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
• HPI
– 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
Time
• 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
patient
• Time for critical care services
(minus separately billable services)
• Time with family?
• Teaching physician/Resident
physician
Critical Definition
•
Critically ill or critically injured
patient
– 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 treatmentdecisions 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
EMR
• 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
patient
• ROS copied word for word for each
patient
• PE copied word for word for each
patient
MDM
• 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!
