Capturing RVUs for the Care You Provide through Documentation

Capturing RVUs for the Care You Provide through Documentation
Dr. Daria Starosta, Director of Practice Efficiency

Objective for Practice Improvement
Improve Overall Documentation of Medical Records and Revenue Capture for the Care Provided to our Patients

Medical Necessity Guidelines
The Medicare statute prohibits payment for items or service 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.” EmCare’s policy indicates clinicians should only order items and services that they believe are medically necessary for the diagnosis and treatment of the patient The patient’s medical record must contain detailed documentation to support the medical necessity of the item or service. Medical necessity, not the amount of medical record documentation is the major determining factor in the selection of a service or level of service.

Practice Improvement Three Simple Steps
Document Medical Decision Making Reduce Downcodes of E&M’s Improve Procedure Documentation

Medical Decision Making
Three (3) major components in determining the E&M Level History Physical Medical Decision Making Medical Decision Making is the primary driver for determining potential level of service. (Clinical Impressions section)

Possible Diagnosis Management Options Considered Amount and Complexity of Data Risk of Complications, Morbidity and Mortality Associated with Presenting Problem

Why did the patient come to the ED? Did the symptoms get worse? Are the symptoms more frequent or intense? Over what time frame? What is the severity of the pain or symptoms? Document in the HPI and/or ROS

The patients progress in the ED What you did to establish the diagnosis Your differential diagnosis When you interpret an x-ray or EKG check off “interpreted by me”

Ordering Tests/Meds/ Interventions CAT Scans/Ultrasounds Document Rule out diagnosis AAA, PE, Ectopic, Appendicitis, DVT, Intracerebral Bleed, etc. Backslash your R/O diagnosis on the T-Sheet Why are you giving fluid boluses Dehydration, elevated glucose, forced diuresis due to ingestion

Medical Decision Making Documentation
ED Course Did symptoms or pain get better or persist? Still SOB Still having CP Now tolerates PO fluids Did you want to admit? Did you want them to have a test or see a consultant What medications were given?

Medical Decision Making Levels
Straightforward Low Complexity Moderate Complexity High Complexity

Medical Decision Making Levels – Moderate Risk
Used for Moderate Exacerbation of Chronic Illnesses, such as Asthma or COPD, and patient requires up to 2 breathing treatments. Moderate Risk patients have had symptoms for more than 3days with NO change. For CMS (Medicare), Levels 3 and 4 require a Moderate Risk.

Medical Decision Making Levels – Moderate Risk
URGENCY = difference between a Level 3 and a Level 4 patient. Moderate Risk Patients without Urgency are patients with sore throat that require an antibiotic. Largely documented in HPI using descriptive words such as: worsening, radiating, increasing over the last 1-2 days, qualifies.

URGENCY QUALIFYING DOCUMENTATION
Pt has signs and symptoms (documented by the ED provider) worsened recently (within 48hrs.), key words: “increased”, “worsened”, “progressed”, “dull ache to sharp pain”. Pt has signs and symptoms (documented by ED provider) with recent onset that indicates urgency. All of the following indicate urgency: SOB Wheezing Numbness Dizziness or vertigo Active bleeding (except menstrual) Radiating signs or symptoms, including pain Pts was given IM, IV, or SQ medication for pain (not PO) or was the patient given serial prescription pain meds by any route in the ED. Pt was given IV medication (of any type-not just pain meds) or IV fluids (bolus or continuous, not KVO) in the ED. Pt was given multiple or continuous nebulizer treatments in the ED. EKG or a radiology study other than x-ray (including Ultrasound, CT, MRI, IVP, etc.) was performed on the patient while in the ED. A psych consult was ordered. Pt had a temp of 104 F or higher (any age, taken by any method) during the ED stay. Pt was brought to the ED with neck and/or spine immobilization. Pt was admitted to the hospital or to observation (including following an ED visit for psych or detox clearance). Pt was sent to the ED from another provider’s treatment location. Must document sent from Dr. so and so, school nurse’s office, etc. Pt needed to be seen in the ED, rather than waiting to see his/her MD in their office.

Medical Decision Making Levels – High Risk Cases
Involuntary Psychiatric Admission Pts presenting with Hallucinations or Delusions Pts presenting with jaw, neck or abdominal pain or near-syncope or dizziness with cardiac workup (EKG and enzymes). Pts presenting with psychiatric illness with severe agitation or combative behavior. Pts requiring use of chemical or physical restraints. Pts requiring CAT Scan of head. Pts with positive orthostatic testing requiring IVF > 60cc/hr.

DOWNCODES A chart is downcoded if the patient's acuity level and the documentation of the provider’s medical decision making is not matched by the provider's documentation of the patient's history and/or physical exam.

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

History Component History of Present Illness (HPI)
Location - e.g...Chest pain Quality - e.g...sharp, dull, burning, pressure Severity - e.g....mild, moderate, severe Duration - e.g...1 minute, 1 hour, 3 years

History Component History of Present Illness (HPI)
Timing - e.g...started at 10am, constant, intermittent Context - e.g...while walking, at rest Modifying factors - e.g...improves with rest, increases with walking Associated signs and symptoms - e.g...nausea, vomiting, HA

“Dull ache to sharp pain” “Increased frequency”
HPI Descriptive “Increasing” “Worsening” “Progressing” “Dull ache to sharp pain” “Increased frequency”

History Component Review of Systems (ROS)
Constitutional Psychiatric Respiratory Skin ENT Hematologic/lymphatic Allergic/immunologic Musculoskeletal Cardiovascular Gastrointestinal Eyes Endocrine Genitourinary Neurologic

History Component Review of Systems (ROS)
A notation of is permissible after a complete review of systems is performed (either in HPI or ROS) “All other systems reviewed and are negative”

Past Medical, Family, Social History (PFSH)
History Component Past Medical, Family, Social History (PFSH)

Unobtainable History Record should describe the patient’s condition or other circumstance which precludes obtaining a history

History Summary Table Note: All levels of history require documentation of a chief complaint.

Minimum Requirements for Body Areas and Organ Systems
PHYSICAL EXAM Minimum Requirements for Body Areas and Organ Systems

Physical Exam BODY AREAS INCLUDE: Head, including face Neck Chest
Abdomen Back Genitalia Extremities, each

Physical Exam ORGAN SYSTEMS INCLUDE: Constitutional Eyes ENT
Respiratory Cardiovascular GI GU Integumentary Musculoskeletal Psychiatric Neurological Hematologic/Lymphatic/ Immunologic

Gastrointestinal Organ System
Organ System Review Gastrointestinal Organ System Document performance of any one of the following: “Inspect” Percussion Auscultation T-System = may document either: GI Rectal – “heme positive or negative” EXAMPLE “Abdomen non-tender”

“Exam of the back shows good ROM with no scoliosis or deformities”
Organ System Review Musculoskeletal Document performance of any one of the following: Examine hands, arms, shoulders, neck, or TMJ Inspect and palpate the joints OR Check range of motion T-System = may document either: “Normal ROM” under “Extremities” or “ Neck” (or pertinent positive) Joint Exam Extremities EXAMPLE “Exam of the back shows good ROM with no scoliosis or deformities”

Hematologic/Lymphatic “No cervical adenopathy”
Organ System Review Hematologic/Lymphatic Document performance of any one of the following: Exam skin for bruises, bleeding, petechiae. Inspect and palpate lymph noted located in arm, breast area, groin or head and neck T-System = may document either: Check or indicate “lymphadenopathy” under any heading EXAMPLE “No cervical adenopathy”

“Anxious but cooperative”
Organ System Review Psychiatric Document performance of any one of the following: Assess mood Thought process Attention or memory T-System = may document either: “mood/affect nml” or “depressed affect” under “Neuro/Psych” EXAMPLE “Anxious but cooperative”

Physical Exam General Rule:
Three (3) or more items for affected Body Area or Organ System related to Chief Complaint

Physical Exam Summary Table

ED Professional E/M Coding Summary Table

Educational Non-Billables
Charts that are sent to RTI missing a key component of documentation. 3 Most Common Reasons: No Documentation Resident Non-Billable Unlicensed Students

0098-No Documentation Missing Key Piece of Documentation: HPI or PE You must document the following on every patient you treat (extent of documentation is dependent upon the risk level of the pt): Chief Complaint HPI ROS Past Histories Physical Exam **Beware of the pitfalls of documenting in EMRs** Cutting and Pasting does not count as your documentation and treatment of the patient

0041-Resident Missing the proper Attestation language that states you, as the Teaching/Attending Provider, supervised the Resident’s care of the patient and conducted your own face to face examination of the patient. According to CMS, the Teaching Physician must be present during the key portion of the patient’s visit: History Exam MDM In order to bill for these patients’ visit, the Teaching Provider must attest to the Resident’s documentation on the above mentioned portions by documenting their own findings. Attending Note: __Resident's history reviewed, patient interviewed and examined. Briefly, pertinent HPI is: _________________________________________ My personal exam of patient reveals: _____________________________ __I agree with assessment and care plan, and confirm the diagnosis(es) above. With exception of _______________________________________ Please see resident notes for details.

Unlicensed Student Practitioner/Scribe Scribe duties include assisting the attending provider with recording his/her examination of the patient, as well as test results, procedures, prescriptions, discussions with family, follow up instructions, all under the attending provider’s direction. Students can act as Scribes for providers. Scribes/Students can not work independently. To clearly delineate the scribe’s contribution to the record, it’s recommended that their signature be footnoted by the phrase “I was acting as a Scribe for Dr. ABC”. The attending provider must then sign the chart and include the notation, “the note accurately reflects work and decisions made by me.”

Steps of Practice Improvement Program
Step 3 – Improve Procedure Documentation Request Critical Care Time when Appropriate Document Ancillary Interpretations Document Fractures/Splints Document Moderate Sedation/Other procedures Document Wound Repairs

Critical Care Definition
A critical illness or injury that acutely impairs one or more vital organs systems, such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition. The services that you provide to “prevent the future deterioration of a patient” also counts towards Critical Care, i.e.: Fluid challenge on a hypotense, dehydrated patient, or multiple mininebs on an asthmatic, or COPD patient that is SOB.

Critical Care Coding Requirements
To Meet Critical Care Coding Requirements, you must answer “YES” to all 3 of the following questions: Is at least one vital organ system acutely impaired? Is there a high probability of imminent, life-threatening deterioration? Did you intervene to try to prevent further deterioration of the patient’s condition? ***PLEASE NOTE: In addition to answering YES to these questions, the Request and Time Requirement of greater than 30min must also be met.

Critical Care Coding Requirements
Most common (but not necessarily all inclusive) Vital Organ Systems include: Central Nervous System Circulatory Renal Hepatic Metabolic Respiratory

Potentially Life-Threatening Conditions
AAA Respiratory Distress w/wo hypoxia Hypotension from dehydration, sepsis, etc. Intracerebral bleeds or Infarcts Hyperkalemia or Renal failure DKA Acute MI Acute Abdomen VT or VF Second or third degree heart blocks Anaphylactic shock Status asthma or seizures Severe Exacerbation COPD

Critical Care Interventions
Intracranial Bleeds, CVAs, Spinal Cord injuries that you monitor closely and arrange transport to a tertiary care facility. Chest pain ongoing, STEMI or Non-STEMI that get transferred for intervention, or that you give Aspirin and any form of Nitrates (Nitropaste, 3 Sublinguals). Interventions are clearly documented, even if the patient did not respond positively to the treatments and care provided.

Document your interventions of the critically ill or injured patient.

Critical Care Time Time spent at bedside
Reviewing test results or imaging studies Discussing patient’s care with other medical staff Documenting in the medical record Time spent with other decision makers when patient is unable to make decisions Time to perform procedures such as gastric intubation, temporary transcutaneous pacing, ventilator management, peripheral vascular access

Complete Chart Documentation

Did the patient go to ICU or CCU?
Critical Care Did the patient go to ICU or CCU?

Procedures Included in CCT
Cardiac output measurements Gastric intubation Temporary transcutaneous pacing Ventilator management Peripheral vascular access

Separately Billable Procedures
CPR Endotracheal intubation Administration of TPA Physician direction of EMS Central Line Placement Wound repairs Laryngoscope Thoracentesis/Thoracostomy Time for procedures not included in CCT, must be deducted from total CCT

Monitor Interpretations
Acceptable Monitor Interp Includes Cardiac Rate Rhythm “Sinus at 80”

EKG Interpretations EKG interp should include at least 3 of the following 6 elements: Rhythm and rate Axis Intervals ST segment change Comparison to prior EKG Summary of clinical condition “Interp by me”

EKG Interpretations Must have a written report of findings when billing separately for the interp Acceptable EKG interp: “ EKG NSR, no ST changes, unchanged from prior EKG with no evidence of ischemia”

Pulse Ox Interpretations
Note originated by a physician is required to bill a separate interp. Percentage, whether patient was on RA or oxygen Example - “84% on room air, hypoxic”

X-ray Interpretations
“Interpreted by Me” vs. “Reviewed by Me” (means you looked at x-ray report)

Ancillary Denials High Cost of Ancillary Denials
CT, X-Ray, MRI denials are on the increase Medical Necessity Criteria must be met Financial impact to both hospital and physician group Signs & Symptoms are key

Fracture Care Exact location of fracture or dislocation must be noted
Specify type of fracture i.e., displaced – non displaced - angulated Specific name of bone Clear indication of treatment Reduction Stabilization Devices Materials utilized

Fracture Care Any fracture care rendered requires a procedure note
Type of anesthesia Materials Method of Treatment with or w/o manipulation/reduction Neurovascular checks Post application Who Follow up treatment time line Document definitive follow-up time beyond 24 hours

Splinting and Strapping
The placement of immobilization/stabilization services. This includes: Splints ACE bandages Air casts Knee immobilizers

These services are billable for: Patients treated for sickness/injuries secondary to gouty arthropathies, sprains, strains, contusions, etc. OR Patients who have sustained fractures in which fracture care cannot be billed (e.g. requiring either admission or follow-up by an orthopedist in 24 hours or less) Note: These services are billable in addition to an E/M level of service.

Emergency physician must apply the splint or strap OR Review placement by performing the post application NV check

Documentation Requirements: Who applied the splint or strap Type of device applied Post-placement NV status upon completion Example: Cock-up splint placed by RN. Recheck by me – NV intact.

Moderate Sedation The following services are included:
Assessment of the patient Establishment of IV access and fluids to maintain patency Administration of agent (begin intraservice time) Maintenance of Sedation Monitoring of Patient Oxygen saturation, Heart rate & Blood pressure Recovery (end intraservice time)

Moderate Sedation Intraservice Time includes:
Starts with the administration of the sedation agent/s Continuous face to face attendance Ends with the conclusion of personal contact (recovery time is not included in the intra-service time)

2008 T-System Revisions

Moderate Sedation Use Hospital Specific Form
(approved by your Anesthesia Department) Or Use T-System Form 23D Leave a copy with the Medical Record Educate Billing Coordinator to send to RTI

Other Common Procedures
I & D of Abscess Paronychia Cyst Release of Subungual Hematoma Remember to include packing and drain placements

Medical Command given for O2 4 liters and Lasix 80 mg IV
EMS Command If you are a command physician and direct treatment pre-hospital, document it in the history section For Example: Medical Command given for O2 4 liters and Lasix 80 mg IV

EMS Command

Step 3 – Improve Procedure Documentation Request Critical Care Time when Appropriate Document Ancillary Interpretations Document Fractures/Splints Document Procedural Sedation/Other procedures Document Wound Repairs

**Use ruler on T sheet for accurate measurements
Wound Repair Procedure Notes should be brief and concise Anesthesia used Type of Injury (Curved angular or stellate) Length & depth (in centimeters)** Describe layered closure (suture material) Condition of injury (contaminated wound) Debridement & undermining **Use ruler on T sheet for accurate measurements

Document use of Chemical Adhesives
Simple Repair Wound is superficial Simple one layer closure Local anesthesia Document use of Chemical Adhesives i.e., Dermabond

Intermediate Repair OR Simple repair PLUS
Requires layered closure of one or more of the subcutaneous tissue & superficial fascia in addition to the skin closure OR A Simple layer closure of a heavily contaminated wound(s) that requires extensive cleaning or removal of particulate matter

Complex Wound Repair Requiring more than layered closure
Retention sutures Sum of lengths of repairs May include Debridement (traumatic laceration or avulsions) Extensive undermining

Debridement Considered a separate procedure ONLY:
WHEN gross contamination required prolonged cleansing WHEN appreciable amounts of devitalized or contaminated tissue are removed WHEN debridement is carried out separately without immediate primary closure

CASE STUDY 1 A 57 yo male presents for evaluation of a swollen, red finger after puncturing it 5 days ago with a hook he pulled from a striped bass. Puncture wound is on his right volar index finger.

CASE STUDY 1 Last night the finger became acutely swollen and he was febrile to 103°. Patient was given IV unasyn and a CBC and finger X-Ray performed. Patient was given iv morphine for severe pain. Patient was discharged home on doxycycline.

CASE STUDY 2 A 25 yo female spent the day on a boat on a sunny 90° day tuna fishing drinking only beer now presents to the ED for evaluation of vomiting, weakness, fever to 101°, BP 80/50, HR = 135, RR = 24, t = Exam is remarkable for an ill appearing female, who is clinically dehydrated and tachycardic.

CASE STUDY 2 Patient receives 1 Liter NS, antiemetics, and labs sent.
Lab work is remarkable for bun/creat 80/1.6 k-5.5 and CPK 12,000. The patient is admitted after 2l ns + hco3.

CASE STUDY 3 A 35yo ED physician presents to the ED c/o severe depression after his 10th consecutive fishing trip, on his new boat, without a single fish. He reports that he is a failure and really needs to talk to someone. He denies SI.

CASE STUDY 3 A psych consult is obtained.
During your interview you mention that you just had a great day on the water limiting out for the day, after which he starts throwing things requiring IM geodon and Ativan for violent behavior. He ultimately is discharged home.

CASE STUDY 4 A 28 yo healthy male presents after a 5 day canyon fishing trip stating on day 4 of the trip he began developing progressive lower abdominal cramping, vomiting and diarrhea. On exam, he is afebrile with normal VS and exam is remarkable only for tenderness in the rlq.

CASE STUDY 4 A CT a/p was ordered ‘evaluate lower abd pain’.
When ordering the CT scan, the reason for study was documented as ‘evaluate lower abd pain R/O appendicitis’. Discharged home with mesenteric adenitis.

CASE STUDY 5 A 50 yo female presents to the ED with a large abscess on her upper back after a green fly bite while fishing the bay. She is febrile to 103 and the abscess is indurated with lymphangitis.

CASE STUDY 5 Labs are drawn, IV antibiotics are given. WBC 2.8, HGB 10.5, PLT 122. The ED documentation indicates that there is a concern for overwhelming sepsis based on fever and Pancytopenia.

ICD-10 Understanding what this change means for you and your patients (You can now have a specific code if your patient is injured in a spacecraft or by an Orca whale)

YEP…there’s an ICD10 Code for That!

ICD-10 10th Revision of International Classification of Diseases
Implemented in the UK in 1995 Implementation Date is scheduled for October 1, 2015 for all HIPAA covered entities ICD-10-CM- Clinical modification of WHO ICD-10 ICD-10 PCS- Procedural compliment. Will affect diagnosis and inpatient procedure coding for everyone covered by HIPAA

Why? ICD-9 is 35 years old Terminology and classifications are outdated Outdated codes produce inaccurate and limited data Lack of specificity Does not work well with EHR

Why? (Cont.) Better Data for:
Measuring quality, safety and efficiency of care Conducting research and epidemiology Setting health policy Design payment system and process claims Monitor resource utilization Prevents and detects healthcare fraud Tracking public health risks

Difference ICD-10 ICD-9 70,000 Diagnosis Codes 72,000 Procedures
All codes are Alphanumeric beginning with letter Mostly Numeric Valid Codes are 3-7 Digits Valid Codes are 3-5 Digits A single code can report a disease and it’s current manifestation (i.e. Type II diabetes with retinopathy)

Differences Outline of History, Physical Exam and MDM will not change; History will need to be more detailed. Make clear the precise mechanism and location of injury. Was the ED visit for a complication? Final Diagnosis requires more anatomical details of the injury and disease status. Most of the documentation changes are within the musculoskeletal section and 36% of the changes involve documentation of laterality.

Requirements Documentation of the anatomic site of the problem with GPS-like specificity. The mechanism of the injury The interrelationship of conditions and disease with details of causes and manifestations. ICD9 - Simple wrist fracture Becomes ICD10 – Initial visit for nondisplaced, closed fracture of middle third of right navicular bone.

Key ICD10 Concepts Severity of Illness (SOI)
Indicates the acuity of pathophysiologic changes that have occurred. Provides a basis for evaluating resource consumption and the patient care provided. Sicker patients are more expensive to treat, they utilize more resources, have a higher rate of complications and have worse outcomes. For example: Aspiration pneumonia vs. plain pneumonia. DM ICD10 codes allow support for documentation of SOI. Significant lab or X-Ray abnormalities need to be documented Simply stating “labs reviewed” is not adequate Should document the pertinent abnormal or significant findings.

Key ICD10 Concepts First Listed (Principal) Diagnosis
When documenting multiple final diagnoses, the order of your diagnosis is very important. 1st Diagnosis listed should be the principal diagnosis, which addresses the primary reason for the patient visit/encounter. Other conditions that are addressed, but not the primary reason for the visit should be addressed AFTER the principal diagnosis.

Key ICD10 Concepts Signs and Symptoms/Unspecified
In cases where the diagnosis is unclear, using signs and symptoms such as “chest pain” and “vomiting” as final diagnoses are supported by ICD10. Always try to document your final diagnosis to your highest level of certainty. Include clinically significant co-morbidities and present on admission (POA) indicators, such as UTI, Decubiti, Vascular catheter, associated infection. Examples of acceptable documentation of final diagnosis: Chest Pain with elevated troponin, concern for acute coronary artery syndrome Pneumonia etiology unclear Vomiting with dehydration and electrolyte imbalance requiring IV therapy

Key ICD10 Concepts Episodes of Care for Injuries and Poisonings, Musculoskeletal and Connective Tissue Problems, such as Pathologic and Osteoporosis fractures Initial Encounter – used while the patient is receiving active treatment by a new physician for injuries, fractures, burns, poisonings and similar conditions in the ED; Almost all ED visits are considered initial. Subsequent Encounter – used when patient is receiving additional care during the healing or recovery of an injury, fracture, burn, poisoning and similar condition. In the ED, this would be cast change, suture removal or medication adjustment. Sequela – used when a patient is being seen for a complication of injury, fracture, burn, poisoning or similar condition. In the ED, this would be the management of a scar that was the result of a burn.

Key ICD10 Concepts Enhanced Anatomic Specificity
Requires much more precise anatomic description of the injury or condition – LOCATION, LOCATION, LOCATION Simply stating “pneumonia” or “ankle sprain” may be inadequate Be sure to document: Laterality – Right/Left/or Bilateral Arm or Leg – Upper or Lower Hand – document individual metacarpals Foot – document individual metatarsals Fingers – specify which fingers are involved Phalanges –document whether proximal, mid, or distal phalanges Toes – document which toe(s) and joint(s) are involved Face – document whether upper or lower eyelids and lips Pneumonia – specify whether right/left/or bilateral

Key ICD10 Concepts ICD10 External Cause of Injury
Document HOW and WHERE an injury occurred. External Causes – such as a fall, assault, accident or complications from a procedure Activity – such as work-related, sports, and the place of occurrence. Complications – such as penetration, foreign body, damage to nail, or involvement of internal organs. Examples: Pedestrian injured in transport accident Air and space transport accidents Slipping, tripping, stumbling, and falls Exposure to inanimate mechanical forces Accidental non-transport drowning and submersion Exposure to electric current, radiation and extreme ambient air temperature and pressure Exposure to smoke, fire and flames Exposure to forces of nature Intentional self-harm

ED Applications ICD-10 increased coding specificity is expected to lower number of rejected claims. Will now need to specify laterality (left or right) Procedural documentation will be most affected Workman's comp and Auto Insurance claims not initially affected. Costly Conversions for codes

ICD-10 Education The Practice Improvement Department will be holding 9 Documentation Education In-services on ICD-10 Documentation Requirements. Dates and Times will be ed to all providers this week. For more information, please contact Jill Durkin

Remember these Important Steps…
Simple Take Aways Remember these Important Steps…

Sign Your Paper Chart Use your RTI number
Take Away # 1 Sign Your Paper Chart Use your RTI number

Take Away # 2 Medical Decision Making Be descriptive in your HPI Document Test/Interps/Interventions Document ED Course Document Clinical Impressions

Take Away #3 History Chief Complaint History of Present Illness (HPI)
Review of Systems (ROS) Past, Family, Social History (PFSH)

Document Critical Care Time when Appropriate
Take Away # 4 Document Critical Care Time when Appropriate

Take Away # 5 Document Follow up Timeline
Fracture Care… Document Follow up Timeline Example: “Follow up with Ortho in 48 hours”

Core Components of Program
Providers will only document services that they actually provided If a provider is documenting an incomplete record, he/she will only document services or procedures that can be independently recalled or ascertained from the entire record. All addendums must be made on the original record (unless authorized otherwise by your hospital’s HIM department) and must be initialed and dated.

Billing Guidelines Physicians and other practitioners should only submit bills for services rendered that are medically necessary Physicians and other practitioners should not “knowingly or willfully” Bill for services not actually provided Misrepresent services that were not provided Make false statements to government agencies about EmCare’s compliance with any Federal or state rules Falsely certify that services were medically necessary

Billing Guidelines The patient’s medical record should accurately reflect all services and items furnished to a patient and should also provide support for the medical necessity of the service or item If a service or item is provided to a patient that was not ordered by the physician, it should not be billed to the patient In no case should you indicate that a service or item is medically necessary unless it is supported by the patient’s medical record.

QUESTIONS? ? ? ? ? ? ? ? ? ?

Capturing RVUs for the Care You Provide through Documentation

Similar presentations

Presentation on theme: "Capturing RVUs for the Care You Provide through Documentation"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Capturing RVUs for the Care You Provide through Documentation

Similar presentations

Presentation on theme: "Capturing RVUs for the Care You Provide through Documentation"— Presentation transcript:

Similar presentations

About project

Feedback