Coding for Physician/Provider
Services: Understanding Key
Documentation Issues
Presented by
Deborah Holzmark, RN, MBA, CPHQ, MCS-P , CMPE Dixon Hughes PLLC
(828) 236-5794
Agenda
Compliance Overview
Evaluation and Management Coding
Other Issues
Compliance Overview
3
Compliance is serious
business
The average specialty practice incurs
about 4 times its annual net income in
potential liability for inadvertent or
deliberate coding errors
Auditors from the OIG, CMS and other
government bodies estimate that 75-80%
of the codes billed by physicians’ offices
lack sufficient documentation for the level
Audit Performance In a
National Study Group
In January 2000, the Archives
of Family Medicine published a study by George Kikano et al which compared family
physicians billing for E&M services with medical record documentation Non-40% 60% BPC Error Percentage 5 documentation
After reviewing 4137 visits at 138 practices, researchers found errors indicating codes billed were not concurrent with documentation in the charts 43% of the time
Upcoding and downcoding occurred at similar frequencies and differed by more than one code in fewer than 4% of visits Compliant
Non-Compliant
Compliance is how you conduct
your business
Besides its legal implications, incorrect coding significantly impacts practice cash flow
–
A/R problems and collection costs escalateThe top three reasons practices get audited
– Beneficiary complaints – Beneficiary complaints – Whistleblowers
– Peer comparison for random audit (CERT Testing)
Compliance is all about documentation
– The purpose of coding is to quantify the services provided - like an accounting system
Compliance is serious
business
There are five types of Federal fraud enforcement options
– Repayment of overpayment requests Civil monetary penalty – Exclusion – Civil remedies – Criminal Sanctions 7 – Criminal Sanctions
If indicted for Federal crimes, practices also risk audit by other bodies
– IRS
– Commercial Payors – State Medicaid
Definitions of Fraud and
Abuse
What is Fraud?
– Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program or obtain, by means of false or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the any of the money or property owned by, or under the custody or control of, any health care benefit program.
What is Abuse?
– Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally
Common Chart Review Issues
Most common error: upcoding one level
– Most common reason for upcoding: lack of
sufficient history documentation
Other common errors:
– Missing notes
9
– Missing notes
– Incomplete notes
– Missing supporting documentation (lab results)
– No mention orders for additional services
– Downcoding
– Wrong category
History Documentation
Higher level codes that require
comprehensive history:
– 99204-99205 New Office
– 99222-99223 Initial Inpatient
– 99222-99223 Initial Inpatient
– 99244-99245 Consults
– 99254-99255 Consults Inpatient
– 99344-99345 Home, New
Review of Evaluation Management
Documentation Guidelines
– History
11– History
– Physical Exam
– Medical Decision-making
Documentation of History
The levels of E&M service are based on four
types of history (Problem Focused, Expanded
Problem Focused, Detailed and
Comprehensive) Each type of history includes
some or all of the following elements:
– Chief Complaint (CC) :This is either Present or Absent
– History of Present Illness (HPI): This is either Brief or Extended
– Review of Systems (ROS): This is either Problem Pertinent, Extended or Complete
Documentation of History
The extent of these elements you provide
must be based on the nature of the
presenting problem and clinical
judgement. It must be necessary and
appropriate to provide the level of
13
appropriate to provide the level of
history you document.
Chief Complaint (CC)
A chief complaint is a concise statement describing the symptom, problem, condition or other factor that is the reason for the encounter.
YOU MUST ALWAYS DOCUMENT THE CHIEF COMPLAINT!
COMPLAINT!
History of Present Illness
(HPI)
A chronological description of the development of the
patient’s present illness from the first sign or symptom, or from the previous encounter to present. It includes:
– Location: RLQ
– Quality: Burning, aching
– Severity: Seven on a one to ten scale
15
– Severity: Seven on a one to ten scale
– Duration: For the last seven weeks
– Timing: Constant pain
– Context: fell down stairs
– Modifying factors: Ice doesn’t seem to help
History of Present Illness
(HPI)
–
For a Brief HPI, you would describe one to
three of these
–
For an Extended HPI, you would describe
four or more of these
Review of Systems
The following 14 systems are recognized, you must document patient’s personal history of each area:
Constitutional symptoms Eyes
Ears, Nose, Mouth, Throat Cardiovascular
Respiratory Gastrointestinal Genitourinary Musculoskeletal 17 Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic
Problem Pertinent: At least one
Extended: two to nine of these would be documented
Complete: you would document at least ten of these
Past, Family and Social
History(PFSH)
Past History: The patient’s past experience
with illnesses, operations, injuries and
treatments:
prior major illness and injuries prior major illness and injuries prior hospitalizations current medications allergies immunizations feeding/dietary status prior operations
Past, Family and Social
History(PFSH)
Family History: A review of medical events in the
patient’s family, including diseases which may be
hereditary or place the patient at risk
– Health status or cause of death of parents, siblings, children
– specific diseases related problems identified in the
19
– specific diseases related problems identified in the history
Past, Family and Social
History(PFSH)
Social History: An age appropriate review of past
and current activities
– marital status
– current employment – occupational hx
– drugs, alcohol, tobacco – education
– sexual hx
Histories are either Pertinent or
Complete
PFSH
A pertinent review: at least one item from any of the three history areas
A complete review: at least one item from two of the three history areas for
– established patient office visits
21
– established patient office visits – ER visits
A complete review: at least one item from all three history areas for
– new patient office visits – initial hospital inpatient – consultations
History
Important tips:
– You can use a patient information form to collect data, however you must:
You must refer to the patient information form in your note and that you reviewed it with the in your note and that you reviewed it with the patient AND
Document all positive responses in your note, for example if they check a history of heart disease, you must document in your note the details of this problem.
History
– You do not have to re-record a ROS and/or PFSH at each visit, but you must note there has been no change from the previous assessment and note the date of the previous assessment or describe any new information – When you do a complete ROS, at least 10 organ
23
– When you do a complete ROS, at least 10 organ systems, those systems with positive or negative PERTINENT responses must be individually
documented. For the remaining systems, a notation indicating all other systems are negative is permissible, but you must actually review the other systems.
Per Medicare:
Record Past/Family/Social History (PFSH)
appropriately considering the clinical
circumstance of the encounter. Extensive PFSH is
unnecessary for lower-level services. The same
applies to ROS.
Don't use the term "non-contributory".
Don't record unnecessary information solely to
Don't record unnecessary information solely to
meet requirements of a high-level service when
the nature of the visit dictates a lower-level
Per Medicare:
Document an ROS for the system(s) related to the
presenting problem. It is required for all levels of
systemic review (meaning that it is required for all
codes except the least codes in all code families).
Record positives and pertinent negatives.
– Never note the system(s) related to the presenting
25
– Never note the system(s) related to the presenting problem as "negative".
– Use notations such as "normal" or "negative" only for systems not related to the presenting problem.
– When using "negative" notation, always identify which systems were queried and found to be negative.
Don't count physical observations as ROS (count
them as Physical Examination).
History Requirements
Type of History History of Present Illness Review of SystemsPast, Family, and/or Social History
Problem Focused Brief (1-3) N/A N/A
Expanded Problem Focused Brief (1-3) Problem Pertinent N/A
Detailed Extended (4+) Extended (2-9) Pertinent (1 of 3)
Physical Exam
There are four levels of Physical Exam:
– Problem Focused
– Expanded Problem Focused – Detailed
– Comprehensive
27
There are Three Types of Documentation
Guidelines for Physical Exams:
– 1995 General Multisystem – 1997 General Multisystem – 1997 Single Organ Exams
General Multi-System
Exam
Type of Exam Number of Organ Systems Number of Bullets or Elements Problem Focused One or more One to Five Elements
Expanded Problem Focused One or more At least Six Elements
Detailed Six or more and At least Two Elements
Detailed Six or more and At least Two Elements OR
Two or more and At least Twelve Elements
Comprehensive Nine or more All elements AND
General Multi-System
Exam
Constitutional
– Any three of the seven vital signs (may be done by ancillary staff) sitting or standing BP Supine BP 29 Pulse Respiration Temperature Height Weight
– General appearance of the
patient(e.g.:development, nutrition, body habitus, deformities, attention to grooming)
General Multi-System
Exam
Eyes
– Inspection of conjuctivae and lids
– Exam of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
– Opthalmoscopic exam of optic disc (e.g., size, C/D – Opthalmoscopic exam of optic disc (e.g., size, C/D
ratio,appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages)
Lymphatic
– Palpation of lymph nodes in two or more areas: Neck
General Multi-System
Exam
Ears, Nose, Mouth and Throat
– External inspection of ears and nose (overall appearance, scars, lesions, masses)
– Otoscopic exam of external auditory canals and tympanic membranes
31
tympanic membranes
– Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
– Inspection of nasal mucosa, septum and turbinates
– Inspection of lips, teeth and gums
– Examination of oropharynx: oral mucosa,
salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
General Multi-System
Exam
Neck
– Examination of neck (masses, overall appearance, symmetry, tracheal position, crepitus)
– Examination of thyroid (e.g., enlargement, tenderness, mass)
Respiratory
– Assessment of respiratory effort (e.g., intercostal
retractions, use of accessory muscles, diaphragmatic movement
– Percussion of chest (e.g., dullness, flatness, hyperresonance)
General Multi-System
Exam
Cardiovascular
– Palpation of heart (e.g., location, size, thrills)
– Auscultation of heart with notation of abnormal sounds and murmurs
– Exam of:
33
– Exam of:
carotid arteries (e.g., pulse amplitude, bruits) abdominal aorta (e.g., size, bruits)
femoral arteries (e.g., pulse amplitude, bruits) pedal pulses (e.g., pulse amplitude)
General Multi-System
Exam
Chest (Breasts)
– Inspection of breasts (e.g., symmetry, nipple discharge)
– Palpation of breasts and axillae (e.g., masses or lumps, tenderness)
General Multi-System
Exam
Gastrointestinal (Abdomen)
– Exam of abdomen with notation of presence of masses or tenderness
– Exam of liver and spleen
35
– Exam for presence or absence of hernia
– Exam (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
General Multi-System
Exam
Genitourinary – Female:
Pelvic exam ( with or without specimens) including – exam of external genitalia and vagina
– exam of urethra – exam of urethra – exam of bladder – exam of cervix – exam of uterus – exam of adnexa/parametria
General Multi-System
Exam
Musculoskeletal
– Examination of gait and station
– exam of joints,bones and muscles of one or more
of the following six areas:
37
of the following six areas:
1. Head and neck
2. Spine, ribs and pelvis
3. Right upper extremity
4. Left upper extremity
5. Right lower extremity
6. Left lower extremity
General Multi-System
Exam
The exam of a given area should include:
Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions
Assessment of range of motion with notation of Assessment of range of motion with notation of any pain, crepitation, or contracture
Assessment of stability with notation of dislocation, subluxation, or laxity
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
General Multi-System
Exam
Skin
– Inspection of skin and subcutaneous tissue (e.g.., rashes, lesions, ulcers)
– Palpation of skin and subcutaneous tissue (e.g.., induration, subcutaneous nodules, tightening)
39
Neurological
– Test cranial nerves with notation of any deficits
– Examination of deep tendon reflexes with notation of pathological reflexes
– Examination of sensation (e.g.., by touch, pin, vibration, proprioception)
General Multi-System
Exam
Psychiatric
– Brief assessment of mental status including: orientation to time, place, person
recent and remote memory
mood and affect (e.g.., depression, anxiety, agitation) mood and affect (e.g.., depression, anxiety, agitation)
Medical Decision Making
Number of Diagnoses or Management Options
Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
41
Multiple Moderate Moderate Moderate Complexity
Medical Decision Making
L e v e l o f R is k P r e s e n t in g P r o b le m s D ia g n o s t ic P r o c e d u r e s O r d e r e d M a n a g e m e n t O p t io n s S e le c t e d M in im a l O n s e lf-lim ite d o r m in o r p ro b le m (e g ., c o ld , in s e c t b ite ) q L a b te s ts re q u irin g v e n ip u n c tu re q C h e s t x ra y s q E K G /E E G q U rin a ly s is q R e s t q G a rg le s q E la s tic B a n d a g e s q S u p e rfic ia l d re s s in g s q U rin a ly s is q U S q K O H p re p d re s s in g s L o w q T w o o r m o re s e lf-lim ite d o r m in o r p ro b le m s q O n e s ta b le c h ro n ic illn e s s (e g ., H T N , D M , C a ta ra c t) q A c u te u n c o m p lic a te d q P h y s io lo g ic te s ts n o t u n d e r s tre s s q N o n -C V im a g in g w ith c o n tra s t q S u p e rfic ia l n e e d le b io p s ie sq L a b te s t re q u irin g a rte ria l p u n c tu re q O T C d ru g s q M in o r s u rg e ry w ith n o id e n tifie d ris k fa c to rs q P T /O T q IV F w ith o u t a d d itiv e s
Medical Decision Making
Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected Moderate q One or morechronic illnesses with mild
exacerbation
q Two or more
q Physiologic tests under
stress
q Diagnostic endoscopies
with no identified risk factors
q Minor surgery
with identified risk factors q Elective major surgery with no 43 stable chronic illnesses q Undiagnosed new problem
q Acute illness with
systemic symptoms
q Acute complicated
injury (eg., head injury with brief LOC)
q Deep needle biopsy q CV imaging studies with
contrast and no risk factors
q Obtain fluids from body
cavity identified risk factors q Prescription drugs q Therapeutic nuclear medicine q IV fluids with additives q Closed treatment of fracture or dislocation without manipulation
Medical Decision Making
Level of Risk
Presenting Problems Diagnostic Procedures Ordered
Management Options Selected
High q One or more
chronic illnesses with severe exacerbation
q Acute or chronic
q CV imaging with risk
factors
q Cardiac EP tests
q Diagnostic endoscopies
with risk factors
q Elective major
surgery with risk factors
q Emergency major
surgery Acute or chronic
illnesses that pose a threat to life or bodily function (eg., multiple trauma, progressive rheumatoid arthritis) q An abrupt change in neurological status (eg., sensory loss)
with risk factors
q Discography surgery q Parenteral controlled substances q Drug therapy requiring intensive monitoring for toxicity q Decision not to resuscitate
Office Visits: Initial and
Established
Code History Physical Decision Making 99201 Problem Focused Problem Focused Straight-Forward
99202 Expanded Problem Focused Expanded Problem Focused Straight-Forward
99203 Detailed Detailed Low Complexity
45
99204 Comprehensive Comprehensive Moderate Complexity
99205 Comprehensive Comprehensive High Complexity
Code History Physical Decision Making 99211 N/A Physician may not be present
99212 Problem Focused Problem Focused Straight Forward
99213 Expanded Problem Focused Expanded Problem Focused Low Complexity
99214 Detailed Detailed Moderate Complexity
Special Issues
Special Issues
Special Issue:
Time Based Services
Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling
Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face
physician/patient encounter or the floor time (in the case of
inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the
47
the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the
type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the
coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.
Time Based Services
In the office and other outpatient setting,
counseling and/or coordination of care must be
provided in the presence of the patient if the time
spent providing those services is used to
determine the level of service reported.
determine the level of service reported.
Face-to-face time refers to the time with the physician
only. Counseling by other staff is not considered
to be part of the face-to-face physician/patient
encounter time. Therefore, the time spent by the
other staff is not considered in selecting the
Time Based Services
You must document total time, time spent in
counseling/coordination of care and topics/issues
addressed
– Example 45 minute visit, 25 minutes spent in counseling and discussion regarding surgical intervention versus conservative treatment.
49
Time Based Services
EXAMPLE:
A cancer patient has had all
preliminary studies completed and a medical
decision to implement chemotherapy is made. At
an office visit the physician discusses the
treatment options and subsequent lifestyle effects
of treatment the patient may encounter or is
of treatment the patient may encounter or is
experiencing. The physician need not complete a
history and physical examination in order to select
the level of service. The time spent in
counseling/coordination of care and medical
decision-making will determine the level of service
billed.
Medicare Overpayments
Statistically significant sampling
May be audited by party other than
Medicare
Results with general issues and
51
Results with general issues and
spreadsheet
Extrapolation
Medicare Overpayments
Review records carefully upon
request/seek advice
Include everything
Check for and include history forms,
Check for and include history forms,
testing results, previous and
subsequent notes if applicable
Maintain copies of everything
provided!!!
Lessons Learned
Know the E&M Guidelines
– Overpayment reviews focus on
documentation of any type of visit
including new patients, established
patients, consults, hospital visits,
53
patients, consults, hospital visits,
nursing home visits, etc..
–
http://www.cms.hhs.gov/MLNEdWebGui
de/25_EMDOC.asp
– Read the Evaluation and Management
Services Guide!
Lessons Learned
Know your Local/National Coverage
Decisions!
– Overpayment reviews specifically
reference LCD’s, NCD’s and articles
reference LCD’s, NCD’s and articles
from the Medicare Bulletins
– Part A, Part B, Coverage and Pricing,
LCDs
Lessons Learned
The constant history
– Review of records showing repetition of
history documentation exactly the same
for each visit
55
– In Overpayment review, a primary care
physician was requested to repay over
$11,000 on review of 99215. Cited
Lessons Learned
Electronic signature
– Ensure EMR adequately implements the
utilization of electronic signature
– Overpayment review: cited a large
– Overpayment review: cited a large
percentage of charts for lack of
signature. Overturned on appeal
Lessons Learned
Flow of electronic information
– When a visit is printed, does it include
the reviewed history?
– Chart reviews show a request for a visit
57
– Chart reviews show a request for a visit
date of service documentation does not
necessarily include printed review of
history that would significantly impact
code selection
What Medicare Says:
Medicare expects the documentation to be generated during the time of service or shortly thereafter.
Delayed entries within a reasonable time frame (24 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
The medical record may not be altered. Errors must be The medical record may not be altered. Errors must be
legibly corrected so that the reviewer can draw an inference as to their origin. Deletions should have only a single thin line drawn through the deletion. These corrections, deletions or additions must be dated and legibly signed or initialed. Every note stands alone, i.e., the services performed must be documented at the outset.
What Medicare Says:
Delayed written explanations will be considered for
purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.
All entries must be legible to another reader to a degree that
59
All entries must be legible to another reader to a degree that a meaningful review can be conducted. Recommendation is made that only JCAHO approved abbreviations be used to prevent patient care errors and allow for proper review by subsequent readers. Illegible notes will not be used in determining medical necessity of a claim.
All notes shall contain the patient’s name and be dated and signed by the author.
If the signature is not legible and does not identify the author, a printed version should be also recorded.
What Medicare Says:
The medical record should be complete and legible. Each patient encounter should include:
– the date
– the reason for the encounter
– appropriate history and physical exam
– review of lab, x-ray data and other ancillary services
– assessment and a plan of care, including discharge plan (if appropriate)
appropriate)
Past and present diagnoses should be accessible to the treating and/or consulting physician
Reasons for and results of x-rays, lab tests and other ancillary services should be documented or included in the medical record Relevant health risk factors should be identified.
Patient’s progress, including response to treatment, change in
treatment, change in diagnosis, and patient non-compliance should be documented.
What Medicare Says:
The written plan of care should include, when appropriate:
– Treatments and medications, specifying frequency and dosage – Any referrals and consultations
– Patient/family education
– Specific instructions for follow up
The documentation should support the intensity of the patient evaluation and/or treatment, including thought
processes and the complexity of medical decision-making
61
patient evaluation and/or treatment, including thought
processes and the complexity of medical decision-making All entries to the medical record should be dated and
authenticated by the physician/provider signature.
The CPT/ICD-9-CM codes reported on the CMS-1500 form should reflect the documentation in the medical record.
Questions?
Deborah Holzmark, RN, MBA, CPHQ. MCS-P,CMPE
