DEPARTMENT: Health Information Management Services / POLICY DESCRIPTION: Coding Documentation for Outpatient Services
PAGE: 6 of 11 / REPLACES POLICY DATED: 7/14/97, 3/6/98, 4/16/99
APPROVED: May 9, 2000 / RETIRED:
EFFECTIVE DATE: August 1, 2000 / REFERENCE NUMBER: HIM.COD.002
SCOPE: All personnel responsible for performing, supervising or monitoring coding of outpatient services including, but not limited to:
Corporate Health Information Management Services Administration
Facility Health Information Management Resource Management
Case Management/Quality Resource Management Emergency Department
Registration/Admitting/ Scheduling Ancillary Departments
Ethics and Compliance Officer Laboratory Department
External Coding Contractors Radiology Department
Ambulatory Surgery Center/Business Office/Medical Records Physician Advisors
Business Office/Centralize Business Office/Medicare Service
Center/Financial Service Center/Revenue Service Center
Internal Audit & Consulting Services
This policy applies to diagnostic and procedural coding and reporting of outpatient services. Examples of these services include, but are not limited to, outpatient visits and outpatient referrals for laboratory, radiology, cardiology, cardiopulmonary and other diagnostic testing; laboratory testing performed on referred specimens only; observation services; emergency care; and ambulatory surgery performed in either a freestanding or hospital-based ambulatory surgery center (ASC). This policy does not apply to physician office or home health services. For inpatient services, refer to the Coding Documentation for Inpatient Services Policy, HIM.COD.001.
PURPOSE:
To ensure minimal variation in coding practices and the accuracy, integrity and quality of patient data, and improve the quality of the documentation within the body of the medical record to support code assignment.
The Company’s commitment to data integrity is documented in Attachment A.
POLICY:
The Company will follow the current guidelines for outpatient diagnosis coding and reporting published in AHA Coding Clinic, 4th quarter, 1995, or the most current AHA Coding Clinic Guidelines.
The Company will apply the Current Procedural Terminology (CPT) coding conventions and general guidelines as published by the AMA for surgical and diagnostic procedure coding.
Insurance carrier and state reporting requirements should be followed when reporting procedure codes from the ICD-9-CM Volume 3 for diagnostic and surgical procedures.
HCFA mandates the utilization of Level I (CPT) and Level II (National Medicare) HCPCS codes for Medicare patients. Level III HCPCS codes are created and maintained by the local Medicare carriers. It should be noted that Level III HCPCS codes may override Level I or Level II codes, therefore, it is critical to follow local carrier coding policies and procedures.
Definition(s):
Allied Health Professional (AHP): Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually-granted clinical privileges by the facility’s Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Coding: Coding is a function by which there is an assignment of a numeric or an alphanumerical classification to identify diagnoses and procedures. These classifications or “codes” are assigned based upon a review of the source document (medical record). The classifications utilized for this purpose include: ICD-9-CM (International Classification of Disease – 9th edition – Clinical Modification); CPT-4 (Current Procedural Terminology) or HCPCS Level II or III (HCFA Common Procedure Coding System).
PROCEDURE:
All individuals performing coding of outpatient services, including the above listed departments and facilities, must comply with the following:
- Basic Coding for Outpatient Service (ref: AHA Coding Clinic, 4th quarter, 1995)
The appropriate code or codes from 001.0 through V82.9 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting when an established diagnosis has not been diagnosed or confirmed by the physician. The documentation should describe the patient’s condition, using terminology that includes specific diagnoses or the symptoms, problems or reasons for the encounter.
The Company recognizes that there are unique payer coding and billing requirements. These requirements are addressed in section 4 of this policy.
a) The diagnosis, condition, problem, symptom, injury or other reason for the encounter or visit which is chiefly responsible for the services provided. This diagnosis is listed first for reporting purposes. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
b) Documented conditions that coexist at the time of the encounter or visit and require or affect patient care, treatment or management. Diagnoses that were previously treated and no longer exist should not be coded.
c) V Codes (V01.0 - V82.9) may be used to code encounters for circumstances other than a disease, symptom, problem or injury. For additional guidance on the use of V Codes, refer to AHA Coding Clinic, 4th quarter, 1996.
d) Codes must be reported using the maximum number of digits required for that code. Three or four digit codes may be used only when they are not further subdivided.
e) Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis.” Code the condition(s) to the highest degree of certainty for that encounter or visit, such as symptoms, signs, or other reason for the visit.
f) When only diagnostic services are provided during an encounter or visit, sequence first the symptom, sign, condition, problem or other reason for encounter or visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter or visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. Example: Complete blood count, liver profile for patient on methotrexate for rheumatoid arthritis. Assign codes V58.69, 714.0.
g) When only therapeutic services are provided during an encounter or visit, sequence first the diagnosis, condition, problem or other reason for encounter or visit shown in the medical record. The only exception is that the appropriate V code is listed first for patients receiving chemotherapy, radiation therapy or rehabilitation services followed by the problem or the diagnosis.
h) For patients receiving pre-operative evaluations only, sequence a code from category V72.8 to describe the pre-op services and code the reason for the surgery as an additional diagnosis. Also code any findings related to the pre-operative evaluation.
i) For routine and administrative examinations, (general check-up, school exam, child check, etc.) list, first, the appropriate V code for the examination. If a diagnosis or condition is discovered, it should be coded as an additional code.
j) For ambulatory surgery cases, code the diagnosis for which the surgery was performed. If the post-operative diagnosis is known to be different from the pre-operative diagnosis at the time the diagnosis is confirmed, code the post-operative diagnosis.
k) For cases in which the patient is admitted to inpatient services following outpatient surgery, apply UHDDS guidelines for principal diagnosis. Also code the reason for the outpatient surgery and the outpatient surgery procedure.
2. Outpatient Laboratory, Pathology, and Radiology Coding Issues (reference: AHA Coding Clinic, First Quarter, 2000).
The following information is intended to assist the coders and staff who perform the coding function to help clarify issues pertaining to outpatient laboratory, pathology and radiology coding issues:
a) In the outpatient setting, the pathologist or radiologist is a physician and if a diagnosis is made, it is appropriate to assign a code to identify the condition.
b) In the absence of physician interpretation of a test result or study, the coder should report the symptoms, signs or other reason for the visit.
3. Minimum Documentation Requirements for coding purposes
a) Absent specific exceptions (e.g., screening mammography) and consistent with Federal and state law, tests and services must be provided based on the order of physicians or allied health practitioners authorized by the medical staff bylaws, rules and regulations to order such tests and services.
b) It is acceptable for a resident to order a test provided the facility's medical staff bylaws, rules and regulations have granted residents the privilege of ordering tests.
c) It is acceptable for an allied health practitioner to order a test provided that the individual ordering the test or procedure has been granted privileges that encompass the specific item(s) ordered, and the medical staff bylaws, rules and regulations specify whether the item(s) ordered must be countersigned by a physician.
d) Orders do not need to be countersigned provided that the individual ordering the test or procedure has been granted privileges that encompass the specific item(s) ordered and the medical staff bylaws, rules and regulations specify that no countersignature by a physician is required.
e) The facility's medical staff bylaws, rules and regulations must define who can accept and document verbal orders.
f) The facility's medical staff bylaws, rules and regulations must define who can relay verbal orders and must be based upon state law of who is licensed to order.
g) Facilities may code and bill the account without an authenticated order; however, they need to eventually have the order authenticated. Authentication timeliness should be defined by medical staff bylaws, rules and regulations and enforced by hospital policy and procedure. Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations.
h) Each facility must follow medical necessity guidelines and only perform and charge for services which have been ordered by a qualified individual. The following outlines the required documentation to support complete test orders, coding and billing of outpatient services.
1. Outpatient Referrals (diagnostic lab, x-ray, etc.)
i) Documentation must include but, should not be limited to, as appropriate to the service:
(a) An authenticated physician or qualified health care professional order for services. Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations;
(b) A diagnosis or reason service was ordered;
(c) Test result, demographic information; and
(d) Signed consent for services (if required).
ii) Each facility must establish a system for retention of the required documentation, including documentation necessary to substantiate coding and billing of the service. This may be maintained either in a centralized location such as the Health Information Management (Medical Records) Department or in a de-centralized location such as the laboratory. Refer to the Records Management Policy, EC.014.
iii) Referred Specimens: Documentation for laboratory tests on referred specimens only, where there is no patient contact with the laboratory, must include, as appropriate to the service:
(a) An authenticated physician or qualified healthcare professional order for testing. Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations;
(b) Date and time of specimen collection;
(c) A diagnosis or reason for ordering each test; and
(d) Demographic information (if required).
iv) This documentation may be kept in a decentralized location such as the laboratory.
- Outpatient Visits
i) Documentation maintained must include, but should not be limited to, as appropriate to the service, an outpatient medical record that includes:
(a) An authenticated physician or qualified healthcare professional order for services (an order may not be required for certain services such as screening mammograms). Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations;
(b) Clinician visit notes;
(c) A diagnosis or reason the service was ordered;
(d) Test results;
(e) Therapies;
(f) A problem list;
(g) Medication list;
(h) Demographic information; and
(i) Required consents.
ii) Coding of the diagnosis must be completed using the medical record or encounter form that is completed by the provider at the point of service.
iii) Documentation in the medical record must support the diagnosis and CPT codes marked on the test requisition or order form or encounter form. It is important to review and update the ICD-9-CM and CPT codes on these forms at least annually. (Note: ICD-9-CM is updated each October, while CPT is updated each January).
iv) The documentation or source document referred to by the coder should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the service. Coders may assign diagnosis codes based on the reason for the referral. A specific diagnosis based on test results usually is not available and may not be available until after subsequent evaluations or physician visits.
3. Emergency Visits
i) Documentation maintained must include, but should not be limited to, as appropriate to the service, an emergency medical record that includes:
(a) Encounter Form;
(b) Required consents;
(c) Physicians emergency documentation;
(d) Nursing notes;
(e) Test results;
(f) Demographic information; and
(g) Treatment.
ii) Diagnosis and CPT surgical procedure codes (if applicable) are assigned by the coder based on the diagnosis and procedures recorded by the treating physician in the emergency room record.
iii) The physician’s or qualified healthcare professional’s emergency medical record documentation and test results are reviewed to assist in code assignment.
4. Observation Visits
i) Documentation must include but should not be limited to:
(a) A history and physical;
(b) Written progress notes;
(c) An authenticated physician order for placement in observation and for treatment. Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations;
(d) Clinical observations including the reason for observation services; and
(e) Final progress note or summary that includes the diagnosis and any procedures performed and treatment rendered.
ii) The observation unit medical record is reviewed by the coder to assist in the code assignment process.
5. Ambulatory Surgical or Diagnostic Procedural Services
i) As applicable, documentation maintained must include an ambulatory medical record that includes, but should not be limited to:
a) An authenticated physician/qualified health care professional order for services. Methods of authentication may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws, rules and regulations;