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

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

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

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

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.

Right to the Point NO Fluff

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.

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.

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.

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.

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

The Driver

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.

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

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

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.

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

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

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

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.

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

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.

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

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).

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

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

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

Decision Point

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

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

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

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

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

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

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.

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.

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.

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

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%

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

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

Take Two

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

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.

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

Financial Ramifications PDX Hypotension MS-DRG 316 Other Circulatory System Diagnoses without CC/MCC Relative Weight .6147 Approximate Reimbursement =$4302.90 (Blended rate= $7,000) PDX Acute Systolic CHF MS-DRG 291 Heart Failure and Shock with MCC Relative Weight 1.4943 Approximate Reimbursement = $10,4601 (Blended rate = $7,000)

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 1.1222 Reimbursement $7,855.40 (blended rate $7,000)

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

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

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.

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

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.

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.

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

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.

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.

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.”

Evidence Based Medicine There Must Be a Better Way!

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.

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

Questions Questions about this presentation? Contact Glenn Krauss at glennkrauss@earthlink.net