Documenting Patient Care

Objectives Identify the components and rules for choosing the levels of Evaluation and Management (E/M) services Learn how chronic conditions can count as part of History Discover keys to documenting creditworthy examinations Practice creating compliant notes Apply principles to specific practice samples www.reimbursementspecialist.com

Components of E/M Services History Physical Exam Medical Decision Making Counseling Coordination of Care Time Nature of Presenting Problem www.reimbursementspecialist.com

Elements of History CC HPI ROS PFSH Chief complaint Usually in the patient’s words, this establishes “medical necessity” HPI History of Present Illness Chronological description of the development of the patient’s present illness from first sign and/or symptom ROS Review of systems PFSH Past Medical, Family, and Social History www.reimbursementspecialist.com

Elements of HPI Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms www.reimbursementspecialist.com

Elements of HPI (cont.) Location Duration Severity Where the problem is occurring Often the same as the chief complaint Specific descriptors (e.g., rt leg, chest, frontal) – Words like “systemic” are questionable Duration How long the patient has had the problem Includes specific and non-specific descriptors (e.g., 3 hours, couple of days, several months, since June) – Don’t use very generic terms like “a long time” Severity How bad is the condition or disease Use words like severe, uncontrolled, improving If you choose to use specific rating or pain on a scale of 1 – 10, get a point of reference from the patient www.reimbursementspecialist.com

Elements of HPI (cont.) Quality Context Timing Descriptive terms that further define the condition e.g., Raised, itchy, productive, supporative Context Circumstances under which the condition occurred e.g., At work, while walking, when lying down Timing Time of the day or other associated timing e.g., After meals, every morning www.reimbursementspecialist.com

Elements of HPI (cont.) Modifying Factors Things the patient has done to improve the condition e.g., Took aspirin, previous prescription, surgery or hospitalizations, put feet up Doesn’t matter if effort was successful or not Associated Signs and Symptoms Additional problems that may be related to the chief complaint www.reimbursementspecialist.com

Alternative HPI Can be current status of three chronic illness e.g., Hypertension, CHF, COPD, Diabetes Must be reason for visit 1 – 2 illness is brief HPI 3 is extended HPI www.reimbursementspecialist.com

Review of Systems Current status of various body systems 14 systems can be reviewed Listed in CPT “Evaluation and Management Services Guidelines” page 8 Review may be positive or negative e.g., Patient has frequent headaches e.g., Patient denies vision change Similar to “Associated Signs and Symptoms ROS can be gleaned from anywhere in your documentation www.reimbursementspecialist.com

Elements of ROS Constitutional Eyes Ears, Nose, Mouth, Throat Weight loss, general health Eyes Changes of vision, discharge, tearing Ears, Nose, Mouth, Throat Hearing, pain, dryness, hoarseness, drainage Cardiovascular Chest pain, irregular heartbeats, edema Respiratory Shortness of breath, wheezing, cough, orthopnea www.reimbursementspecialist.com

Elements of ROS (cont) Gastrointestinal Genitourinary Musculoskeletal Constipation or diarrhea, heartburn, pain, vomiting Genitourinary Incontinence, burning, itching, genital rashes, initial onset of menses Musculoskeletal Pain, stiffness, strength Integumentary Rashes, sores, changes in hair or nails Neurological Dizziness, loss of sensation, weakness, seizures, pain www.reimbursementspecialist.com

Elements of ROS (cont.) Psychiatric Endocrine Hematologic/Lymphatic Mental status changes, nervousness, confusion, fear Endocrine Change in blood sugar levels, dehydration Hematologic/Lymphatic Swelling, fatigue, bleeding, bruising, varicose veins Allergic/Immunologic Swelling, rashes, frequency of infections www.reimbursementspecialist.com

Level of ROS 1 system reviewed 2 – 9 systems reviewed Problem Pertinent ROS 2 – 9 systems reviewed Extended ROS 10 or more systems reviewed Complete ROS www.reimbursementspecialist.com

PFSH Past Medical History Family History Social History Previous diseases, hospitalizations, surgeries, medications, allergies Family History Significant medical history of family members including cause of death and hereditary illnesses Social History Marital status, living arrangements, employment, smoking, drinking, drug use www.reimbursementspecialist.com

Level of PFSH One element only Two or three elements Pertinent PFSH Two or three elements Complete PFSH Two elements for codes for established patients or subsequent visits All three elements required for new patients, initial visits, consults, etc. www.reimbursementspecialist.com

History When a physician selects a level of care and then discovers it to be overcoded, it is usually a deficiency in the documentation in the History section. That is because in selecting the level of History, all three of the components, HPI, ROS and PFSH, must be met at the level indicated to select a particular level of history. www.reimbursementspecialist.com

Selecting the level of History 3/3 99204 99205 99215 99201 99212 99202 99213 99203 99214 Problem Focused Expanded Problem Focused Detailed Comprehensive HPI Brief 1-3 Extended 4 or more ROS None Pertinent to problem 1 system 2-9 Complete 10 or more PFSH Pertinent 1 area 2 or 3 areas www.reimbursementspecialist.com

Without a Review of Systems (ROS) the highest possible code for a new patient is: 99201 established patient is 99212   Without a Past, Family, and Social History (PFSH) the highest possible code for a new patient is: 99202 established patient is 99213 www.reimbursementspecialist.com

Document at least 2 systems in your ROS making it an extended ROS. A good rule of thumb for the History of Present Illness (HPI) is to document at least 4 elements making it an extended HPI.   Document at least 2 systems in your ROS making it an extended ROS. Document at least 1 item in past, family or social history to get a pertinent PFSH. www.reimbursementspecialist.com

HISTORY The level of history you document serves as a foundation for your final selection of level of care. www.reimbursementspecialist.com

Example: History Dictation Patient in today with some pain. Does not feel good. Patient is accompanied by sister who states that she had to ask for the afternoon off to bring the patient in due to the pain. NO location, duration, quality, severity, timing, context, modifying factors, associated signs and symptoms, ROS, PFSH = NO Hx www.reimbursementspecialist.com

Example: History Dictated: Location Dictated: The patient in c/o abdominal pain since yesterday. 2 elements of History of Present Illness (HPI) noted = Brief HPI No Review of Systems. No Past, Family, Social History. History requires that all three be met in order to select a level of History. This is a PROBLEM FOCUSED History. Duration www.reimbursementspecialist.com

Example: History Dictation Location Dictation The patient in c/o abdominal pain since yesterday. Patient states it is a burning sensation and places pain level at a six out of ten. 4 Elements of HPI. No ROS. No PFSH. Still a PROBLEM FOCUSED History. You can’t get any higher without a review of systems (ROS). duration quality severity www.reimbursementspecialist.com

Example: History Dictation location Dictation The patient in c/o abdominal pain since yesterday. Patient states it is a burning sensation and places pain level at a six out of ten. ROS negative for GI and otherwise significant for palpitations 2 years ago. No one else in the family has any symptoms. The additional 2 items of ROS and 1 PFSH make this a DETAILED History. duration quality severity www.reimbursementspecialist.com

Elements of HPI Extended or Brief? HPI: Mary Smith was seen in my clinic today on referral by Dr. Jones. She is a 46-year-old woman who presents with a right breast lump which she noticed on breast self exam 2 weeks ago. She performs breast exam monthly and has not noticed the lump previously. She states that the lump is quite firm and somewhat tender to touch. She denies weight loss or nipple discharge. 6 Elements of HPI: Location, context, duration, quality, severity, associated signs and symptoms www.reimbursementspecialist.com

ROS: She denies fever, visual changes, sore throat, headaches, change in bladder or bowel habits, shortness of breath, or chest pain. She has had some menstrual irregularity this year that her gynecologist attributes to onset of menopause. She has also noticed some swollen lymph nodes in her neck and axillary regions. She has no other current problems. 9 Elements of ROS: Constitutional, eye, ENT, neurologic, GU, GI, respiratory, CV, lymph www.reimbursementspecialist.com

Patient unable to give History Some patients can’t provide history Unconscious Intubated Mentally ill Mentally retarded Certain illnesses (e.g., Alzheimers) Intoxication Document any known information from other sources EMTs or family, etc. Document reason patient unable to give history www.reimbursementspecialist.com

Physical Examination The physical examination will play itself out based on the Nature of the Presenting Problem (NPP). It is good medical practice to limit the examination of a patient with the complaint of a sore throat to that specific system. In contrast, the examination on a woman in her child-bearing years complaining of abdominal pain may warrant an examination of several systems. www.reimbursementspecialist.com

Nature of Presenting Problem (NPP) Be guided by the NPP and your good judgement in deciding the extent of the physical examination. www.reimbursementspecialist.com

Physical Examination Dictated: “Vitals stable.” = NO CREDIT Dictated: “HEENT normal.” = NO CREDIT Dictated: “Abdomen benign.” = NO CREDIT Dictated: “Neck benign.” = NO CREDIT None of the above hit on any of the bullet points in the Multi-system or Single Organ System Examinations. See E&M Guidelines pages 14 & 15 www.reimbursementspecialist.com

Physical Examination Dictated: “Vitals stable.” = NO CREDIT Rather: “Temperature 98.1; pulse 108; Respiratory rate 24.” Counts for 1 Bullet. (CONSTITUTIONAL) Dictated: “HEENT normal.” = NO CREDIT Rather: “Tympanic membranes within normal limits. Oropharynx is clear.” Counts for 2 Bullets. (HEENT) Dictated: “Abdomen benign.” = NO CREDIT Rather: “No organomegaly, masses or bruits.” Counts for 3 Bullet. (ABDOMEN) Dictated: “Neck benign.” = NO CREDIT Rather: “Supple, no adenopathy or thyromegaly.” Counts for 2 Bullets (NECK). www.reimbursementspecialist.com

① ② PE: VS: wt 138 lbs, t 98.2, p 66, r 16 bp 110/70. Genl: NAD HEENT: EOMI, PERRLA. Anicteric. Oropharynx clear. TMs intact canals clear bilat. Neck: Supple w/thyromegaly, cervical node enlargement. Chest: Clear to auscultation. Heart: RRR. Abdomen: Non-tender and nondistended, no masses, rebound or guarding. Extremities: No cyanosis, clubbing or edema. ③ ④ ⑤ ⑥ ⑦ ⑨ ⑧ ⑩ ⑪ ⑫ ①①① ⑬ ⑭ www.reimbursementspecialist.com

Level of Examination 14 bullets = Detailed Examination www.reimbursementspecialist.com

How many bullets does it take? Document 5 or less bullets and it is a Problem Focused Examination. (PF) Document at least 6 bullets and you’ve achieved an Expanded Problem Focused Examination. (EPF) Document at least 12 bullets and you’ve achieved a Detailed Examination. (DET) www.reimbursementspecialist.com

Components of Medical Decision Making Diagnoses and Treatment Options Complexity of Data Reviewed Risk presenting problem diagnostic procedures ordered management options selected www.reimbursementspecialist.com

Number of Diagnoses or Management Options Assessment, clinical impression, or diagnosis Initiation of, or changes in, treatment Referrals made, consultations requested or advice sought www.reimbursementspecialist.com

Medical Decision Making: 1) Diagnoses just mentioning a condition is not enough, make an assessment for it to count. Example 1: HTN Improved Example 1: HTN well controlled with medication Example 2: DM Improved Example 2: DM controlled through diet and exercise www.reimbursementspecialist.com

Medical Decision Making: 1) Management Options In your Plan section, indicate how the problems are being addressed: Example 1: ‘will cover options with patient’ Improved Example 1: patient is being referred to physical therapy www.reimbursementspecialist.com

Number of Presenting Problems Patients may present with many problems Only count problems being addressed today Include co-morbid conditions and complications Count problems not being treated but which may have an impact on the treatment Information may be found in Chief Complaint History of Present Illness Review of Systems Past Medical History Assessment www.reimbursementspecialist.com

Complexity of Presenting Problem Problem self-limited or minor Problems that would resolve without medical care Problem is stable or improving Stable for chronic illnesses that are controlled Improved for acute illnesses that are getting better Problem is worsening Chronic illnesses that are uncontrolled or poorly controlled or that are progressing Acute illnesses that are not responding to treatment Relapses www.reimbursementspecialist.com

New or Established Problem New Problems Problems that this provider has not seen before in this patient Patient may have been treated by another provider Patient may have had the condition for a long time If patient has been seen for this problem by another provider in this group, problem is established Established Problems Problems already being treated by this provider www.reimbursementspecialist.com

Management Options New problem with additional work-up planned Additional workup includes Laboratory studies Radiology studies Medicine studies Consults www.reimbursementspecialist.com

Medical Decision Making: 2) Data Reviewed itemize lab results in your documentation – "WBC elevated" or "chest x-ray unremarkable“ mention reviewing x-ray films brought in by patient www.reimbursementspecialist.com

Medical Decision Making: 2) Data Ordered note labs ordered and reason for ordering to establish Medical Necessity rationale must be evident note all diagnostic procedures ordered and the reason for ordering must provide support in dictation as well as the order document www.reimbursementspecialist.com

Medical Necessity Link diagnoses and procedures by putting a small number in a circle next to the procedure and the same number next to its corresponding diagnoses Order documents for labs, x-rays and other ancillaries can also be approached in the same way See example of fee ticket: last tab in your handout ① ① www.reimbursementspecialist.com

Medical Decision Making: 3) RISK This is not something you write out such as “this was a high risk visit”… This is derived from the entire note based on your documentation of the presenting problem, all diagnostic procedures ordered and your mention of the planned management options www.reimbursementspecialist.com

RISK Risk associated with the presenting problem Risk associated with any diagnostic tests ordered or performed Risk associated with any treatment option selected Use Table of Risk to choose a level pg 50 The auditor will be using this table in deciding the level risk for the visit www.reimbursementspecialist.com

Level of Risk If risk of… presenting problem, diagnostic procedures, and management options are of different levels, pick the highest one Your highest level of risk is your overall RISK Information in Table of Risk is example Although you may not refer to the table of RISK everytime you see a patient, this provides a primer or introduction to this very component www.reimbursementspecialist.com

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Selecting level of MDM 2/3 99201 99202 99212 99203 99213 99204 99214 99205 99215 Straightforward Low Moderate High # of Diagnostic and Management Options 1 2 3 4 Amt of Data to be Reviewed Risk Min(1) Low(2) Mod(3) High(4) www.reimbursementspecialist.com

Assessment and Plan: Signs & Symptoms Risk: Moderate; (acute illness with system symptoms) Differential diagnoses not codeable New problem additional workup planned Assessment: Patient with nausea and vomiting for 12 hours. Food poisoning vs. allergic reaction vs. viral infection. She is also dehydrated and exhausted but unable to sleep. Plan: We will start an IV and also give her something to relieve her nausea. We will continue to watch her to see if this will improve the situation and we may give her some Benadryl if she shows further signs of allergic reaction. We will also get a CBC and electrolyte panel. We will hold her here in the clinic until she is stabilized or we may have to admit her if this does not help her. Mgmt option Data ordered Medical Decision Making: MODERATE www.reimbursementspecialist.com

Selecting a Level of Care Step one: Is patient NEW or ESTABLISHED Step two: What kind of services is it? Outpatient / Inpatient / ER / Consultation / OTHER Step Three: Evaluate levels of History, Examination and Medical Decision Making Step Four: Select the level care taking care that the right number of components are met for the type of visit at hand. www.reimbursementspecialist.com

Adding the Three Key Components History Examination Medical Decision Making New Patient 3/3 Established Patient 2/3 Should always include MDM www.reimbursementspecialist.com

New Patient 3/3 Consultation 3/3 History Problem Focused Expanded Problem Focused Detailed Comprehensive Examination Medical Decision Making Straightforward Low Moderate High Level of Care 99201 99241 99202 99242 99203 99243 99204 99244 99205 99245 www.reimbursementspecialist.com

Established Patient 2/3 History Minimal Problem that may not require the presence of a physician Problem Focused Expanded Problem Focused Detailed Comprehensive Examination Medical Decision Making Straightforward Low Moderate High Level of Care 99211 99212 99213 99214 99215 www.reimbursementspecialist.com