E/M Documentation: Deal or No Deal? Documentation Guidelines. Documentation Elements 3/25/2013

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E/M Documentation:

Deal or No Deal?

Presented by Maggie Mac, CPC, CEMC,

CHC, CMM, ICCE and Dennis Mihale, MD

Documentation Guidelines

• 1995 vs 1997 guidelines – ’95 for ___?____ – ’97 for ___?____ • General Multi-System? • Specialty specific? • Mix and match?

– HPI~ 3 chronics/status • Systems vs. Areas

Documentation Elements


– Using check off boxes to validate HPI obtained by staff

• Reference to: – Previous ROS/PFSH

– “Changes as noted on form”, “unchanged” – “Previous examination

– Remaining ROS – “All others negative” • PFSH – “non-contributory”,

“unremarkable”, negative (for what?) • History unobtainable (why?)


Documentation Elements (Cont.)

• Medical Decision Making

– No diagnosis

– Unclear diagnosis – HA, HTN, DM – No status

– Medical necessity for diagnostic tests (rule-outs ok – but not on claim form!) – No plan of care/follow-up treatment – Failure to document prescriptions

prescribed or sample prescription drugs given to patient

Documentation Elements (Cont.)

• Inadequate capture of work process

– Failure to document ordered tests – Cold reading of films or tracings

• “Personal review” – Request of old records

– History obtained by… (what was it?) – Discussions with other providers – Review AND SUMMARY of old records

E/M Code Assignment

• “All of my new patients are consults”

• Preventive vs. Problem – ABN?

• Cluster coding – Fear of the “F” word – Confusion


E/M Code Assignment (Cont.)

Modifier misuse/abuse

– High risk modifiers

– No documentation to support

NCCI Edits

– Unbundling

– No documentation to support

Per Medicare CERT Reports

• Billing an add-on code without the

primary surgical code

• Part of global surgery package (NCCI)

• Performing service out of scope of

practice specialty

• Name on official red, white & blue

Medicare card matches claim

• Invalid/missing referring provider

• Duplicate claims

Paper Templates

• Circles? Slash Marks? Straight Lines?

• Cross-outs?

• Check-offs?

• Boxes?

• Abnormals – no details

• Signature, date and LEGIBLE name of

provider with credentials


Incident-to/Shared Visits

• Shared Visits

– Inadequate use of NPP’s – Not understanding the rules

• Incident-to Visits

– Inadequate plan of treatment for NPP follow-up

– Not understanding the rules

• OIG Work Plan 2012 and 2013


• Counseling/Coordination of care –

total time, counseling time, details of counseling

• Prolonged services • Prolonged discharge • Critical care

Other Timed Non-E/M services • Physical therapy • Psychotherapy • Surgical complications • Infusions • Re-programming services

Critical Care

• Meeting definition of critically ill


• Time for critical care services

(minus separately billable services)

• Time with family?

• Teaching physician/Resident



Critical Definition

Critically ill or critically injured


A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical Care

• Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

• Critical care services encompass both treatment of “vital organ failure” and “prevention of further life threatening deterioration of the patient’s condition.”

Critical Care Time - Family

• Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

– a) The patient is unable or incompetent to

participate in giving a history and/or making treatment decisions, and


Documentation of Family Critical

Care Discussions

– For family discussions, the physician

should document:

• a. The patient is unable or incompetent to participate in giving history and/or making treatment decisions

• b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family",

Documentation of Family Critical

Care Discussions (Cont.)

• c. Medically necessary treatment

decisions for which the discussion was needed, and

• d. A summary in the medical record that supports the medical necessity of the discussion

– All other family discussions, no matter how

lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.

Critical Care Time

Teaching/Resident Physicians

• Teaching Physicians

– Time spent teaching may not be counted

towards critical care time.

– Time spent by the resident, in the

absence of the teaching physician, cannot be billed by the teaching physician as critical care or other time-based services

– Only time spent by the resident and


In-office Labs/Injections

• Performance but no results – Urine pregnancy test

– Urine dipstick w/wo microscopy – FOBT – billed on day reviewed – Hgb, HgbA1C, Blood Glucose – Wet prep

– Mono spot – Rapid Strept

• Injections – Drug, Amount, Lot #, expiration date, site, reactions

Electronic Medical Records

• Conflicts with ROS and patient history and/or presenting problem

• Name/date of individual entering information into electronic record

• Failure to document review of information obtained by ancillary staff (PFSH/ROS) • Electronic signature?

• Cloned records – OIG Work Plan 2012-2013

• “Over-documentation” – not medically necessary


• Danger to Physicians and Providers?

– Configured by vendors – Copy and Paste

– Importing previous information – Conflicting information


EMR Conflicting Data

• Example: CC: Patient presents today c/o chest pain

– HPI: Pt. denies C/P, SOB……. • Example: HPI: Patient noticed mild

pain, right calf X 1 week

– ROS: Pt. denies muscle or joint pain

EMR Cloning

• Full ROS every visit

• Comprehensive exam every visit

• Same HPI every visit

• Example: CC by nurse – “Nausea

and vomiting for 3 days

– Copied and pasted by nurse from prior visit every time

More examples

• Carryover of ROS/PFSH every visit

– Provider billed 99215 just to refill an Rx – Spoke to patient over the phone and

billed a 99215

• Patient seen in clinic for 4 visits over

a period of 5 months


Word for Word

• PFSH copied word for word for each


• ROS copied word for word for each


• PE copied word for word for each



• Listing every diagnosis that patient has

ever had on every encounter

• Unrelated diagnoses

• No longer valid diagnoses

• Not significant to the reason for the

encounter or presenting problems

• Not every co-morbidity was reviewed!


Compliance Oversight

• No compliance buy-in or vested interest – “I employ a certified coder”

– “My office manager handles it” – “We use an EMR system” • No plan

• Plan but not used • Plan but not effective • Plan overkill

• No preventive measures – internal/external

Compliance Oversight (Cont.)

• Providing resources – Continuing education

• For staff (both clinical and administrative) • Themselves

– Books, manuals, authoritative advice • Being inflexible

– “I’m a physician – not a coder” – “This is all ridiculous” – “This takes too much time” – “Too confusing”

• We agree, but not an option – GET HELP!


Maggie Mac






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