E&M Code Assignment & Validation 2016 - MeHIMA · 2016-03-10 · Code Assignment & Validation...

Code Assignment & Validation

Presenter

Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMC

Evaluation & Management Services

Disclaimer

This presentation is for general education purposes only. The information contained in these materials and presented during the lecture or in response to your questions is not intended to be, and is not, legal advice. The laws and regulations at issue in this lecture may be open to interpretation.

This information may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of BNN. No part of this presentation may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from BNN.

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Objectives

To provide you with an overview of:

Evaluation and management (E/M) code assignment

Review the elements of an E/M code

Review the rules associated with E/M code selection

Principles of medical record documentation requirements

Review documentation basics

Review coding documentation guidelines

Identifying & validating appropriate code assignment

Review details for the medical record review process

Medical record risk and documentation improvement opportunities3

Documentation Rules:Where do they come from?

CPT book language and code descriptors

CMS “Documentation Guidelines”

1995 and 1997 versions available

Additional clarification in the CPT Assistant Articles

Medicare Internet-Only Manuals

CMS NCCI Manual

Payer rules, transmittals, software edits4

8 Interpretations of the CMS DGs

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What do Payers want from Documentation?

Reasonable proof that services provided are consistent

with coverage policies for enrollees including:

Site of service

Medical necessity of all services provided

Services provided have been accurately reported

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Not that simple anymore

Unable to just document what is wrong with a patient and

what they want to do

Physicians fail audits in some cases due to 1-2 missing

words

How many rules could there be?

Documentation Rules

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Documentation Principles/Requirementsof E/M Services The medical record must be complete & legible

Each encounter should include:

Chief Complaint

Patient History

Findings of Physical Exam

Available Results (previous diagnostic tests)

Assessment of Patient Status

Clinical Impression or Diagnosis

Plan for Care

Identification of Observer & Date 8

Documentation Principles/Requirements

Signature requirements per

CMS CR#6698

MLN Matters SE#1419

Services provided must be authenticated by the author. Stamp signatures are NOT accepted.

Acceptable methods:

Electronic signature

Handwritten signature

Signature Log

Signature Attestation Statement: certain form/format is not required; however, MACs have published their own samples

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Remember…

Medicare has advised that the overarching criterion for code selection should be medical necessity: 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.

(CMS Manual System, Pub 100-4, Ch. 12, Sub Sec 30.6.1A)

Documentation in History, Exam & Medical Decision Making should consistently support medical necessity.

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Example #1

Patient with well-controlled diabetes comes in c/o stubbed toe. Patient completes history questionnaire at the office. Using the questionnaire, Comprehensive history is obtained (4 HPI, 10 ROS, 3 PFSH) along with a comprehensive exam (8 OS).

Assessment: Contusion toe and stable Diabetes. Patient is instructed to elevate foot, use ice prn and OTC Motrin 200mg. Watch for swelling or circulation issues. Return if worsening.

Option #1: 99215 based on comprehensive history and exam

Option #2: 99213 based on low MDM and either comprehensive history or exam

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Example #2

Patient presents with abdominal pain. A comprehensive history and exam are documented. Assessment is gastritis; labs were ordered and patient advised to take over the counter medication for pain relief and drink plenty of fluids. Return prn or if not better.

Option #1: 99213 based on low MDM

Option #2: 99215 based on comprehensive history and exam

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MDM can vary from visit to visit, although the diagnosis may be the same, the treatment plan(s) can change

The fact that a patient has an underlying condition or chronic problem is only significant if it impacts the encounter on that day (and is documented that it was assessed)

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Test Yourself

True or False

Additional diagnoses from a problem list can be added to the assessment to help support an E/M level of service.

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Test Yourself

True or False

A comprehensive exam is required for all patients.

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Test Yourself

True or False

Non-covered preventive visits may be billed as an E/M level of service to ensure payment.

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Selecting the E/M Service

Identify the category or subcategory of service

E.g., Category - Office or Other Outpatient Services, Subcategory - New Patient

Review the instructions for the category or subcategory

Review the level of E/M service descriptors

Determine the level of History documented

Determine the extent of the Exam

Determine the complexity of MDM

Select the appropriate E/M service 17

Which Codes Require What?New vs Established?

2 of 3 (examples)

» Office or other outpatient services (established patient)

» Subsequent hospital

» Nursing facility care

» Subsequent observation care

3 of 3 (examples)

» Office or other outpatient services (new patient)

» Emergency department

» Initial observation care

» Initial hospital care

» Consultation Services

» Admit & Discharge on Same Day (inpatient & observation) 18

New – has not received any face-to-face professional services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty/subspecialty within the group practice, within the last three years

Established – has received face-to-face services in the last three years


The Key ComponentsHistory (conversation) Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Examination (hands-on) Problem Focused


Detailed

Comprehensive

Medical Decision Making (thought process) Straightforward

Low

Moderate

High

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Contributory Factors

Counseling

Coordination of Care

Nature of Presenting Problem Can the level of service billed support the medical

necessity of the diagnosis?

Time - Plays a role in Counseling and/or Coordination of Care

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E/M Coding Requirements

HISTORY: 4 levels determined by the amount of the following documented

History of Present Illness (HPI)

Review of Systems (ROS)

Past, family and/or social history (PFSH)

EXAMINATION: 4 levels determined by the number of Body Areas or Organ Systems examined

CHIEF COMPLAINT (CC): Chief reason for seeing the patient.

• MEDICAL DECISION MAKING: 4 levels determined by the acuity/complexity of patient’s condition– # of Diagnosis/ Management

Options– Amount & Complexity of Data– Risk

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HistoryChief Compliant (CC)

A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s own words

History of Present Illness (HPI) Further defines and clarifies the chief complaint; expands the chief

complaint and supports medical necessity and provides information to clarify presenting problem

Review of System (ROS) Inventory of body systems obtained through questions to identify

signs and/or symptoms the patient is experiencing - what the patient is telling the provider

Past, family and/or social history (PFSH) Review of the patient’s past medical history (illnesses, injuries,

surgeries); family history and age-related social history 22

Chief Complaint - Nature of Presenting Problem

Each visit record MUST include the reason the patient is being seen (nature of the presenting problem)

If seen in “follow-up” … to what?

If seen for medication management… medication management for what condition(s)?

Failure to document a chief complaint may lead to an unbillable service

Helps support medical necessity

Where can the chief complaint be documented?

Sometimes the chief complaint may change from what the patient says to the nurse, to the information they provide to the provider - make sure any differing information is addressed.

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Examples Unacceptable – does not describe reason for visit

Follow Up

Follow Up Meds

Could be better

Medication Management for Low Back Pain

6 month follow up (for what) + Diabetes + Hypertension

Good Documentation

6 month follow-up lipids

Monthly follow-up chronic pain of neck and back

6 year well child check

Left wrist pain25

ExampleCC: Patient here for f/u diabetesBad:

HPI: Patient c/o fever and cough x 3 daysROS: No SOB or other cold symptomsExam: ENT: TMs clear, pharynx red. Lungs clear. A&P: URI. Continue OTC meds. Return if worsening

Better:HPI: Patient following diet. Blood sugars at home had been stable but have been slightly elevated. C/O fever and cough x 3 days.A&P: Diabetes, stable. Continue meds.URI. Continue OTC meds. Return if worsening

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The HPI is a 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.

The HPI further defines and clarifies the chief complaint, expands upon the chief complaint and supports medical necessity, provides information to clarify the presenting problem.

Generally well documented when visit is for acute problem – need the information to diagnose.

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Elements of the HPI

LocationQuality Severity TimingDuration ContextModifying Factors Associated Signs/Symptoms

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Brief = 1-3 elements 9924299201 - 9920299212 - 99213

Extended = 4+ elements or update 3+ chronic illnesses

99243 - 9924599203 - 9920599214 - 99215

Status of 3+ Chronic Conditions It is not enough to list just the chronic conditions.

The fact that the patient has chronic conditions and is on medication does not satisfy the documentation guidelines.

Documentation needs to be in the “history” portion of the note -not in the Assessment/Plan. Remember that the history documentation should be the verbal interaction between the provider and the patient without professional interpretation.

Since Sept 10, 2013 can be used with either guidelines (‘95 or ‘97)

ROS and PFSH should also be documented.

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Chronic Conditions ExampleBad:Patient presents today for follow-up of Diabetes, HTN and Hypercholesterolemia. Continues to take meds.

Better:Patient here today for f/u of Diabetes, HTN and Hypercholesterolemia. States that blood sugars have been in the normal range and she continues on Insulin. Her blood pressure has been 110/70 on average and she has had no further complaints of headaches or blurred vision. She continues to follow her low cholesterol diet and states she has lost 3 lbs.

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Test Yourself

True or False The following Nursing Initial Screening may be

accepted and counted as appropriate documentation of HPI

Nursing Initial Screening:Pt has a new rash on her arm she would like checked. Some rough spots, red and itchy. Pt noticed rash 5 days ago and getting worse.

Provider Notes:Reviewed and agree with above history of present illness.

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CMS E/M Services Guide

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

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NGS Frequently Asked E/M Questionshttps://www.ngsmedicare.com18. I have heard that four or five years ago NGS issued some sort of correspondence which stated that the history of present illness can only be documented by the provider. I have not been able to find this on the NGS website but have seen it referenced by Yale, among others. Can you verify this?

Answer: There are two elements of history that can be elicited and documented by someone other than the provider: the Review of Systems (ROS) and the Past, Family and Social History (PFSH). A staff member or medical student may elicit this information from the patient, but the provider is obliged to review it, amend it if necessary, and indicate in writing that he/she has done so. The provider is responsible for eliciting and documenting the History of the Present Illness (HPI), since this requires defined clinical skill. That said, the provider may utilize the services of a Scribe in documenting the HPI, as with any other element of an E&M service.

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Review of Systems (ROS)

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Review of Systems (ROS)ROS is an inventory of body systems obtained through a series of questions from the provider seeking to identify signs and/or symptoms which the patient may be currently experiencing.

ROS is not a list of past medical conditions (i.e. asthma, diabetes, arthritis)

ROS can be confused with exam elements - remember that the ROS is what the patient is telling the provider (subjective), not what the provider examines (objective)

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Elements of the ROS

Constitutional

Eyes

ENT

Cardiovascular

Respiratory

Musculoskeletal

Gastrointestinal

Genitourinary

Psychiatric

Integumentary

Neurological

Allergic/Immunologic

Endocrine

Hematologic/Lymphatic

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None992419920199212

Problem Pertinent = 1 System992429920299213

Extended = 2-9 Systems992439920399214

Complete = 10+ Systems99244 – 9924599204 – 9920599215

ROS - “All Others Negative”The guidelines state: “for services that require a complete ROS, at least 10 organ systems must be reviewed with positive and/or pertinent negative responses individually documented.

For the remaining systems a notation indicating “all other systems are negative” is permissible. In the absence of such a notation, at least 10 systems must be individually documented”

Must document “positive or pertinent negatives” as related to the chief complaint

Must be medically necessary

For your practice, what does “all others” mean? 37

“Hot Button Area”

“Double dipping” - What is it and can it be done?

The intent of the Documentation Guidelines was not to make the provider restate themselves. Information can be counted more than once as long as it is “elaborated on”. CC: Pain in arm

HPI: Pain in right arm

Remember that the guidelines do not state how the note has to be documented. Information can be contained throughout the note. (HX Section)

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Document Pertinent Positives &/or NegativesWatch for Contradictions

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Past, Family, Social History (PFSH)

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Past, Family & Social History (PFSH)

Past HistoryAllergies, Current Medications, Immunizations, Previous Trauma, Surgeries, Previous Illnesses/Hospitalizations.

Family HistoryHealth of Parents, Siblings, Children. Family Members w/ diseases related to the chief complaint.

Social HistoryAge appropriate review of past and current activities, marital status and/or living conditions, employment, military status, occupational history, education, use of drugs, alcohol, tobacco.

NOTE: For categories of subsequent hospital care and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.

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Past, Family & Social History (PFSH)

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Complete (2 of 3)99215

Complete (3 of 3)99244 – 9924599204 – 99205

None99241 - 9924299201 - 9920299212 - 99213

Pertinent (1 of any)992439920399214

ROS vs Past HistoryROS vs. Past History

The ROS is an “inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient has or may be experiencing”- again, should be related to the chief complaint.

Allergy - ROS vs. Past History

Counted as ROS if related to the chief complaint or current signs/symptoms. Documentation that the patient has “no allergies” or NKDA is Past History information if the patient has no related complaints.

A list of “diagnoses” that the patient has is not a ROS but rather Past history.

Examples: Patient has Diabetes, Hypertension, COPD

Patient c/o increased thirst prior to taking her insulin for her Diabetes and her COPD seems to be worse with increased SOB

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Documentation Guidelines (DG) - (Per CMS)

ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information.

The review and update may be documented by: Describing any new ROS and/or PFSH information or

noting that there has been no change in the information; and

Noting the date and location of the earlier ROS and/or PFSH.

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The ROS and/or PFSH may be recorded by the ancillary staff or on a form completed by the patient (e.g. an ROS Intake Form).

To document that the physician reviewed the ROS and/or PFSH information, there must be a notation supplementing or confirming that the information was recorded by someone else.

The provider of the service must document the chief complaint (CC) and history of present illness (HPI)

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“Non-contributory” Can be interpreted as “not medically

necessary” - try to stay away from this terminology

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If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes the provider from obtaining a history.

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Determining the History Score: To qualify for a given type of history all of the elements must be met or exceeded

E/M Level LEVEL HPI ROS PFSH

992419920199212

Problem Focused Brief(1-3 HPI)

N/A N/A

992429920299213


Brief(1-3 HPI)

Problem Pertinent(1 ROS)

N/A

992439920399214

Detailed Extended(4 or more HPI)

Extended(2-9 ROS)

Pertinent(1 PFSH)

99244-9924599204-9920599215

Comprehensive Extended(4 or more HPI)

Complete(10+ ROS)

Complete(Est: 2 PFSH)(New: 3 PFSH)

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EXAM - 1995 vs 1997 Guidelines

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EXAM - 1995 vs 1997 Guidelines

What are the differences?

1995 Guidelines are more generic

Body Area (BA): Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine

Organ System (OS): Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psyche, Respiratory, Skin

1997 Guidelines are very specific and use “bullets”

Numeric requirements

Parenthetical examples are for clarification

“and” really means “or”

• 1995 Guidelines– Expanded problem focused vs

detailed– No guidelines– Be consistent

• 1997 Guidelines– General Multi-System vs Specialty

Exams

• Both are accepted for now.

• Currently, there are no proposed guidelines in the pipeline.

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1995 Exam Guidelines (NGS)Body Area (BA)

Head, Neck, Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine

Organ System (OS)

Constitutional, Cardio, ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin

Problem Focused (99241, 99202, 99212)

1 BA/OS

Expanded Problem Focused (99242, 99202, 99213)

2-7 BA’s/OS’s - limited

Detailed (99243, 99203, 99214)

2-7 BA’s/OS’s - extended (or 2 or more, at least 1 in detail)

Comprehensive (99244-99245, 99204-99205, 99215)

8+OS’s (only OS’s count toward a Comprehensive exam) OR

Complete exam of a single organ system

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1995: Note

When using the 1995 Guidelines, the documentation of vital signs or general appearance of the patient will give credit for the “constitutional” organ system.

The “constitutional” organ system is not used as one of the systems that can be documented in detail to give credit for a “detailed exam” as the documentation should be specifically related to the “chief complaint”.

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2-7 areas or systems

expanded documentation of the areas and/or systems examined;

requires more than checklists;

needs to have normal/abnormal findings expanded upon

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1995 Detailed Exam (NGS E/M Documentation Training Tool)

1997 Exam GuidelinesTwo types of examinations: General Multi-System Exam - body areas and

organ systems

Single Organ System Exam - more extensive exam of a specific organ system 10 single organ system exams

• Cardiovascular• ENT• Eye• Genitourinary• Hematologic/Lymph

• Musculoskeletal• Neurological• Psychiatric• Respiratory• Skin 54

1997 Guidelines - General Multi-System Exam

Body Area (BA) Head, Neck,

Chest/Breast, Genitalia/Buttocks, Abdomen, Extremities (4), Back/Spine

Organ System (OS) Constitutional, Cardio,

ENT, Eyes, GI, GU, Hem/Lymph, Musculoskeletal, Neurologic, Psych, Respiratory, Skin

Problem Focused (99241, 99201, 99212)

1-5 bulleted items

Expanded Problem Focused (99242, 99202, 99213)

6-11 bulleted items in one or more organ system or body area

Detailed (99243, 99203, 99214)

12-17 bulleted items; 2 bulleted items in 6 systems or areas or 12 bulleted items in at least 2 areas or systems

Comprehensive (99244-99245, 99204-99205, 99215)

18+ bulleted items; 2 bulleted items in at least 9 organ systems or document every element in each box with a shaded border and at least one element in each box with an un-shaded border.

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Exam DG

Specific abnormal/relevant negative findings of the affected body area/organ system should be documented. A notation of “abnormal” without elaboration is not sufficient.

Describe abnormal or unexpected findings in asymptomatic areas/systems.

Briefly note negative or normal to document normal findings in unaffected areas/systems.

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“Hot Button Areas” - Exam

There is a difference between the 1995 and 1997 guidelines. Review the “exam” elements for both sets of guidelines and decide which is best for your group/specialty.

ROS vs. Exam - cannot count as both(ROS is the talk, Exam is the walk).

Having patient give their height and/or weight is not “exam”. Vitals are the “measurement of”.

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Medical Decision MakingNumber of Diagnoses or Treatment Options

Amount and/or Complexity of Data to be Reviewed

Risk of Complications and/or Morbidity or Mortality

Determining the MDM Score (SF, Low, Mod, High)

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Medical Decision Making (MDM) Elements

The “thought process” of the physician Complete documentation of “thought process” including

issues being ruled out will support medical necessity and higher levels of service billed.

Refers to the complexity of establishing the diagnosis and developing a treatment plan based on the following: Number of Diagnoses and/or Management Options Amount and/or Complexity of Data Reviewed Risk of Complications, Morbidity or Mortality

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Types of Medical Decision Making

Four levels recognized:

Straightforward

Low complexity

Moderate complexity

High complexity

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Medical Decision Making (MDM) Elements

Number of Diagnoses or Management Options

Amount or Complexity of Data Reviewed

Risk of Complications, Morbidity or Mortality

2 of the 3 elements of Medical Decision Making must be met or

exceeded61

MDMNumber of Diagnoses/Management Options

Number of Diagnoses or Management Options Considered

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. 62

MDM

For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plan and/or further evaluation.

Only conditions that are assessed and impact the encounter are determining factors when selecting the level of visit (i.e., chronic conditions, co-morbidities)

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Bad example:


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Bad example:


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Better example:


For a presenting problem with an established diagnosis the record should reflect whether the problem is:

Improved, well controlled, resolving or resolved

Inadequately controlled, worsening, or failing to change as expected

For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis or as “possible”, “probable”, or “rule out” (R/O) diagnosis:

Outpatient diagnoses coding rule: Use signs & symptoms for your final diagnosis instead of a possible dx.

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Quantifying Diagnosis and Management Option

Number of Diagnoses and Management Options PointsSelf Limiting or Minor Problems - Stable, Improved or Worsening (Maximum of 2) 1

Established Problem - Stable Improved 1

Established Problem - Worsening 2New Problem - No Additional Work-up Planned(Maximum of 1) 3

New Problem - Additional Work-up Planned 4

Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive68

Self Limited Problem

Self limited/minor vs. new problem There is no definition in the CMS E/M Guidelines

Examples include a cold, an insect bite and tinea corporis.

CPT Manual E/M Services Guidelines, Nature of Presenting Problem defines a "self-limited or minor" problem as “one that runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status or has a good prognosis with management/ compliance."

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NGS E/M FAQAdditional Work-up

17. How does NGS interpret “additional work up?“

Answer: NGS does not differentiate between diagnostic tests done on the same date of service as the encounter, and those scheduled following the encounter. Either would be considered “additional workup planned."

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Quantifying Amount of Complexity of Data Reviewed

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Amount & Complexity of Data Points

Ordered and/or reviewed clinical lab test (1 point max) (CPT 80000) 1

Ordered and/or reviewed radiology test (1 point max) (CPT 70000) 1

Ordered and/or reviewed test in the CPT Medicine Section (1 point max) (CPT 90000)

1

Discussed the test results with performing or interpreting physician (1 point max) 1

Decision to obtain old records or additional HX from someone other than patient, e.g., family, caretaker, previous physician (1 point max)

1

Reviewed and summarized old records or and/or obtained history from someone other than patient and/or discussion case with another health care provider (2 points max)

2

Independent visualization of image, tracing or specimen (2 points max) 2

Totals: 1 = minimal, 2 = limited, 3 = moderate, 4 = extensive

Quantifying Amount of Complexity of Data Reviewed

“Independent visualization and direct view of image” - is this worth 1 or 2 points?

Guidelines state “the direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented”

General feeling is that it depends on who is billing for the interpretation. If the same provider (group) is also billing for the interpretation then only 1 point is awarded; however if the provider (group) is not billing for the interpretation, then 2 points will be awarded.

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Quantifying Risk

Table indicates three areas of risk: Risk of the presenting problem(s) Risk of Diagnostic procedure(s) ordered Risk of Management option(s)

Documentation Guidelines state: Highest Level of Risk in any category

determines overall risk

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Table of RiskRisk Level Presenting Problem(s) or Diagnostic Procedure or Management Options

Min (1)

One self-limited or minor problem, eg cold, insect bite, tinea corporis Venipuncture CXR,EKG,EEG Urinalysis, KOH US

Rest Gargle Elastic bandages Superficial dressings

Low (2)

Two or more self-limited or minor problems One stable chronic illness, eg well controlled Acute uncomplicated illness or injury, eg cystitis, simple sprain (full recovery w/o

functional impairment is expected)

PFT Non-cardiac imaging

studies Superficial needle

biopsies Arterial puncture Skin biopsies

OTC drugs Minor surgery w/o risk PT OT IV fluids w/o additives

Mod (3)

One or more chronic illnesses with mild exacerbation, or side effects of tx Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness (or

increased probability of prolonged impairment)

Stress tests Endoscopies w/o risk

factors Deep/incisional biopsies Card cath w/o risk Obtain cavity fluid from

body cavity, eg, lumbar puncture, Thoracentesis, culdocentesis

Minor surgery w/risk Elective major surgery w/o risk Prescription drug management Therapeutic nuclear meds IV fluids w/additives Closed reduction of fracture or

dislocation

High (4)

One or more chronic illnesses with severe exacerbation, progression, or side effects from tx

Acute/chronic illness/injury that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe RA, psychiatric illness w/potential threat to self or others, peritonitis, acute renal failure (or high probability of severe, prolonged impairment)

An abrupt change in neurologic status, eg, seizure, TIA, weakness or sensory loss

Cardiac catheter w/risk EPS studies Endoscopies w/risk Discography

Elective major surgery w/risk Emergency major surgery Parenteral controlled

substances Drug therapy requiring

intensive monitoring for toxicity DNR decision or to de-escalate

care because of poor prognosis

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MDM: Risk ofSignificant Complications, Morbidity, &/or Mortality

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.

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.

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Determining MDM

Reminder: Two of the three elements in the table must be met or exceeded 76

Corresponding E/M Code

Level of MDM # of Diagnosisor Mgmt Options

Amount or Complexity of Data Reviewed

Risk of Complications,Morbidity, or Mortality

99241-9924299201-9920299212

Straightforward Minimal(1)

Minimal or None(0-1)

Minimal(1)

992439920399213

Low Complexity Limited(2)

Limited(2)

Low(2)

992449920499214

Moderate Complexity

Multiple(3)

Moderate(3)

Moderate(3)

992459920599215

High Complexity Extensive(4)

Extensive(4)

High(4)

Medical Necessity

Supported in the documentation of: Chief Complaint/presenting problem

why the patient presents for services

Relevant exam components pertinent to chief complaint and flow to medical decision making

Medical decision making establishing a working diagnosis and

corresponding treatment plan that addresses the chief complaint

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Validation Process

Purpose, Scope, Approach

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Purpose, Scope, ApproachPurpose

To prevent possible legal & financial implications

To maintain/promote

Compliance Detection

Correction

Prevention

Verification

Comparison79


Scope Determine whether you will perform a retrospective vs

prospective review Determine the number of charts per provider

Recommended: 10 – 20 encounters Determine a reasonable time frame you will select from Determine your focus

Example: E/M full claim review, focused review Select charts

Random: Select every 5th or 10th chart Targeted: only 99214s & 99215s

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ApproachPresent results in a professional and educational

mannerProvide providers the opportunity to review and study

the results

Review and discuss results with provider one-on-one

Approach your meeting with the provider as a learning opportunity for both of you

Discuss documentation improvement opportunities

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Monitor and Track Results

Work at correcting problems identified

Establish an on-going reporting and feedback system

Record error rates and trends in documentation

Example: not documenting a thorough history or not recording a valid chief complaint, invalid signatures

Document and respond to systematic issues/concerns uncovered during the review or your discussions

Address over coding to minimize potential pay back

Address under coding to maximize potential payments82

Remember…

Accept the Fact that No Tool Can Replace A Provider In Determining Medical Necessity

Communicate

Timely

Concisely

In terms in which providers can relate83

In the World of Electronic Health Record

EHR Concerns- Functionality, Templating, Cloning, etc.

84

Coding Aspects of the EHRs Is an electronic health record (EHR) a

great way to capture coding information?

How does your EHR capture coding information?

Does your EHR code for you?Is it accurate?

85

Is an EHR a great way to capture coding information?

Yes, information is legible, easily accessible, regardless of documentation location; information is recorded for years to come.

No, nothing is fool proof. If providers do not use the system as

intended, it may become a compliance issue

Vendors/IT are not always familiar with rules/regulations

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How does your EHR Capture Coding Information?

History and Exam are relatively easy to abstract from EHRs

Text boxes

Check off boxes

Free text

Areas of weaknesses in most EHRs are the most subjective areas of the SOAP:

History of present illness

Medical decision making

How is Medical Decision Making quantified? 87

Does your EHR code for you?Is it Accurate?

Which Guidelines are used - 1995 vs. 1997?

Do you have the ability to modify the requirements?

Does the EHR program suggest changing documentation to support the higher levels of code?

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EHR Coding Functionality

Providers need to understand the concepts of coding to use an EHR to its fullest coding capabilities

Elimination of non-compliant coding functionality

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Medical Necessity Challenges

» Unlike EHRs, paper records provide an overall sense of an authentic entry:

» Diagnosis may help if the qualifying descriptors are present (e.g., critical nature of the patient’s condition, life-threatening)

» Data ordered and treatment options give a reasonable insight into the provider’s impression of the acuity of the patient’s illness.Example:

» “Return prn” indicative of a low MDM

» Hospitalization, surgery and complex evaluations indicate moderate to high MDM

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What is “Cloning?”NGS – Policy Educationhttps://ngsmedicare.com

Documentation is considered cloned when it is worded exactly like or similar to previous entries

It can also occur when the documentation is exactly the same from patient to patient:

All diabetic patients start to look alike (no individuality); or

Every patient visit looks alike (difficult to differentiate one visit from another)

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NGS – Policy Educationhttps://ngsmedicare.com

Whether the documentation was the result of an Electronic Health Record, or the use of a pre-printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient.

Cloning may be the most worrisome aspect of an EHR

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EHR Review Approach to Identify Cloning

Obtain 5-10 charts per provider; at least 3-4 from same patient, in sequence

Interpret patterns in documentation to identify potential cloning

Note concerns for quality and liability

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Cloning / Templating

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Overview / Introduction to

Scribes

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Guidelines for “Scribe”

Providers using the services of a “scribe” must adhere to the E/M Documentation Guidelines, but in addition:

Medical record must indicate the name of the person who is “acting as a scribe for Dr. X”

Provider is expected to deliver the service and is still responsible for the medical record

Provider must authenticate the medical record confirming that the note is accurate

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Overview / Introduction to

Incident-to Billing

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Incident-to BillingMedicare Internet-Only Manual (IOM) 100-02 Chapter 15, Section 60

CMS allows services of certain nonphysician practitioners to be billed as incident-to a physician’s professional services

NGS: Under Medicare Part B, “incident-to” provisions apply in an office setting only. There is no incident-to billing in a facility under Part B. (Only POS=11)

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Incident-to Billing Requirements The following requirements are associated with "incident to"

billing as defined by Medicare:

Physician-initiated course of treatment and continued active participation in the course of treatment and management

Direct supervision: physician is physically present in the same office suite

Both practitioners are employed by the same entity

Billed under the physician who is in the office that day, not necessarily the physician who initiated the plan of care

Incident-to billing does not apply to new patients or established patients with new problems 99

E/M DocumentationThe Impact of ICD-10-CM

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ICD-10-CM – Sample Summary of Results

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Determination Definition # of Claims %

Outpatient ClaimsAgree * No coding changes (up to 9 codes reviewed)

* Agree with claim or coding summary112 40 %

Additional code(s) supported

* Medical record documentation supported additional ICD-10-CM code(s); or* Reporting of additional ICD-10-CM code(s) was required based on the official coding guidelines.

44 16 %

Incorrect code(s) * Medical record documentation supported different ICD-10-CM code(s) compared to the code(s) reported* Documentation to support a diagnosis code was not provided

87 30 %

Both:* Additional code(s) supported and* Incorrect code(s) reported

40 14 %

Total # of claims 283

ICD-10-CM Simple Documentation Tips

When Applicable, remember to document:

Acuity Acute, Chronic, Acute on Chronic

Severity Mild, Moderate, Severe

Laterality Right, Left, Bilateral

Cause & Effect Due to, With, Secondary to, Complicated by, Caused by, etc.

Anatomic Site Specificity

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Reference for Guidance Centers for Medicare and Medicaid Services (CMS)

Billing Rules

Bundling Edits

http://www.cms.hhs.gov/

National Government Services (NGS)

Local MAC

https://www.ngsmedicare.com/

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Contact Information

Santa Allaire, RHIT, CCS, CPC, CIRCC, CEMCManager

[email protected]

BAKER | NEWMAN | NOYES LLC

Toll Free: 1-800-244-7444

Fax: 207-774-1793 105

E&M Code Assignment & Validation 2016 - MeHIMA · 2016-03-10 · Code Assignment & Validation...

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