1Revised April 2011TUMG Compliance 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.

Revised April 2011 TUMG Compliance 2 Documenting an Outpatient Visit Overview of Basic Principles Before viewing, print the file: Documenting an Outpatient Visit which contains a handout and a quiz

3Revised April 2011TUMG 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: 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

4Revised April 2011TUMG 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.

5Revised April 2011TUMG Compliance This is the first of a 6-part series focused on documenting outpatient services. Part 1: Overview of Basic Principles Part 2: Documenting a History Part 3: Documenting an Exam Part 4: Documenting Medical Decision Making Part 5: Time-Based Codes Part 6: Linking to Resident Notes

6Revised April 2011TUMG Compliance TUMG Physicians are responsible for documenting their outpatient visits and selecting the level of service to be billed to the carrier.

7Revised April 2011TUMG Compliance Purpose of Presentation To provide information regarding documenting and selecting a level of service for outpatient visits 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. To provide links to source documents that will assist physicians in the understanding and application of documentation guidelines.

8Revised April 2011TUMG Compliance The WYSI-WYG Principle (WYSI-WYG) The WYSIWYG principle defines the relationship between documentation and level of service What You See Is What You Get Corollary: If it isn’t written, it didn’t happen, and it can’t be billed

9Revised April 2011TUMG Compliance Physician: I know the service is a Physician Note Chief Complaint Expanded History Detailed Exam Moderate Decision Making An understanding of Evaluation and Management Guidelines, paired with the WYSI-WYG Principle, greatly reduces the potential for Level of Service – Documentation Mismatches Reviewer/Coder: I see a 99202

10Revised April 2011TUMG 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?

Revised April 2011 TUMG Compliance 11 Physician Note Chief Complaint History Exam Medical 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. Decision Making Exam History It’s a matter of writing and/or dictating…

12Revised April 2011TUMG Compliance To insure that documentation supports the level of service: Understand and apply General Principles of Medical Record documentation Understand and apply General Principles of Medical Record documentation Understand and apply Evaluation and Management documentation guidelines click here: (jump to slide 18) Understand and apply Evaluation and Management documentation guidelines click here: (jump to slide 18)click hereclick here Link to other supporting documentation (resident notes, staff notes, patient questionnaires) 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

13Revised April 2011TUMG Compliance To insure that Medical Necessity is established a note should contain A clearly stated chief complaint click here A clearly stated chief complaint click hereclick hereclick here A clearly stated diagnosis(es) or, in absence of a diagnosis, signs and symptoms 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 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

14Revised April 2011TUMG 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… Note 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.

15Revised April 2011TUMG Compliance Need More Information? The TUMG Compliance Educator / Audit Specialist is available to any physician/section/department that would like further information on outpatient documentation guidelines or other compliance topics. Contact: Sue Straumanis, CPC, CHC Phone:

Revised April 2011 TUMG Compliance 16 End of Presentation To Earn Compliance Credit: Complete and Sign the “Documenting an Outpatient Visit” Quiz Fax to:

17Revised April 2011TUMG 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” This is usually stated in the patient’s own words. Source: Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Healthcare Professionals. 11 th Edition – Oct. 2009, pg Corollary: The Chief complaint cannot be inferred. Click here to return to main presentation Click here to return to main presentation

18Revised April 2011TUMG 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 New Patients OR Initial Consults, the Physician must MEET or EXCEED documentation requirements for three of three E/M Components History History Exam Exam Medical Decision Making 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/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

19Revised April 2011TUMG 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. Medical Decision Making must always be one of the two components when determining level of service to ensure medical necessity is being met.

20Revised April 2011TUMG 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 Problem- focused Straight forward ExpandedExpanded Straight- forward DetailedDetailedLow ComprehensiveComprehensiveModerate ComprehensiveComprehensiveHigh 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?

21Revised April 2011TUMG 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 Problem-focusedProblem-focused Straight forward ExpandedExpandedStraight-forward DetailedDetailedLow ComprehensiveComprehensiveModerate ComprehensiveComprehensiveHigh With new patients or consults, the LOWEST of the three E/M key components documents determines the level of service. In this case, a or

22Revised April 2011TUMG 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 N/AN/AN/A Problem- Focused Straight-forward Exp. Problem- Focused Low DetailedDetailedModerate ComprehensiveComprehensiveHigh A physician note documents a detailed History, expanded Exam and Moderate Medical Decision Making. What established patient code is supported by the documentation?

23Revised April 2011TUMG 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 N/AN/AN/A Problem- Focused Straight-forward Exp. Problem- Focused Low DetailedDetailedModerate ComprehensiveComprehensiveHigh 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 *Click here to return to main presentation*Click here to return to main presentation*