Disclaimer This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur without the permission of Tulane University. Tulane University retains all intellectual property interests associated with the presentation. Tulane University makes no claim, promise, or guarantee of any kind about the accuracy, completeness, or adequacy of the content of the presentation and expressly disclaims liability for errors and omissions in such content. 1/12/2019 TUMG Compliance

Documenting an Outpatient Visit Overview of Basic Principles Before viewing, print the file: Documenting an Outpatient Visit which contains a handout and a quiz 1/12/2019 TUMG Compliance

Read Before Proceeding Physicians and Staff may earn one compliance credit by viewing this presentation, completing the assessment, and faxing the assessment to the HIPAA Compliance Office: 504-988-7777 This presentation may be viewed for compliance credit only once in a fiscal year (July 1 - June 30). To check to see how many compliance credits you have and to see which training sessions you have completed, contact the University Privacy and Contracting Office at 504-988-7739 1/12/2019 TUMG Compliance

It is the policy of TUMG to provide healthcare services that are in compliance with all state and federal laws governing its operations and consistent with the highest standards of business and professional ethics. Education for all TUMG physicians is an essential step in ensuring the ongoing success of compliance efforts. 1/12/2019 TUMG Compliance

This is the first of a 9-part series focused on documenting outpatient services. Part 6: Documenting Pre-Operative and Confirmatory Consults Part 7: Time-Based Codes Part 8: Linking to Resident Notes Part 9: Modifiers 24 and 25 Part 1: Overview of Basic Principles Part 2: Documenting a History Part 3: Documenting an Exam Part 4: Documenting Medical Decision Making Part 5: Documenting Consults 1/12/2019 TUMG Compliance

TUMG Physicians are responsible for documenting their outpatient visits and selecting the level of service to be billed to the carrier. 1/12/2019 TUMG Compliance

Purpose of Presentation To provide information regarding documenting and selecting a level of service for outpatient visits To provide links to source documents that will assist physicians in the understanding and application of documentation guidelines. Man’s mind, once stretched by a new idea, never returns to its original dimensions. Oliver Wendell Holmes 1/12/2019 TUMG Compliance

The WYSI-WYG Principle (WYSI-WYG) The WYSIWYG principle defines the relationship between documentation and level of service (LOS) What You See Is What You Get Corollary: If it isn’t written, it didn’t happen, and it can’t be billed 1/12/2019 TUMG Compliance

An understanding of Evaluation and Management Guidelines, paired with the WYSI-WYG Principle, greatly reduces the potential for Level of Service – Documentation Mismatches Physician: I know the service is a 99204 Reviewer/Coder: I see a 99202 Physician Note Chief Complaint Expanded History Detailed Exam Moderate Decision Making 1/12/2019 TUMG Compliance

Outpatient Visit Essentials 1) Documentation that supports the level of service billed Does the note contain all the elements required for the level of service selected? 2) Clearly established Medical Necessity Does the note provide a clear reason for the visit, and are the assessment and plan clearly related to the reason for the visit? 1/12/2019 TUMG Compliance

Medical Decision Making It’s a matter of writing and/or dictating… History Physician Note Chief Complaint History Exam Medical Decision Making Exam Decision Making To avoid “underdocumenting,” the physician’s note must reflect all the elements of History, Exam and Medical Decision Making performed for each outpatient encounter. 1/12/2019 TUMG Compliance

To insure that documentation supports the level of service: Understand and apply General Principles of Medical Record documentation Understand and apply Evaluation and Management documentation guidelines click here Link to other supporting documentation (resident notes, staff notes, patient questionnaires) Links to Documentation Resources (click on the link to open) 1995 General Principles of Medical Record Documentation 1997 General Principles of Medical Record Documentation Linking to resident notes and teaching physician guidelines 1/12/2019 TUMG Compliance

To insure that Medical Necessity is established a note should contain A clearly stated chief complaint click here A clearly stated diagnosis(es) or, in absence of a diagnosis, signs and symptoms A clearly stated or easily inferred rationale for ordering diagnostic or other ancillary services WORD OF CAUTION: The only instance where information can be inferred is for ordering diagnostic or other ancillary services. The chief complaint and the diagnosis cannot be inferred; they must be clearly documented 1/12/2019 TUMG Compliance

Auditors are not psychics I sense a complete review of systems…but the crystal ball is cloudy regarding a chief complaint and the exam… Medical Record Reviewers or Coders do not fill in gaps in a note. Each outpatient visit must stand alone. Reviewers will not look back at prior notes to support a level of service. Note 1/12/2019 TUMG Compliance

Need More Information? Contact: The TUMG Business Services Staff are available to any physician/section/department that would like further information on outpatient documentation guidelines or other compliance topics. Contact: TUMG Business Services 1/12/2019 TUMG Compliance

Complete and Sign the “Documenting an Outpatient Visit” Quiz End of Presentation To Earn Compliance Credit: Complete and Sign the “Documenting an Outpatient Visit” Quiz Fax to: 504-988-7777 1/12/2019 TUMG Compliance

Chief Complaint “The Chief Complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is reason for the encounter, usually stated in the patient’s own words.” Source: Medicare Resident and New Physician Guide, 7th edition, page 75, 2003. Corollary: The Chief complaint cannot be inferred. Click here to return to main presentation 1/12/2019 TUMG Compliance

Basics of E/M Coding – 6 slides The Meet or Exceed Principle New Patients OR Initial Consults, the Physician must MEET or EXCEED documentation requirements for three of three E/M Components History Exam Medical Decision Making Established Patients OR Follow-Up Consults, the Physician must MEET or EXCEED documentation requirements for two of three E/M Components. History/Exam History/Medical Decision Making Exam/Medical Decision Making There are six slides in this section of the presentation– at slide 6 there is a link to return to the main presentation 1/12/2019 TUMG Compliance

A word about Established Patient documentation Although Established Patient/Follow-Up Consult E/M level of service is based on two of three E/M components, that does not mean that the physician should not document elements of all three E/M components if the information is germane to the treatment of the patient. If all three key components are documented (History, Exam and Medical Decision Making), the LOWEST of the three components will be dropped and the level of service determined from the remaining two components. 1/12/2019 TUMG Compliance

New Patients – Selecting A Level of Service E/M Code and Visit Time (in minutes) 1- History of Present Illness 2 – Exam 3 – Medical Decision Making 99201-10 99241-15 Problem-focused Straight forward 99202-20 99242-30 Expanded Straight-forward 99203-30 99243-40 Detailed Low 99204-45 99244-60 Comprehensive Moderate 99205-60 99245-80 High A physician note documents a detailed History, expanded Exam and Moderate Medical Decision Making. What New Patient code or Consult code is supported by the documentation? 1/12/2019 TUMG Compliance

New Patients – Selecting A Level of Service E/M Code and Visit Time (in minutes) 1- History of Present Illness 2 – Exam 3 – Medical Decision Making 99201-10 99241-15 Problem-focused Straight forward 99202-20 99242-30 Expanded Straight-forward 99203-30 99243-40 Detailed Low 99204-45 99244-60 Comprehensive Moderate 99205-60 99245-80 High With new patients or consults, the LOWEST of the three E/M key components documents determines the level of service. In this case, a 99202 or 99242. 1/12/2019 TUMG Compliance

Established Patients – Selecting A Level of Service E/M Code and Visit Time (in minutes) 1- History of Present Illness 2 – Exam 3 – Medical Decision Making 992011-10 No Physician Required 99212-20 Problem-Focused Straight-forward 99213-15 Exp. Problem-Focused Low 99214-25 Detailed Moderate 99215-40 Comprehensive High A physician note documents a detailed History, expanded Exam and Moderate Medical Decision Making. What established patient code is supported by the documentation? 1/12/2019 TUMG Compliance

Established Patients – Selecting A Level of Service E/M Code and Visit Time (in minutes) 1- History of Present Illness 2 – Exam 3 – Medical Decision Making 992011-10 No Physician Required 99212-20 Problem-Focused Straight-forward 99213-15 Exp. Problem-Focused Low 99214-25 Detailed Moderate 99215-40 Comprehensive High With established patients, the LOWEST of the two highest E/M key components documented determines the level of service. In this case, documentation supports a level 99214. Click here to return to main presentation 1/12/2019 TUMG Compliance