/O) diagnoses.
In your initial clinical impression, advantageous to list your provisional diagnoses that will be substantiated or ruled out with further diagnosis plan and work up

35. Best Strategy Documentation
Chief Complaint: Chest Pain
HPI- Eighty-five year old female patient unassigned presented to the ER with abdominal pain 8 out 10 radiating to the chest, associated shortness of breath, worse at night and after eating a large meal. Patient states pain was waxing and waning for last few days, became intolerable this morning, not relieved by Maalox, prompted her to seek medical attention in the Emergency Room.

36. Best Strategy Documentation
Assessment & Plan
Chest pain- possible MI but less likely given the fact the patient does not have any risk factors for MI other than age. Will still initiate the ROMI protocol to ensure we don’t get caught in situation of blind obedience
Abdominal pain- likely mesenteric ischemia in light of the fact patient’s abdominal pain is worse after eating a large meal. Will order mesenteric duplex ultrasound and CT scan with contrast to evaluate status of vasculature. Will consult surgery for their recommendations of further work-up. IV pain meds as needed and NPO for now.

37. Practical Documentation Tips
When documenting MDM, a list of established diagnoses or potential diagnoses is insufficient for coding purposes without additional indications in the record of meaningful and necessary evaluation for each problem.
Practitioners should record relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which evaluation and management is clearly demonstrated
Tip- stability of chronic conditions should be documented as well as discussion of relationship to abnormal diagnostic results to established or provisional diagnoses.

38. Documentation Approach
Tell Documentation
Show Documentation
Assessment:
Dizziness and headache
TIA-
Acute sinusitis
Hypertension
Hyperlipidemia
Gout
History of breast cancer
Assessment:
Dizziness and headache
TIA- with patient describing an episode of slurred speech and difficulty finding words and weakness of left arm, this may be a TIA, will order a follow-up CT as initial in ER was indeterminate.
Hypertension- BP reading in the ER indicated hypertensive urgency, 205/120, perhaps BP elevation contributing to patient’s dizziness and headache. Will monitor and step up her anti-hypertension meds

39. Clinical Case Study
HPI: Mrs. Cold Weather presented to the Emergency Room with shortness of breath of three days duration, complains of chest pain at the same time of shortness of breath, waxing and waning, stabbing at some time, 8 out of 10, not relieved by her usual nitro.
PFH: Ischemic cardiomyopathy, hypertension, EF 10-15%

40. Clinical Case Study Continued….
PSH: quite smoking 20 years ago, lives with her husband who is in good health for his age
Past Surgical History; Non-contributory
Labs: BNP 2276, cardiac enzymes and Troponin mildly elevated
Chest X-ray shows cardiomegaly with pulmonary vascular congestion

41. Clinical Case Study Continued….
Clinical Impression:
Chest pain and shortness of breath rule out MI, rule out MI protocol
Elevated BNP- will start IV Lasix IV 80 mg, monitor output, chest X-ray PM,
Reduced EF- left ventricular systolic dysfunction
Chronic renal insufficiency

42. Take Two

43. Clinical Case Study Continued….
Clinical Impression: Mrs. Cold Weather with history of ischemic cardiomyopathy and end stage renal disease presents with chest pain and shortness of breath
Possible MI, will follow MI protocol
Possible Acute systolic CHF, likely chronic in nature also, continue to diurese. Will contact patient’s regular cardiologist
End stage renal disease- will need monitor renal function closely and diurese carefully

44. Table of Risk
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.
DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

45. Severity Risk Ramifications
PDX: Hypotension
Secondary DX
Congestive Heart Failure
Chronic Renal Failure
Hyperkalemia
Hyperlipidemia
Hypercholesteremia
PDX: Acute Systolic CHF
Secondary DX
Chronic Renal Failure End Stage with fluid overload
Hyperkalemia
Hyperlipidemia
Hypercholesteremia

46. Financial Ramifications
PDX Hypotension
MS-DRG 316
Other Circulatory System Diagnoses without CC/MCC
Relative Weight .6147
Approximate Reimbursement =$ (Blended rate= $7,000)
PDX Acute Systolic CHF
MS-DRG 291
Heart Failure and Shock with MCC
Relative Weight
Approximate Reimbursement = $10,4601 (Blended rate = $7,000)

47. APR-DRG Ramifications
PDX Hypotension
APR-DRG 207
Other Circulatory System DX
SOI 1/ROM 1
Relative weight .4850
Reimbursement $3,395 (blended rate $7,000)
PDX Acute Systolic CHF
APR-DRG 194
Heart Failure
SOI 3/ROM 1
Relative weight
Reimbursement $7, (blended rate $7,000)

48. Now a Word from our Sponsor
Progress note Day #2
No events overnight, patient has no complaints, appears comfortable
Pneumonia-will start IV antibiotic, order WBC
COPD exacerbation-will start Duonebs, IV steroids, pulmonary toilet, will encourage smoke cessation
Hypertension –will monitor

50. New & Improved Progress Note Day # 3
No events overnight, patient has no complaints, appears comfortable
Pneumonia-will start IV antibiotic, order WBC
COPD exacerbation-will start Duonebs, IV steroids, pulmonary toilet, will encourage smoke cessation
Hypertension, will monitor

51. Principles of Documentation
The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making as it relates to the patient's chief complaint for the encounter.

52. Principles of Documentation
The patient's progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented

53. Importance of Proper and Accurate Documentation
Services billed to the Medicare program are the sole responsibility of the Medicare provider.
Your documentation needs to be unique, specific, and should accurately reflect the services you are billing.

54. Importance of Proper and Accurate Documentation
Documentation not only must reflect necessity and the services provided but also must be consistent among the providers involved in an episode of care.
Medicare payment for services may be denied if the supporting documentation is not thorough.

55. Clinical Thought Processes
Progress note Day #2
CC- shortness of breath
HPI- patient still complaining of shortness of breath but only when he first gets up in morning
Pneumonia-improving, WBC trending down to 16 from 24, bands 8, still has fever and x-ray slow clearing, will continue IV antibiotics, follow labs,
COPD exacerbation-slowly improving, lungs still junky, easily short of breath with minimal exertion, will continue Duonebs, IV steroids, pulmonary toilet, will encourage smoke cessation

56. Clinical Thought Processes
Progress note Day #3
CC- shortness of breath
HPI- patient still complaining of shortness of breath but no episodes in last 12 hours
Pneumonia-improving, WBC almost back to within upper limits of normal, morning labs show WBC 12 from initial 24, bands 2, fever has just about cleared, x-ray slow clearing, will step down to PO antbx, anticipate discharge tomorrow.
COPD exacerbation-resolving, responded well to hospital course of therapy. Patient agrees to smoking cessation counseling outpatient.

57. Nature of Presenting Problem
Ensure the nature of the patient’s presentation corresponds to CPT’s contributory factors of the nature of the presenting problem and/or patient’s status descriptions for the code reported.

58. Nature of Presenting Problem
For instance:
99231 – “Usually the patient is stable, recovering or improving.”
99232 – “Usually the patient is responding inadequately to therapy or has developed a minor complication.”
99233 – “Usually the patient is unstable or has developed a significant complication or a significant new problem.”

59. Evidence Based Medicine
There Must Be a Better Way!

60. The Five Step Process
Determine that the service is medically necessary
Provide the service needed in order to properly meet the patient’s needs.
Document the service provided.
Select the most appropriate CPT/HCPCS code for the medically necessary service that was provided and properly documented.
Submit the service to Medicare that was medically necessary and documented.

61. Medical Necessity
E & M CC
History
Physical Exam
MDM
Clinical Impression

62. Questions
Questions about this presentation? Contact Glenn Krauss at