Turn
"What's in it for me?"
into
"What's in it for us?"
Understanding physician reimbursement and its correlation to CDI
E&M DOCUMENTATION
A. DOCUMENTATION OVERVIEW
- General Principles
- Chief Complaint
- HPI
- PFSH
- ROS
- Physical Examination
- Medical Decision-Making
- Risk Table
- Discharge Encounter & Time Documentation
- Discharge Summary
- Critical Care Status and Time
- Critical Care Codes
- Non-Medicare Consultations
- Medicare Consultations
- Nursing Facility Services (SNF, Swing Bed, LTCF)
B. OBSERVATION
1. Observation Status and Order
2. Observation Codes
3. Condition 44
C. OTHER TIMED SERVICES
1. Prolonged Care 1st Hour and Additional 1/2 Hour(s)
2. Counseling and Coordination of Care (Time-Based Charges)
D. PRESENT ON ADMISSION
1. POA—Present-on-Admission Indicators
DOCUMENTATION GUIDELINES
Documentation is not just a record of a transaction between a provider and the patient. It is a:
• Means to monitor utilization and quality standards
• Means to collect data for research and education
• Legal document in professional liability suits
• Means to support the claims for payment by third-party payers
• Means of communication and continuity of care among physicians and other healthcare professionals involved in the patient's care
A physician's documentation should provide a coder, a fellow provider, the patient, a third-party payer, an auditor, a lawyer, or even a judge with the following answers:
• Is the reason for the patient encounter documented in the medical record?
• Are all the services you provided documented?
• Does the medical record clearly and accurately explain why support services, procedures, and/or supplies were prescribed?
• Is the assessment of the patient's condition apparent in the medical record?
• Does the medical record contain information on the patient's progress and treatment results?
• Does the medical record include a plan of treatment for the patient?
• Does the information in the medical record describing the patient's condition provide reasonable medical rationale for the services and the choice of setting that is to be billed?
• Does the information in the medical record support the care given in the event that another healthcare professional must assume the patient’s care or perform a medical review?
GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
• The medical record should be complete and legible.
• The documentation of EACH patient encounter should include:
o Reason for the encounter, relevant history, physical examination findings, and prior diagnostic test results
o Assessment, clinical impression, or diagnosis
o Plan for care
o Date and legible identity of the observer
• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
• Past and present diagnoses should be accessible to the treating and/or consulting physician.
• Appropriate health risk factors should be identified.
• The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
• The CPT and ICD-9-CM codes reported on the billing statement should be supported by the documentation in the medical record.
MEDICAL DECISION-MAKING
Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
- The number of possible diagnoses and/or the number of management options that must be considered
- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed
- The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options
The four levels of decision-making are:
- Straightforward
- Low complexity
3. Moderate complexity
- High complexity
There are three elements considered for each level of 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
DESCRIPTION OF ELEMENTS
NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS
The number and types of problems addressed during the encounter will dictate the number of possible diagnoses and/or management options. There will be diagnosed and undiagnosed problems.
Generally, decision-making with respect to a diagnosed problem is easier than that for an undiagnosed problem. The number and type of diagnostic tests may be an indicator of the number of possible diagnoses.
Problems that are improving or resolving are less complex than those that are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity or management problems.
For each encounter, whether explicitly stated or implied in documentation, the following must be addressed in management plans and/or further evaluation:
o Assessment
o Clinical impression
o Diagnosis
PROBLEM WITH DIAGNOSIS
For a presenting problem with an established diagnosis, the record should reflect whether the problem is:
a) Improved, well controlled, resolving, or resolved
b) Inadequately controlled, worsening, or failing to change as expected
PROBLEM WITHOUT DIAGNOSIS
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated as:
a) A differential diagnosis
b) A possible, probable, or rule-out (R/O) diagnosis
The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom the advice is requested.
AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Below are areas of review and order that increase the amount and/or complexity:
- Documentation of a diagnostic service (test or procedure) ordered, planned, scheduled, or performed at the time of the encounter (e.g., lab, x-ray).
- Documentation of review of lab, radiology, and/or other diagnostic test. Documentation of “WBC elevated” or “chest x-ray unremarkable” is acceptable.
3. Documentation of a decision to obtain old records.
- Documentation to obtain additional history from the family, caretaker, or other source to supplement that obtained from the patient.
- Relevant finding from the review of old records and/or receipt of the additional history from the family, caretaker, etc., should be documented. A notation of "old records reviewed" or "additional history obtained from family" without elaboration is insufficient.
- The results of discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.
- The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.
RISK OF SIGNIFICANT COMPLICATIONS & MORBIDITY
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problems, the diagnostic procedures, and the possible management options.
· Comorbidities/underlying diseases or other factors that increase the complexity of medical decision-making by increasing the risk of complications, morbidity, and/or mortality should be documented.
· If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure (e.g., laparoscopy) should be documented.
· If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure should be documented.
· The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied.
· The Risk Table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high.
· Because the determination of risk is complex and not readily quantifiable, the table includes common, clinical examples rather than absolute measures of risk.
The assessment of the risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.
The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.
THE HIGHEST LEVEL OF RISK IN ANY ONE CATEGORY (presenting problems, diagnostic procedures, or management options) DETERMINES THE OVERALL RISK.
** SEE RISK TABLE