Medical Practice Management Making the Pieces Fit

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Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN 55435 www.hcca-info.org | 888-580-8373

Medical Practice Management

Making the Pieces Fit

Alice Anne Andress, CCS-P, CCP Susan Parker, Corporate Compliance Officer

According to CMS

-E & M Service -Errors

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Risk Areas For Physician Services

• Superbills-code steering

• Employees choosing levels of E&M

• Lack of medical necessity

• New vs established patients

• Abd vs GI

• Consults-use of “referring”

Risk Areas For Physician Services

• Modifier -25

• Hemoccult slides

• 1995 Comprehensive examination

• Pattern billing

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Risk Areas For Physician Services

• Lack of understanding of E&M requirements

– Missing ROS

– Lack of HPI

– Lack of PFSH

– Lack of MDM

False Claims

• Professional courtesy was supported by

the AMA as an ethical requirement in the past.

• Now, a violation of the False Claims Act, as physicians are misrepresenting their charges when billed to

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False Claims

• Fraud Alert issued in 1991 by the OIG – routine waiver of co-payments (I/O) and/or deductibles is also

misrepresenting the actual charge for the service.

• Medicare Carriers Manual, Section 5220, calls for investigation of physician’s waivers of co-payments and deductibles when they are waived routinely.

PRINCIPLES OF DOCUMENTATION

1) The medical record should be first and foremost a tool of clinical care and communication.

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PRINCIPLES OF DOCUMENTATION

3) The documentation of each patient encounter should include:

• The reason for the encounter and relevant history, physical exam, findings and prior diagnostic test results.

PRINCIPLES OF DOCUMENTATION

• The physician’s assessment of the patient’s condition, clinical impressions or diagnoses.

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PRINCIPLES OF DOCUMENTATION

• The date and legible identity of the observer (physician, nurse, etc).

• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

PRINCIPLES OF DOCUMENTATION

• Past and present diagnoses should be accessible to the treating and/or consulting physician.

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PRINCIPLES OF DOCUMENTATION

• The patient’s progress, response to treatment and changes in the treatment or diagnoses should be documented.

• The CPT and ICD-9-CM codes reported must be supported in medical record

PRINCIPLES OF DOCUMENTATION

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Key Components

• History

• Examination

• Medical Decision Making

• *Time

Key Components

Time is only a factor when

counseling is more than 50%of the

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Components of History

• Chief Complaint (CC)

• History of Present Illness (HPI)

• Review of Systems (ROS)

• Past, Family, Social History (PSFH)

Chief complaint

Reason for the

visit-– Usually in the patient’s own words.

– Beware of vague language

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Chief complaint

Why does the patient seek care?

– Unbearable symptoms

– Anxiety about meaning of symptoms

– They are in a life crisis

History of Present Illness (HPI)

HPI is . . .

•An expansion on the chief compliant

•A story about the patient’s problem

It should contain all the information necessary to

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History of Present Illness (HPI)

Brief: 1-3 elements

Extended: 4 or more elements OR status of at least 3 chronic or inactive conditions

History of Present Illness (HPI)

Location:

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History of Present Illness (HPI)

Duration:

How long do the symptoms last?

History of Present Illness (HPI)

Quality:

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History of Present Illness (HPI)

Severity:

On a scale of 1 to 10, how bad is it? Is it interfering with daily functioning?

History of Present Illness (HPI)

Timing:

When did you first experience the symptom/problem?

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History of Present Illness (HPI)

Context:

What were you doing when this

occurred?

Where were you when this began?

History of Present Illness (HPI)

Modifying factors:

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History of Present Illness (HPI)

Associated signs and symptoms:

What else bothers you when this occurs?

Review of Systems(ROS): A definition . . .

An inventory of body systems obtained through a

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www.hcca-info.org | 888-580-8373 31 Brief: 1 organ system Extended: 2-9 organ systems Complete:

10 or more organ systems

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Eyes: Do you have any blurred vision?

GI: Do you have any problems with your bowels, diarrhea, constipation?

Resp: Do you have a cough, any trouble breathing,

wheezing?

CV: Do you have any chest pain? Shortness of breath?

Review of Systems(ROS):

Organ Systems . . .

Pertinent PFSH –directly related to the problem. At

least 1 item from any of the history areas

Complete PFSH-depends on the category of E&M.

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3 out of 3 rule



2 out of 3 rule

Past, Family, Social History (PFSH)

• Office visit – new patient

• Hospital observation service

• Hospital initial inpatient service

• Consultations

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• Office visit – established patient

• Emergency department service

• Hospital subsequent service

Complete PFSH – Two Areas

Medical Problems Hospitalizations Surgical history Trauma OB/GYN history Allergies

Age appropriate immunizations

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• Diseases that may be hereditary or place the patient at risk.

• Health of the parents, siblings, children or cause of death of any of these relatives.

Family History

Alcohol use Drug use

Living arrangements

Job status, occupational history Marital status

Sexual history

Education background Current employment Any other relevant history

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CONSTRUCTION 101

History Building Blocks

Problem Focused

cc- diarrhea

HPI- diarrhea x2 days

Key:

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Expanded Problem Focused

cc- diarrhea

HPI - diarrhea x2 days, also complaining of abdominal pain

ROS- complains of diarrhea, abdominal pain, no loss of appetite

Key:

cc. HPI-brief (1-3), ROS- GI

Detailed

cc- diarrhea

HPI - diarrhea x2 days, also complaining of abdominal pain,

pain described as a cramping sensation, took Pepto Bismol but it didn’t help

ROS- complains of diarrhea, abdominal pain, no loss of appetite denies chest pain, admits to some fatigue PFSH-HTN

Key:

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Comprehensive

cc- diarrhea

HPI - diarrhea x2 days, also complaining of abdominal pain, pain is described as a cramping sensation, took Pepto Bismol but it didn’t help

ROS- complains of diarrhea, abdominal pain, no loss of appetite, denies chest pain, pt admits to some fatigue,

shortness of breath or cough, no muscular aches, no skin disorders, denies dizziness, cold symptoms, no problems with urination, pt is anxious about not feeling well

PFSH-HTN,Non-smoker, Father- HTN, CVA 1993

Comprehensive

Key:

Cc- HPI-Extended

duration, s/s, quality, mod factors

ROS- Complete

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The provider may choose whichever set of exam guidelines best suits the patient’s visit . . .

1995 or 1997

Examination

Problem Focused - a limited examination of

the affected body area or organ system

Expanded Problem Focused - a limited

examination of the affected body area or organ system and other symptomatic or related organ system(s).

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Examination

Detailed - an extended examination of

the affected body area(s) or other

symptomatic or related organ system(s).

Comprehensive - a general

multi-system examination or complete

examination of a

single organ system

ALERT

A comprehensive exam consists only of organ systems!

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1) Head, including the face

2) Neck

3) Chest, including breasts and axilla

4) Abdomen

5) Genitalia, groin, buttocks

6) Back, including spine

7) Each extremity

Examination - Body Areas

1) Constitutional 2) Eyes 3) ENMT 4) Cardiovascular 5) Respiratory 6) GI 7) GU

Examination : Organ Systems

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Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN 55435 www.hcca-info.org | 888-580-8373

1997 Examination

Guidelines

EXAMINATION

1997 GUIDELINES

GENERAL MULTI-SYSTEM EXAMINATION

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Multi-system Examination

LEVEL OF EXAM PERFORM AND DOCUMENT

Problem Focused: One to five elements identified by a bullet.

Expanded Problem Focused: At least six elements identified by a bullet.

Detailed: At least two elements identified by a bullet from each of six areas/systems or at least 12 elements identified by a bullet in two or more areas/systems.

Comprehensive: Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine

areas/systems.

Medical Decision Making

• Number of diagnoses or management options

• Amount and/or complexity of data reviewed

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www.hcca-info.org | 888-580-8373 57 Medical Decision Making Number of dx or mgmt options Amount and/or

Complexity of data Overall risk

Minimal Low Moderate High Minimal/none Limited/low Moderate Extensive Minimal Limited Multiple Extensive

Medical Decision Making (MDM)

Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected Minimal

Insect bite, Cold, Tinea corpis EKG, Chest x-ray, KOH Urinalysis

Rest, Gargle, Bandages

Low

Cystitis, sprains, controlled DM,controlled BP

Pulmonary functions, BE, Skin biopsies

OTC drugs,PT, OT, IV fluids, minor surgery/no risk

Moderate

Lump in breast, colitis, pneumonia Arteriogram, lumbar puncture, endoscopies/no risk

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A government definition . . .

A service that is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.

Medical Necessity

• Be safe and effective

• No experimental

• Be cost effective

• Be appropriate

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A patient who has not received any professional

services from a physician or any other physician in the group within the past three years.

NEW vs. ESTABLISHED PATIENTS

History: Problem Focused

CC, Brief HPI

Examination: Problem Focused

Limited exam of affected body area or organ system

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History: Expanded Problem Focused

CC, Brief HPI, Problem pertinent ROS

Examination: Expanded Problem Focused

Limited exam of affected body area or organ system and other related or symptomatic organ systems

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

LEVEL II• 99202 New

History: Detailed

CC, Extended HPI, Extended ROS, PFSH-1

Examination: Detailed

Extended exam of the affected body area(s) or organ system(s) and other related organ systems

Medical Decision Making: Low

Limited, Limited, Low

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History: Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: Moderate

Multiple, Moderate, Moderate

LEVEL IV• 99204 New

History: Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

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www.hcca-info.org | 888-580-8373 67 Generally, no actual physician involved in care

Visit of 5 minutes or less

LEVEL I • 99211 Established

History: Problem Focused

CC, Brief HPI

Examination: Problem Focused

Limited exam of affected body area or organ system

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

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History: Expanded Problem Focused

CC, Brief HPI, Prob. Pertinent ROS

Examination: Expanded Problem Focused

Limited exam of affected body area or organ system and other related or symptomatic organ systems

Medical Decision Making: Low

Limited, Limited, Low

LEVEL III • 99213 Established

History: Detailed

CC, Extended HPI, Extended ROS, PFSH -1

Examination: Detailed

Extended exam of the affected body area(s) or organ system(s) and other related organ systems

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History: Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: High

Extensive, Extensive, High

LEVEL V • 99215 Established

A consultation is a service provided for the purpose of obtaining an

opinion or advice

regarding evaluation and treatment of a patient at the request

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www.hcca-info.org | 888-580-8373 73 Three R’s of a Consult 1. Request 2. Render an opinion 3. Report

CONSULTATIONS

Request must be documented in the medical records of both the requesting physician and the consultant.

No designation between a new or established patient.

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OFFICE CONSULTATION • 99241

History: Problem Focused

CC, Brief HPI

Examination:Problem Focused

Limited exam of affected body area or organ system

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

OFFICE CONSULTATION • 99242

History: Expanded Problem Focused

CC, Brief HPI, ROS-Problem Pertinent

Examination: Expanded Problem Focused

Limited exam of affected body area or organ system and other symptomatic or related organ system (s)

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OFFICE CONSULTATION • 99243

History: Detailed

CC, Ext. HPI, ROS-Ext., PFSH-Pertinent

Examination: Detailed

Extended exam of affected body area or organ system and other symptomatic or related organ system (s)

Medical Decision Making: Low

Limited, Limited, Low

OFFICE CONSULTATION • 99244

History: Comprehensive

CC, Brief HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: Moderate

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History: Comprehensive

CC, Brief HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: High

Extensive, Extensive, High

OFFICE CONSULTATION • 99245

History:Detailed / Comprehensive

CC, Extended HPI, Extended ROS, PFSH--1

Examination:Detailed / Comprehensive

Extended exam of the affected body area(s) or organ system(s) and other related organ systems

Medical Decision Making: Straightforward /Low

Minimal, Minimal, Minimal

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History:Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH-3 areas

Examination:Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: Moderate

Multiple, Moderate, Moderate

INITIAL HOSPITAL CARE • 99222

History:Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH-3 areas

Examination:Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: High

Extensive, Extensive, High

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History:Problem Focused

CC, Brief HPI

Examination:Problem Focused

Limited exam of affected body area or organ system

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

SUBSEQUENT HOSPITAL CARE • 99231

History: Expanded Problem Focused

CC, Brief HPI, ROS-Problem Pertinent

Examination: Expanded Problem Focused

Limited exam of affected body area or organ system and other symptomatic or related organ system (s)

Medical Decision Making: Moderate

Multiple, Multiple, Moderate

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History:Detailed

CC, Extended HPI, Extended ROS, PFSH -1

Examination:Detailed

Extended exam of the affected body area(s) or organ system(s) and other related organ systems

Medical Decision Making: High

Extensive, Extensive, High

SUBSEQUENT HOSPITAL CARE • 99233

Report the

total duration of time

spent by a physician for final

hospital discharge of a patient.

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Patient who is admitted as an inpatient and discharged on the same date, should notuse codes 99238 and 99239.

Use codes 99234-99236.

HOSPITAL DISCHARGE CODES

99238 - Hospital Discharge

Discharge of patient requiring 30 minutes

or less

99239 - Hospital Discharge

Discharge of patient requiring greater than

30 minutes

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• FINAL EXAMINATION

• DISCUSSION OF HOSP STAY

• INSTRUCTIONS TO CAREGIVERS

• PREPARATION OF DISCHARGE RECORDS

• PRESCRIPTIONS • REFERRALS

COMPONENTS OF DISCHARGE

History:Problem Focused CC, Brief HPI • Examination:Problem Focused

Limited exam of affected body area or organ system

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

INITIAL INPATIENT

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History: Expanded Problem Focused

CC, Brief HPI, ROS-Problem Pertinent

Examination: Expanded Problem Focused

Limited exam of affected body area or organ system and other symptomatic or related organ system (s)

Medical Decision Making: Straightforward

Minimal, Minimal, Minimal

INITIAL INPATIENT

CONSULTATIONS • 99252

History: Detailed

CC, Ext. HPI, ROS-Ext., PFSH-Pertinent

Examination: Detailed

Extended exam of affected body area or organ system and other symptomatic or related organ system (s)

Medical Decision Making: Low

Limited, Limited, Low

INITIAL INPATIENT

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History:Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: Moderate

Multiple, Moderate, Moderate

INITIAL INPATIENT

CONSULTATIONS • 99254

History:Comprehensive

CC, Extended HPI, Complete ROS, Complete PFSH

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making:High

Extensive, Extensive, High

INITIAL INPATIENT

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History: Detailed/Comprehensive

CC, Ext. HPI, ROS-Ext., PFSH-Pertinent

Examination: Detailed/Comprehensive

Extended exam of affected body area or organ system and other symptomatic or related organ system (s)

Medical Decision Making:Straightforward/Low

Minimal, Minimal, Minimal

HOSPITAL OBSERVATION

INPATIENT CARE SERVICES 99234

History: Comprehensive

CC, Ext. HPI, ROS-Complete, PFSH-Complete (3)

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

HOSPITAL OBSERVATION

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History: Comprehensive

CC, Ext. HPI, ROS-Complete, PFSH-Complete (3)

Examination: Comprehensive

Complete Single Sys. Specialty/Complete Multi-system

Medical Decision Making: High

Extensive, Extensive, High

HOSPITAL OBSERVATION

INPATIENT CARE SERVICES 99236

Alice Anne Andress, CCS-P, CCP

Director of Physician Services Parente Randolph, LLC

215.230.4240

aandress@parentenet.com

Susan K. Parker

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