Overview of Coding and Documentation

Initial Steps Evaluate and monitor the patient Treat the patient Document the service Code the service

Document the Service Document all services/procedures rendered to a patient in the EMR Remember: if you did not document it, you did not do it and it cannot be paid

Documentation Guidelines Your documentation must support your services Teaching Physician guidelines – government payors have strict guidelines regulating when a physician bills with a Resident’s involvement Florence is rewriting

The HCPCS coding system consists of two levels Level I – Current Procedural Terminology (CPT) Codes  Developed and maintained by the AMA  Consist of five-digit codes and two-digit modifiers Level II – HCPCS National Codes  Developed by CMS and maintained by a national panel  Consist of one alpha character followed by four-digits  Also have modifiers

ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification ICD-9 coding is a classification system that arranges diseases and injuries into groups according to established criteria ICD-9 is based on the World Health Organization’s Ninth Revision, International Classification of Diseases Code changes are made annually by the government and are effective October 1 – September 30 All CPT codes submitted to payors must have an accompanying ICD-9 code(s) Effective October 2014 ICD-10 replaces ICD-9 – THE WORLD CHANGES DRAMATICALLY!!!!!

General Principles of Documenting - Florence The medical record should be complete and legible The documentation of EACH patient encounter should include:  Date;  Reason for the encounter;  Appropriate history and physical exam;  Review of lab, x-ray data, and other ancillary services (where appropriate);  Assessment; and  Plan of care (including discharge plan, if appropriate)

General Principles of Documenting - Florence Patient’s progress, including response to treatment, change in diagnosis, and patient non- compliance; Relevant health risk factors; Written plan of care should include (when appropriate):  Treatments and medications, specifying frequency and dosage;  Any referrals and consultations; and  Patient/family education

General Principles of Documenting Documentation should support the intensity of the evaluation and/or treatment, including thought processes and complexity of medical decision making; All entries should be dated and authenticated by physician signature; and The CPT/ICD-9-CM codes reported on the CMS should reflect the documentation in the medical record.

CPT Coding and Documentation E&M Services – (Evaluation and Management Services)  Levels of Care E&M Documentation  CMS/AMA Guidelines

E&M Coding Key Components  History  Exam  Decision Making Contributory Factors  Counseling  Coordination of care  Presenting problem  Time

Key Components History Exam Decision Making

History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family & Social History (PFSH)

Exam Organ Systems  For a General Multi-System Exam Body Areas

Medical Decision Making Complexity of establishing a diagnosis  The number of diagnoses or management options;  The amount and complexity of data ordered or reviewed; and  The risk of complications and morbidity/mortality.

VCUHS Clinical Documentation Improvement

Why Focus on Documentation Physician documentation is the basis for the hospital coding. Accurate and complete medical record documentation is critical to reflect the high quality of care provided by the medical staff. The documentation in the medical record is the key driver of the quality outcome scores for the hospital. Inadequate documentation can lead to a misrepresentation of the quality of care provided by the facility.

Documentation Basics All diagnoses and conditions that are monitored, evaluated and/or treated during the hospital stay should be documented Diagnosis must be stated in codeable terminology ( ICD 9 codes) to be included in the coding process.

Importance of Documentation Capturing the appropriate diagnosis and condition is critical for: Accurate severity of illness and risk of mortality reporting. Compliance with CMS rules and regulations. Appropriate reimbursement for the care provided. Supporting length of stay and resources utilized. Preparation for bundled payments and value based purchasing (VPB). Support of physician billing.

Examples of Unable vs Acceptable Low Hgb, transfuse Hypertensive emergency, urgency, crisis Urosepsis, change foley COPD, home O2 CHF Air space disease Thin, low prealbumin Unresponsive Skin breakdown Replete lytes, low Na, K+ Specify type of anemia Malignant or accelerated hypertension. Sepsis secondary to UTI Chronic respiratory failure Type of pneumonia (organism), CAP, HCAP Type of malnutrition Coma Pressure ulcer Hyponatremia, Hypokalemia

Specificity of Diagnosis Anemia – low Acute blood loss anemia - moderate Pancytopenia secondary to chemo - high CHF – low Chronic systolic or diastolic heart failure - moderate Acute systolic or diastolic heart failure – high Respiratory insufficiency – low Chronic respiratory failure – moderate Acute respiratory failure - high

Specificity of Diagnosis Poor nutritional status – low Mild or moderate malnutrition – moderate Severe malnutrition – high Renal insufficiency – low Acute renal failure or injury – moderate Acute renal failure secondary to ATN – high GCS, unresponsive – low Coma - high