Documenting Patient Care Objectives n n Identify the

Documenting Patient Care

Objectives n n 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 n Physical Exam n Medical Decision Making n Counseling n Coordination of Care n Time n Nature of Presenting Problem n www. reimbursementspecialist. com

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

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

Elements of HPI (cont. ) n Location ¨ ¨ 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 n n Duration ¨ How long the patient has had the problem n 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” n Severity ¨ How bad is the condition or disease n n 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. ) n Quality ¨ Descriptive terms that further define the n e. g. , Raised, itchy, productive, supporative n condition Context ¨ Circumstances under which the condition n e. g. , At work, while walking, when lying down n occurred Timing ¨ Time of the day or other associated n e. g. , After meals, every morning www. reimbursementspecialist. com timing

Elements of HPI (cont. ) n Modifying Factors ¨ Things the patient has done to improve the condition n e. g. , Took aspirin, previous prescription, surgery or hospitalizations, put feet up ¨ n 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 n 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 n 3 is extended HPI n www. reimbursementspecialist. com

Review of Systems n Current status of various body systems ¨ 14 n systems can be reviewed Listed in CPT “Evaluation and Management Services Guidelines” page 8 ¨ Review may be positive or negative n e. g. , Patient has frequent headaches n 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 n Constitutional ¨ n Eyes ¨ n Hearing, pain, dryness, hoarseness, drainage Cardiovascular ¨ n Changes of vision, discharge, tearing Ears, Nose, Mouth, Throat ¨ n Weight loss, general health Chest pain, irregular heartbeats, edema Respiratory ¨ Shortness of breath, wheezing, cough, orthopnea www. reimbursementspecialist. com

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

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

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

PFSH n Past Medical History ¨ n Family History ¨ n Previous diseases, hospitalizations, surgeries, medications, allergies 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 n One element only ¨ Pertinent n 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 n 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 HPI 99201 99202 99203 99205 99212 99213 99214 99215 Problem Expanded Focused Problem Focused Brief 1 -3 ROS None PFSH None Detailed Comprehensive Extended 4 or more Pertinent to Extended Complete problem 2 -9 10 or more 1 system None Pertinent Complete 1 area 2 or 3 areas www. reimbursementspecialist. com

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

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

Example: History Dictation n 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. n NO location, duration, quality, severity, timing, context, modifying factors, associated signs and symptoms, ROS, PFSH = NO Hx www. reimbursementspecialist. com

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

Example: History Location Dictation n 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. n 4 Elements of HPI. No ROS. No PFSH. duration quality severity n Still a PROBLEM FOCUSED History. n You can’t get any higher without a review of systems (ROS). www. reimbursementspecialist. com

Example: History location Dictation duration n The patient in c/o abdominal pain since yesterday. Patient states it is a burning sensation and places pain level at a sixquality out of ten. ROS negative for GI and otherwise significant for palpitations 2 years ago. No one else in the family has severity any symptoms. n The additional 2 items of ROS and 1 PFSH make this a DETAILED History. 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 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 n Some patients can’t provide history ¨ ¨ ¨ n n 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 n 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) n Be guided by the NPP and your good judgement in deciding the extent of the physical examination. www. reimbursementspecialist. com

Physical Examination n n 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. n See E&M Guidelines pages 14 & 15 www. reimbursementspecialist. com

Physical Examination n n n n 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 ④ ⑥ ⑧ ⑪ ② PE: VS: wt 138 lbs, t 98. 2, p 66, r 16 bp 110/70. Genl: NAD HEENT: EOMI, ③ PERRLA. Anicteric. Oropharynx clear. ⑤ TMs intact canals clear bilat. Neck: Supple ⑦ w/thyromegaly, cervical node enlargement. ⑨ Chest: Clear to auscultation. Heart: RRR. ⑩ Abdomen: Non-tender and nondistended, ⑫ no masses, rebound or guarding. Extremities: No cyanosis, clubbing or ⑬ edema. 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) n Document at least 6 bullets and you’ve achieved an Expanded Problem Focused Examination. (EPF) n Document at least 12 bullets and you’ve achieved a Detailed Examination. (DET) n www. reimbursementspecialist. com

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

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

Medical Decision Making: 1) Diagnoses just mentioning a condition is not enough, make an assessment for it to count. n n 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: n n Example 1: ‘will cover options with patient’ Improved Example 1: patient is being referred to physical therapy www. reimbursementspecialist. com

Number of Presenting Problems n Patients may present with many problems ¨ Only count problems being addressed today n n n 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 n Problem self-limited or minor ¨ Problems n 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 n Problem is worsening ¨ Chronic illnesses that are uncontrolled or poorly controlled or that are progressing ¨ Acute illnesses that are not responding to treatment n Relapses www. reimbursementspecialist. com

New or Established Problem n New Problems ¨ Problems that this provider has not seen before in this patient n n Patient may have been treated by another provider Patient may have had the condition for a long time ¨ n 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 n New problem with additional work-up planned ¨ Additional workup includes Laboratory studies n Radiology studies n Medicine studies n Consults n www. reimbursementspecialist. com

Medical Decision Making: 2) Data Reviewed itemize lab results in your documentation n ¨ n – "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 n ¨ rationale must be evident note all diagnostic procedures ordered and the reason for ordering n ¨ 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 ① procedure and the same number next to its corresponding diagnoses ① n Order documents for labs, x-rays and other ancillaries can also be approached in the same way n See example of fee ticket: last tab in your handout n www. reimbursementspecialist. com

Medical Decision Making: 3) RISK n n 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 n Risk associated with any diagnostic tests ordered or performed n Risk associated with any treatment option selected n Use Table of Risk to choose a level pg 50 n ¨ The auditor will be using this table in deciding the level risk for the visit www. reimbursementspecialist. com

Level of Risk n If risk of… ¨ presenting problem, ¨ diagnostic procedures, and ¨ management options are of different levels, pick the highest one n Your highest level of risk is your overall RISK ¨ Information n 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 99203 99204 99205 99213 99212 Straightforw Low ard 99214 99215 Modera te High 99202 # of Diagnostic and Management Options 1 2 3 4 Amt of Data to be Reviewed 1 2 3 4 Min(1) Low(2) Mod(3) High(4 ) Risk www. reimbursementspecialist. com

New problem additional workup planned Assessment and Plan: Risk: Moderate; (acute illness with system symptoms) Signs & Symptoms Differential diagnoses not codeable Assessment: Patient with nausea and vomiting for 12 hours. Food poisoning vs. allergic reaction vs. viral infection. She is also dehydrated and exhausted but Mgmt option 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 here in the clinic until she is stabilized or we may have to admit her if this does not help her. Medical Decision Making: MODERATE Data ordered www. reimbursementspecialist. com

Selecting a Level of Care n n 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 n n History Examination Medical Decision Making New Patient ¨ 3/3 n Established Patient ¨ 2/3 n Should always include MDM www. reimbursementspecialist. com

New Patient 3/3 Consultation 3/3 History Problem Focused Expanded Problem Focused Detailed Comprehensi ve Comprehensive Examinati on Problem Focused Expanded Problem Focused Detailed Comprehensi ve Comprehensive Medical Decision Making Straightforw ard 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 Examinatio require n the presenc Medical e of a Decision physicia Making n Level of Care 99211 Problem Focused Expanded Problem Focused Detailed Comprehensive Straightforw ard Low Moderate High 99212 99213 99214 99215 www. reimbursementspecialist. com