Evaluation and Management Coding and Documentation 1 www

Evaluation and Management Coding and Documentation 1 www. codingnetwork. com © 2016 The Coding Network, LLC 1. 1. 2015

Course Agenda v Evaluation and Management Services v Components of E&M Services History v Examination v Medical Decision-Making v Nature of Presenting Problem v Coding using Time v EMR precautions and cloning v Diagnosis Coding v Modifiers v 2 www. codingnetwork. com © 2016 The Coding Network, LLC

References Medicare Contractor: Cigna Government Services �http: //www. cgsmedicare. com/ CMS Evaluation and Management Guide: https: //www. cms. gov/Outreach-and-Education/Medicare. Learning-Network-MLN/MLNProducts/Downloads/evalmgmt-serv-guide-ICN 006764. pdf ICD-10 -CM Official Guidelines for 2017: �http: //www. cdc. gov/nchs/data/icd/10 cmguidelines_201 7_final. pdf www. codingnetwork. com © 2016 The Coding Network, LLC

Components of E&M Services Seven Components are used to define the levels of E&M services. www. codingnetwork. com © 2016 The Coding Network, LLC 1. History 2. Examination 3. Medical Decision. Making 4. Counseling 5. Coordination of Care 6. Nature of Presenting Problem 7. Time 4

Key Components for Selection of Level of Service Three (3) key components: v History v Examination v Medical Decision-Making Key components drive the decision for level of service unless a visit is predominantly counseling or coordination of care. 5 www. codingnetwork. com © 2016 The Coding Network, LLC

NATURE OF PRESENTING PROBLEM A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. There are five (5) types of presenting problems defined as follows: MINIMAL v A problem that may not require the presence of the physician or other qualified health care professional, but service is provided under the physician’s or other qualified health care professional’s supervision. SELF-LIMITED OR MINOR v A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. 6 www. codingnetwork. com © 2016 The Coding Network, LLC

LOW SEVERITY v A problem where the risk of morbidity without treatment is low; there is little or no risk of mortality without treatment; full recovery without functional impairment is expected. MODERATE SEVERITY v A problem where the risk of morbidity or mortality without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. HIGH SEVERITY v A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment. 7 www. codingnetwork. com © 2016 The Coding Network, LLC

Medical Necessity v Medical necessity of service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during or as soon as practicable after it is provided in order to maintain an accurate medical record. (Section 30. 6. 1 of the Medicare Claims Processing Manual) 8 www. codingnetwork. com © 2016 The Coding Network, LLC

Nature of presenting problem and medical necessity �Medical necessity of E/M services is based on the following attributes of the service that affected the physician's documented work: Number, acuity and severity/duration of problems addressed through history, physical and medical decision making. The context of the encounter among all other services previously rendered for the same problem. Complexity of documented comorbidities that clearly influenced physician work. Physical scope encompassed by the problems (number of physical systems affected by the problems). www. codingnetwork. com © 2016 The Coding Network, LLC

Key Component #1: History The extent of history of present illness, review of systems and past family and/or social history obtained and documented is dependent upon clinical judgment and the nature of presenting problem(s). v History is comprised of some or all of the following elements: v Chief Complaint (CC) v History of Present Illness (HPI) v Review of Systems (ROS) v Past, Family and/or Social History (PFSH) 10 www. codingnetwork. com © 2016 The Coding Network, LLC

v There are four (4) types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. To qualify for a given type of history, all three (3) criteria of HPI, ROS and PFSH must be met or exceeded. TYPES OF HISTORY HPI ROS PFSH PROBLEM FOCUSED Brief N/A 1 -3 EXPANDED Brief Problem PROBLEM 1 -3 Pertinent FOCUSED DETAILED N/A 1 Extended Pertinent 4+ 2 -9 1 Est. 1 -2 New COMPREHENSIVE Extended Complete 4+ 10 2 -3 Est. 3 New 11 www. codingnetwork. com © 2016 The Coding Network, LLC

The Elements of Present Illness are: location quality severity duration timing context modifying factors associated signs and symptoms Types of HPI Extended Brief 1 -3 elements have been documented At least 4 elements or the status of at least 3 chronic or inactive conditions have been documented. 12 www. codingnetwork. com © 2016 The Coding Network, LLC

HPI Elements Defined: Location - Site of the symptoms “where”, exact location of problem. Examples: Sore Throat Swollen Knee Abdominal Pain Quality - Features, characteristics or attributes of a symptom. - What does the problem look, feel or sound like? Examples: Pain – sharp, dull, radiating, throbbing, stabbing Scratchy Throat Laceration – jagged, straight 13 www. codingnetwork. com © 2016 The Coding Network, LLC

HPI Elements Defined: Severity - Hardness, sharpness, intensity of pain on a scale of 1 -10. (Severity is also a quality. ) Examples: Pain on scale of 1 -10 “Patient feels very well. ” Forced to sit down. Duration “How Long, ” length of time of symptoms. Examples: For 1 week 2 days ago Timing - Regularity of an occurrence, relationship to something else, why and when does the problem occur. Examples: During the night Frequent Comes and goes All the time After eating www. codingnetwork. com © 2016 The Coding Network, LLC 14

HPI Elements Defined: Context - How the complaint occurred, circumstances surrounding a complaint; what precedes or follows a symptom. Under what circumstance did the patient first notice the problem? Examples: Hurt arm in a motorcycle accident. Fell from tree. While sleeping, After lifting a heavy box Modifying Factors Associated Signs and Symptoms - Factors that alter, limit, change or reduce a symptom. - What makes the symptom worse or better? Examples: Wheezing stops when inhaler is used. Antacid stops the burning. Pain is better since her surgery. - Factors that accompany the main symptom. - What other symptoms are present? Examples: Abdominal pain with nausea and vomiting. Scratchy throat and headaches. www. codingnetwork. com © 2016 The Coding Network, LLC 15

Example HPI www. codingnetwork. com © 2016 The Coding Network, LLC

HPI must be documented by the Provider (CGS Medicare Contractor). �History of present illness (HPI) is the “physician work” associated with medical clinical judgment in gathering the appropriate information in relation to a chief complaint. �Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness representing “physician work”. �Although a nurse or medical assistant may ask a patient some HPI questions, this should be treated only as preliminary information. The physician must further delve into the responses by obtaining additional clinical information to discern how to proceed with the exam and medical decision making. www. codingnetwork. com © 2016 The Coding Network, LLC

Review of Systems (ROS): An inventory of body systems obtained through a series of questions to identify signs and/or symptoms which the patient may be experiencing or has experienced. The following 14 systems are recognized: v v v v Constitutional symptoms (fever, weight loss, etc. ) Eyes Ears, Nose, Mouth and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Integumentary (skin and/or breast) Musculoskeletal Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 18 www. codingnetwork. com © 2016 The Coding Network, LLC

TYPES OF Problem Pertinent 1 organ system directly related to the problem(s) identified in HPI. Complete 10 or more organ systems. Extended 2 -9 organ systems directly related to the problem identified in HPI and a limited number of additional systems. 19 www. codingnetwork. com © 2016 The Coding Network, LLC

Review of Systems (ROS) Example www. codingnetwork. com © 2016 The Coding Network, LLC

Past, Family and/or Social History Past History A review of the patient’s past experience or lack thereof with illnesses, injuries and treatments that include significant information about: v v v v v prior major illnesses and injuries prior operations prior hospitalizations current medications allergies (drug, food) age appropriate immunity status age appropriate feeding/dietary status pregnancy history growth history functional status history 21 www. codingnetwork. com © 2016 The Coding Network, LLC

Family History v A review of medical events in the patient’s family, including diseases of family members which may be hereditary or place the patient at risk. 22 www. codingnetwork. com © 2016 The Coding Network, LLC

Social History An age-appropriate review of past and current activities that includes significant information about: v marital status and/or living arrangements v current employment v occupational history v military history v use of drugs, alcohol and tobacco v level of education v sexual history v other relevant social factors 23 www. codingnetwork. com © 2016 The Coding Network, LLC

TYPES OF PFSH Complete 2 -3 history areas reviewed and documented for established and emergency department patients. Pertinent One history area reviewed and documented. Complete 3 history areas reviewed and documented for new patients, initial hospital care and consultations. 24 www. codingnetwork. com © 2016 The Coding Network, LLC

Documentation Guidelines for History: General v If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition/circumstances which precludes obtaining history, i. e. , patient unconscious, patient intubated. 25 www. codingnetwork. com © 2016 The Coding Network, LLC

Complete ROS v At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. v For the remaining systems, a notation indicating “all other systems have been reviewed and are negative” is permissible. In the absence of such a notation, at least ten systems must be individually documented. 26 www. codingnetwork. com © 2016 The Coding Network, LLC

Appropriate Reference for a Complete ROS v All other systems have been reviewed and are negative v The remainder of the systems were reviewed and are negative. v ROS was obtained and except as listed in the HPI, all other systems are negative. v A complete review of systems was otherwise negative. 27 www. codingnetwork. com © 2016 The Coding Network, LLC

Inappropriate Reference for a Complete ROS v ROS negative v ROS is unremarkable. v ROS is noncontributory. 28 www. codingnetwork. com © 2016 The Coding Network, LLC

Unacceptable Family History Documentation v Family history noncontributory. v No change. 29 www. codingnetwork. com © 2016 The Coding Network, LLC

Acceptable Family History Documentation v Family history reviewed and is non-contributory to this illness/condition. v Family history unchanged since May 31, 2014. v No family history of cardiovascular disorders. v Patient adopted. Family history unknown. 30 www. codingnetwork. com © 2016 The Coding Network, LLC

Per CGS Medicare Contractor �Increasingly, CGS is seeing components of evaluation and management services completed or updated by nursing or other medical staff in the EMR. For example: In the Past Medical or Family/Social History sections, there is an electronic note stating "updated by Nancy Jones, Medical Assistant" or an electronic statement of "medication list updated by Mary Smith RN. " If the physician does not review and address these components as well; and the only documentation relating to these components is the entry from the nurse or a medical assistant, then these components may not be used in determining the level of E&M service provided as they do not reflect the work of the physician. www. codingnetwork. com © 2016 The Coding Network, LLC

Key Component #2: Examination There are four (4) types of examination. These exams have been defined for general multi-system and ten (10) single organ systems. PROBLEM FOCUSED v Limited exam of the affected body area or organ system. EXPANDED PROBLEM FOCUSED v. Limited exam of affected body area or organ system and other symptomatic or related body area(s) or organ system(s). 32 www. codingnetwork. com © 2016 The Coding Network, LLC

Key Component #2: Examination DETAILED v An extended exam of the affected body area(s) or organ system(s) and other symptomatic or related body area(s) or organ system(s). COMPREHENSIVE v A general multi-system exam or a complete exam of a single organ system and other symptomatic or related body area(s) or organ system(s). 33 www. codingnetwork. com © 2016 The Coding Network, LLC

1995 Examination Documentation Guidelines Body Areas: v Head, including the face v Neck v Chest, including the breasts and axillae v Abdomen v Genitalia, groin, buttocks v Back v Each extremity 34 www. codingnetwork. com © 2016 The Coding Network, LLC

Organ Systems: v v v Constitutional Eyes Ears, Nose, Mouth and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic 35 www. codingnetwork. com © 2016 The Coding Network, LLC

Problem Focused Exam * 1 body area or organ system Expanded Problem Focused Exam * 2 -7 body areas or organ systems 36 www. codingnetwork. com © 2016 The Coding Network, LLC

1995 Guidelines >DETAILED EXAM An extended exam of the affected body area(s) or organ system(s) and other symptomatic or related body area(s) or organ system(s). � Example for assessment of a respiratory condition: Constitutional- 1) BP 2) Temp 3) Pulse 4) Respiration Respiratory- 1) Chest clear to auscultation 2) Non-labored breathing 3) No rhonchi 4) No rales Cardiovascular- 1) Regular Rate 2) and Rhythm 3) Normal S 1 4) and S 2 Gastrointestinal - 1) Abdomen soft 2) Normal bowel sounds 3) No hernia 4) Abdomen flat www. codingnetwork. com © 2016 The Coding Network, LLC

Documentation Guidelines for Examination v Specific abnormal and relevant negative findings of the examination should be documented. A notation of “abnormal” without elaboration is insufficient. v The exam is real time. One cannot indicate “no change in the exam from previous encounter” for the entire exam. 38 www. codingnetwork. com © 2016 The Coding Network, LLC

Key Component #3: Complexity of Medical Decision-Making Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option. The complexity of the assessment and plan of care for a patient is measured by: v number of possible diagnoses and/or management options v amount and complexity of medical records, diagnostic tests and v other data to be obtained, reviewed analyzed v risk of significant complications, morbidity and mortality 39 www. codingnetwork. com © 2016 The Coding Network, LLC

Key Component #3: Complexity of Medical Decision-Making v There are four (4) types of medical decision-making. To qualify for a given type of medical decision-making, two of the three elements in the table must be either met or exceeded. 40 www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENTS Number of diagnoses or management options (per points) Amount and/or complexity of data obtained, reviewed, and analyzed (per points) Risk of complications and/or morbidity or mortality Type of Decision Making Minimal (1) Minimal or none (1) Minimal Straightforward Limited (2) Low Complexity Multiple (3) Moderate Complexity Extensive (>4) High Complexity 41 www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #1: NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS v The number of possible diagnoses and/or the number of management options that must be considered is based on: � The number and types of problems addressed during the encounter; � The complexity of establishing a diagnosis; and � The management decisions that are made by the physician. Layman’s Terms: What’s wrong with the patient? How many and what type of diagnoses are there on this visit? www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #1: Number of Diagnoses or Treatment Options Problem(s) Status Number Points Self-Limited, Minor (Max=2) 1 Est. Problem (to examiner): stable/improved 1 Est. Problem (to examiner): that is inadequately controlled, worsening, or failing to progress as expected 2 New problem (to examiner): no additional workup (Max=1) 3 New problem (to examiner): additional workup planned 4 Results Total = 43 www. codingnetwork. com © 2016 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR MEDICAL DECISION-MAKING: DIAGNOSIS OR MANAGEMENT OPTIONS v. For each encounter, an assessment, diagnosis or clinical impression should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. v. Indicate whether patients with established diagnoses are improving, well-controlled, resolving or resolved, inadequately controlled, worsening, or failing to change as expected. 44 www. codingnetwork. com © 2016 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR MEDICAL DECISION-MAKING: DIAGNOSIS OR MANAGEMENT OPTIONS v For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible, ” “probable, ” or “rule out” (R/O) diagnosis. v The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options such as patient instructions, nursing instructions, therapies and medications. v 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. 45 www. codingnetwork. com © 2016 The Coding Network, LLC

POINTS TO REMEMBER NUMBER OF DIAGNOSES A) New Patient: - New problem with no additional workup (3) - New problem with additional workup (4) v. Additional tests or diagnostic studies v. Request for consult v. Need to review records of requesting/treating physician v. Additional workup includes those efforts necessary to develop a diagnosis or to determine a course of treatment. 46 www. codingnetwork. com © 2016 The Coding Network, LLC

POINTS TO REMEMBER NUMBER OF DIAGNOSES B) Established patient with multiple problems: - 1) Chronic Hepatitis C: responding to therapy (1) - 2) Right knee pain: symptoms worsening (2), MRI ordered - 3) Diabetic neuropathy: good control (1), continue meds List each problem addressed and/or treated individually. Document the status of each using keywords like “new problem”, “stable”, “improving”, “worsening”, “out of control” or “not responding to treatment”. Note: Diagnoses listed in the A/P but not otherwise supported with a status or treatment plan are not considered when assigning a level of service. Do not choose codes from the problem list if not addressed in the visit. 47 www. codingnetwork. com © 2016 The Coding Network, LLC

Diagnoses New or established problems>Addressed during the visit Qualify the diagnosis (e. g. , acute severe, chronic, mild, moderate, etc. ). Co-morbid conditions include conditions that coexist at the time of the visit and influence, require, or affect patient care or treatment. v Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision-making. v Documentation needs to demonstrate that the comorbidity was a significant influence. 48 www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #2: AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED v Review/order clinical lab test(s) v Review/order imaging studies v Review/order medicine test(s) PFT, ECG, echoes, cardiac caths v Discuss results with performing MD (contradictory or unexpected results) v Decision to obtain and review old records and/or obtain history from someone other than patient. 49 www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #2: AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED v Review and summarize old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider v Independent review of image, tracing or specimen (often supplements information from physician who prepared test report or interpretation Layman’s Terms: How much stuff did I have to look at in order to figure out what was wrong? 50 www. codingnetwork. com © 2016 The Coding Network, LLC

Diagnostic Tests �Evidence of physician intent is required for labs, diagnostics or therapeutic procedures. The physician progress note of the visit prior to labs/diagnostic tests needs to show physician intent and medical necessity for the services billed. Indicate in the progress note the reason/condition for each test ordered. www. codingnetwork. com © 2016 The Coding Network, LLC

DOCUMENTATION GUIDELINES AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED v If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E&M encounter, the type of service, e. g. , lab or x-ray, should be documented. v The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as “WBC elevated” or “chest x-ray unremarkable” is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results. 52 www. codingnetwork. com © 2016 The Coding Network, LLC

v. A decision to obtain old records or a decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. 53 www. codingnetwork. com © 2016 The Coding Network, LLC

v Relevant findings from the review of old records and/or the receipt of additional history from the family caretaker or other source supplementing that obtained from the patient should be documented. A notation of “old records reviewed” or “additional history obtained from the family” without elaboration is insufficient. 54 www. codingnetwork. com © 2016 The Coding Network, LLC

v The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented. v The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented. A statement such as “I personally interpreted the x-rays. The findings are. . . ” should be indicated. 55 www. codingnetwork. com © 2016 The Coding Network, LLC

POINTS TO REMEMBER AMOUNT OF DATA Points Review/order clinical lab test(s) Review/order imaging studies Review/order diagnostic test(s) from medicine section Discuss results with performing MD Decision to obtain old records and/or obtain history from someone other than the patient Review and summarize old records Obtain history from someone other than the patient Independent review of image, tracing or specimen Discussion of case with another health care provider max=1 1 1 2 2 56 www. codingnetwork. com © 2016 The Coding Network, LLC

POINTS TO REMEMBER AMOUNT OF DATA Recommended language: v I have reviewed records from (document where records came from) and the summary is as follows: (i. e. , brief summarization of outside consult notes, hospitalization treatment management). v I have personally reviewed and interpreted (state the type of specimen, image or tracing) and my findings are _____. v I will request records from (document the name of the hospital or doctor’s office). v I will order and/or recommend the following (document all tests ordered and procedures that will be performed). 57 www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #3: RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY AND/OR MORTALITY The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories: v Presenting problem(s); v Diagnostic procedure(s); and v Possible management options. www. codingnetwork. com © 2016 The Coding Network, LLC

ELEMENT #3: RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY AND/OR MORTALITY v The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter. v The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. v The highest level of risk in any one category determines the overall risk. Layman’s Terms: Based upon what I am going to do to this patient, what is his risk? www. codingnetwork. com © 2016 The Coding Network, LLC

DOCUMENTATION GUIDELINES RISK OF COMPLICATIONS, MORBIDITY AND/OR MORTALITY v 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. Examples include diabetes mellitus, hypertension, HIV and anti- coagulation therapy. v 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. v If a surgical or invasive diagnostic procedure is performed at the time of the E&M encounter, the specific procedure should be documented. 60 www. codingnetwork. com © 2016 The Coding Network, LLC

v The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or easily inferred. 61 www. codingnetwork. com © 2016 The Coding Network, LLC

Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal v One self-limited or minor problem (e. g. , cold, insect bite, venipuncture, tinea corporis) Laboratory tests requiring v Chest x-rays v EKG/EEG v Urinalysis v Ultrasound (e. g. , echocardiography) v KOH prep v v Low v Two or more self-limited or minor problems v One stable chronic illness (e. g. , well controlled hypertension, non-insulin dependent diabetes, cataract, BPH) v Acute uncomplicated illness or injury (e. g. , cystitis, allergic rhinitis, simple sprain) v Physiologic tests not under stress (e. g. , pulmonary function tests) v Non-cardiovascular imaging studies with contrast (e. g. , barium enema) v Superficial needle biopsies v Clinical laboratory tests requiring arterial puncture v Skin biopsies v Over-the-counter drugs v Minor surgery with no identified risk factors v Physical therapy v Occupational therapy v IV fluids without additives Rest Gargles Elastic Bandages Superficial Dressings 62 www. codingnetwork. com © 2016 The Coding Network, LLC

Table of Risk Cont’d Level of Risk Presenting Problem(s) Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment v Two or more stable chronic illnesses v Undiagnosed new problem with uncertain prognosis (e. g. , lump in breast) Acute illness with systemic symptoms (e. g. , pyelonephritis, pneumonitis, colitis) v v Diagnostic Procedure(s) Ordered Management Options Selected Physiologic tests under v Minor surgery with stress (e. g. , cardiac tress identified risk test, fetal contraction factors stress test) v Elective major surgery v Diagnostic endoscopies (open, percutaneous or with no identified risk endoscopic) with no factors identified risk factors v Deep needle or incisional v Prescription drug biopsy management v Cardiovascular imaging v Therapeutic nuclear studies with contrast and medicine no identified risk factors v IV fluids with additives (e. g. , arteriogram, cardiac v Closed treatment of catheterization) fracture or dislocation v Obtain fluid from body without manipulation cavity (e. g. , lumbar puncture, thoracentesis, culdocentesis) v 63 www. codingnetwork. com © 2016 The Coding Network, LLC

Table of Risk Cont’d Level of Risk High Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment v Acute or chronic illnesses or injuries that pose a threat to life or bodily function (e. g. , multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure v An abrupt change in neurologic status (e. g. , seizure, TIA, weakness, sensory loss) v v v Cardiovascular imaging studies with contrast with identified risk factors v Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors v Discography Elective major surgery (open, percutaneous or endoscopic)with identified risk factors v Emergency major surgery (open, percutaneous or endoscopic) v Parenteral controlled substances v Drug therapy requiring intensive monitoring for toxicity v Decision not to resuscitate or to de-escalate care because of poor prognosis v 64 www. codingnetwork. com © 2016 The Coding Network, LLC

EXAMPLE MDM: monitoring DM, stable, >new symptom chest pain, tests ordered, add Rx www. codingnetwork. com © 2016 The Coding Network, LLC

EXAMPLE MDM: Order labs, indep review of EKG, changed Rx www. codingnetwork. com © 2016 The Coding Network, LLC

EXAMPLE MDM www. codingnetwork. com © 2016 The Coding Network, LLC

EXAMPLE MDM www. codingnetwork. com © 2016 The Coding Network, LLC

Outpatient Evaluation &. Management CPT Code Criteria New Patient 99201 99202 99203 99204 99205 Avg. time (mins) 10 20 30 45 60 Required all three key components CC: Required CC: Required HPI: 1 -3 HPI: 4+ ROS: None ROS: 1 Pertinent ROS: 2 -9 ROS: 10+ PFSH: None PE: PF PFSH: None PE: EPF PFSH: 1 Pertinent PE: Detailed PFSH: 3 PE: Comprehensive MDM: Straightforward MDM: Low MDM: Moderate MDM: High 69 www. codingnetwork. com © 2016 The Coding Network, LLC

Outpatient Evaluation &. Management CPT Code Criteria Established Patient 99211 99212 99213 99214 99215 Avg. time (mins) 5 10 15 25 40 Requires two of the three key components CC: Required CC: Required HPI: 1 -3 HPI: 4+ ROS: None ROS: 1 ROS: 2 -9 ROS: 10+ PFSH: None PE: None PFSH: None PE: PF PFSH: 1 PE: EPF PFSH: 1 PE: Detailed PFSH: 2 -3 PE: Comprehensive MDM: Low MDM: Moderate MDM: na MDM: Straightforward MDM: High 70 www. codingnetwork. com © 2016 The Coding Network, LLC

99213 Example � An established office patient with osteoarthritis CC : “ knee pain. ” History : Patient with known osteoarthritis which had been previously controlled on Tylenol. Now states his left knee has been aching for about two weeks despite two to three doses of Tylenol per day. ROS : Musculoskeletal--Negative for arthralgias or worsening joint pain elsewhere (history is EPF) Physical Exam � � � Mild swelling of left knee compared to the right. Some pain with passive rotation. No overlying warmth or erythema. (exam is EPF) Assessment Worsening osteoarthritis left knee Plan Start OTC ibuprofen po TID, PRN Return visit in two weeks if no improvement www. codingnetwork. com © 2016 The Coding Network, LLC

99213 (continued) �Medical Decision-Making The cognitive labor required for the clinical example satisfies the requirements for Low Complexity Medical Decision-Making requires TWO out of THREE of the following : � Two Problem Points (2 points for one problem, worsening = low) � Two Data Points (none in this example) � Table of risk moderate (one worsening) www. codingnetwork. com © 2016 The Coding Network, LLC

Example 99214 -MDM Established patient with multiple problems: - 1) Chronic Hepatitis C: responding to therapy (1), continue - 2) Right knee pain: symptoms worsening (2), order MRI - 3) DM : good control (1), continue meds - Number Dx/Management options - Data - Table of Risk 4 points (High complexity) 1 (order MRI) Moderate (2 stable and 1 undiagnosed new problem) Overall MDM moderate (1 table = high, but other is moderate) History Detailed or Exam Detailed 4 HPI 2 -9 ROS 1 history 73 www. codingnetwork. com © 2016 The Coding Network, LLC

One more example 99214 -MDM Established patient with multiple problems: - 1) Chronic Hepatitis C: responding to therapy (1), continue - 2) Right knee pain: symptoms better (1), continue OTC meds - 3) DM: good control (1), continue meds - Number Dx/Management options - Data - Table of Risk History Detailed 4 HPI 2 -9 ROS 1 history or 3 points (moderate complexity) none Moderate (3 stable problems) Exam Detailed 74 www. codingnetwork. com © 2016 The Coding Network, LLC

And one more example 99214 using MDM Established patient with multiple problems: - 1) Chronic Hepatitis C: responding to therapy (1), continue - 2) OA knee: symptoms worsening (2), order CT scan - Number Dx/Management options - Data - Table of Risk History Detailed 4 HPI 2 -9 ROS 1 history or 3 points (1 stable, 1 worsening) (moderate) 1 point (CT scan) Moderate (mild progression) Exam Detailed 75 www. codingnetwork. com © 2016 The Coding Network, LLC

99213 Example using MDM Established patient with multiple problems: - 1) Chronic Hepatitis C: responding to therapy (1), continue - 3) DM: good control (1), continue meds - Number Dx/Management options - Data - Table of Risk 2 points (low complexity) none Moderate (2 stable problems) History or Exam is detailed, MDM low complexity Although the table of risk falls into moderate, the other 2 MDM tables do not meet moderate complexity (need at least 1 more moderate) 76 www. codingnetwork. com © 2016 The Coding Network, LLC

99215 -MDM example Established patient with new problem: - 1) Syncope, weakness, ? TIA: CT scan stat - Number Dx/Management options up)(high) - Data - Table of Risk History Comprehensive 4 HPI 10+ ROS 2 history 4 points (new problem, work 1 point High (abrupt change in neuro status) or Exam is comprehensive 8 organ systems 77 www. codingnetwork. com © 2016 The Coding Network, LLC

99212 Established patient with stable problem: - 1) Chronic Hepatitis C: responding to therapy (1), continue - Number Dx/Management options - Data - Table of Risk 1 point (SF complexity) none Low (1 stable problem) History or Exam is PF or EPF, MDM straightforward 78 www. codingnetwork. com © 2016 The Coding Network, LLC

THREE (3) ADDITIONAL COMPONENTS Counseling Coordination of Care Time These components are considered contributory factors in the majority of encounters. However, counseling and coordination of care may not be provided at every patient encounter. 79 www. codingnetwork. com © 2016 The Coding Network, LLC

COUNSELING A discussion with a patient or family concerning one or more of the following areas: v diagnostic results, impressions, and/or recommended diagnostic studies v prognosis v risks and benefits of management (treatment) options v instructions for management (treatment) or follow up v importance of compliance with chosen management (treatment) options v risk factor reduction v patient and family education 80 www. codingnetwork. com © 2016 The Coding Network, LLC

Using Time �You may have noticed that there are “recommended” times for most, but not all E/M encounters. This allotted time is merely a guide. Some encounters may take longer than their allotted times, while others may take less than the time allowed. It is NOT necessary to use the allotted time for any particular encounter if you are coding based on the documentation of the three key components. In other words you are not penalized for being efficient. www. codingnetwork. com © 2016 The Coding Network, LLC

Using Time � However, the E/M guidelines do have a specific provision to allow physicians to use TIME as the controlling factor to determine the level of care when counseling and/or coordination of care equals more than 50% of the encounter, using the typical time assigned to a given E/M code. � In these instances, the physician MUST spend the entire allotted time face-to-face with the patient AND at least HALF of that time must be used for “counseling and coordination of care. ” � If you choose to code based on time, you MUST record the duration of the face-to-face time in the record, AND also state that over half the time was spent on counseling and coordination of care. In addition, the nature of the counseling and coordination of care must be documented. www. codingnetwork. com © 2016 The Coding Network, LLC

USING TIME Document: Total face-to-face Physician/Provider time with the patient (not an estimate, be specific). That more than 50% of the visit was spent counseling Content of the counseling in sufficient detail Example: v Total face-to-face time = 40 minutes; more than 50% spent counseling on treatment options xxx relating to diagnosis of ………… v CPT code =99215 (typical time of this code is 40 minutes) v The time must meet or exceed the specific CPT code assigned and should not be “rounded” to the next higher level. 83 www. codingnetwork. com © 2016 The Coding Network, LLC

COUNSELING/COORDINATION OF CARE www. codingnetwork. com © 2016 The Coding Network, LLC

NEW PATIENT AND ESTABLISHED PATIENT DEFINITIONS NEW PATIENT v A patient who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. v Professional services are those face-to-face services rendered by physicians and other qualified health care professionals and reported by a specific CPT code(s). v Per CMS, if no evaluation and management service has been performed, “the patient may continue to be treated as a new patient. ” Therefore, review of labs and other diagnostic studies prior to seeing a patient does not negate the new patient designation. 85 www. codingnetwork. com © 2016 The Coding Network, LLC

ESTABLISHED PATIENT v A patient who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the same exact specialty and subspecialty who belongs to the same group practice within the last three years. v There is no distinction between new and established patients in the emergency setting. 86 www. codingnetwork. com © 2016 The Coding Network, LLC

ESTABLISHED PATIENT v When a physician/qualified health care professional is on-call or covering for another physician/qualified health care professional, the patient’s encounter is coded as new or established based upon the designation of his regular physician/qualified health care professional. v When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician. 87 www. codingnetwork. com © 2016 The Coding Network, LLC

CATEGORY: Consultation GENERAL ~ A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source: 1) to recommend care for a specific condition or problem OR 2) to determine whether to accept responsibility for a) ongoing management of the patient’s entire care or b) the care of a specific condition or problem. 88 www. codingnetwork. com © 2016 The Coding Network, LLC

CATEGORY: Consultation Documentation Requirements for consultations v The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source. v Recommend stating as an example: The patient is seen in consultation at the request of Dr. Wilson for evaluation of low back pain. v The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source. 89 www. codingnetwork. com © 2016 The Coding Network, LLC

v If the consultant assumes responsibility for management of a portion or all of the patient’s conditions, the services subsequent to opinion/advice are coded at the appropriate level of visit (e. g. , established patient or subsequent hospital or nursing facility care codes). In the office setting the consultant should use the appropriate office consult code: Office (99241 - 99245) First visit Office (99212 -99215) Follow-up visit 90 www. codingnetwork. com © 2016 The Coding Network, LLC

Outpatient Evaluation &. Management CPT Code Criteria Office Consultation New or Established 99241 99242 99243 99244 99245 Avg. time (mins) 15 30 40 60 80 Requires all three key components CC: Required CC: Required HPI: 1 -3 HPI: 4+ ROS: None ROS: 1 Pertinent ROS: 2 -9 ROS: 10+ PFSH: None PE: PF PFSH: None PE: EPF PFSH: 1 Pertinent PE: Detailed PFSH: 3 PE: Comprehensive MDM: Straightforward MDM: Low MDM: Moderate MDM: High 91 www. codingnetwork. com © 2016 The Coding Network, LLC

How to Code Medicare Consult Services in the Office and Outpatient Setting v In the office or other outpatient setting, providers are instructed to bill initial office visit or established patient visits based upon patient status as new or established to the physician. See CPT 99201 -99215. v A new patient is a patient who has not received any professional services (E/M or other face-to-face service) within the previous three years per provider or another provider of the same specialty in the same group. Same group means same TIN. 92 www. codingnetwork. com © 2016 The Coding Network, LLC

EMR CAUTIONS v Cloned notes = when documentation is worded exactly like previous entries v Cutting and pasting, copying forward to increase level of service v Work actually performed? v Contradictory/conflicting information>gender mismatches, or HPI and ROS contradictory v Confusing content Documentation must be specific to each encounter or individual 93 www. codingnetwork. com © 2016 The Coding Network, LLC

Using Electronic Medical Records CGS Medicare � Electronic Health Records allow providers to copy forward clinical documentation. This process of copying existing text in the record and pasting it in a new destination is often used by clinicians to save time when updating notes on an existing patient, it is also known as copy and paste, cloning, and carry forward, among other terms. � Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This "cloned documentation" does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. � All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. www. codingnetwork. com © 2016 The Coding Network, LLC

Cloned Notes �What about populating today’s note with the information from the last visit, to save time, and just updating it? Dangerous. Of course it is time saving, but it is too easy to forget to update or change one part. Would not populate today’s note with the information from the last visit. �The HPI section of the note is unique to the present visit, and may never be copied and pasted from a previous note performed by that provider or another provider. www. codingnetwork. com © 2016 The Coding Network, LLC

Cloned Notes � But, can’t a clinician copy forward the past medical history? Yes, there is no reason that the past medical, social and family history cannot be carried forward from a previous note, as long as the provider reviews it with the patient and updates it. � See separate handout with information from various other Medicare Contractors. www. codingnetwork. com © 2016 The Coding Network, LLC

Use of Voice Recognition �One Part B Medicare Contractor had noticed that many patient records submitted for review contained nonsensical and/or incomplete documentation, suggesting that they had not been reviewed by the provider at the time of preparation. �Medical notes must be comprehensible and legible. The primary purpose of medical documentation is to ensure that the patient's treatment is recorded for the continuity of appropriate treatment by the attending provider(s). It is also important for colleagues, consultants, and office staff as well as other third parties that the notes are written legibly or are typed. Nonsensical and/or incomplete documentation increases the potential of legal implications for a provider. www. codingnetwork. com © 2016 The Coding Network, LLC

Use of Scribes per CGS Medicare Contractor �If a nurse or Non-Physician Practitioner (NPP) acts as a scribe for the physician, the individual writing the note or entry in the record should note "written by (Jane Doe), acting as scribe for Dr. (Smith). " Then, Dr. (Smith) should co-sign, and indicate the note accurately reflects work and decisions made by the physician. � The scribe is functioning as a "living recorder, " documenting in real time the actions and words of the physician as they are done. If this is done in any other way, it is inappropriate. The real time transcription must be clearly documented as noted, by both the scribe and the physician. Failure to comply with these instructions may result in denial of claims. www. codingnetwork. com © 2016 The Coding Network, LLC

Teaching Physician Services For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following: � That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and � The participation of the teaching physician in the management of the patient � Documentation by the resident of the presence and participation of the teaching physician is NOT sufficient to establish the presence and participation of the teaching physician. � For medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service. www. codingnetwork. com © 2016 The Coding Network, LLC

ICD-10 -CM �Currently, Medicare is not denying or auditing Part B claims solely on the specificity of the ICD-10 -CM codes provided as long as the physician submits a diagnosis code from the appropriate family of codes. Medicare Administrative Contractors and Recovery Audit Contractors as well as some commercial payers are following this policy — for now. �This one-year Medicare grace period is scheduled to end on Sept. 30, 2016, at the same time that the industry settles into the ICD-10 first annual maintenance update. www. codingnetwork. com © 2016 The Coding Network, LLC

ICD-10 -CM 2017 ICD-10 -CM � 2, 305 new codes � 553 revised codes � 212 deleted codes �Are you ready for thousands of code changes? Are you ready to code for greater specificity? www. codingnetwork. com © 2016 The Coding Network, LLC

DIAGNOSIS CODING Assign all codes to the highest level of specificity (3 -7 digits). Avoid unspecified codes when there is a more specific code to describe the patient’s illness, condition or injury. Code signs and symptoms if a definitive diagnosis has not been determined. Do not code probable, possible or suspected conditions as definitive diagnoses. Be specific in describing the condition, illness or disease of the patient. -acute vs. chronic -laterality (left side, right side, bilateral) 102 www. codingnetwork. com © 2016 The Coding Network, LLC

ICD-10: Expand documentation to include: �Laterality (left vs. right, or bilateral) Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality �Anatomic details �Acuity (acute vs. chronic) �Disease relationships (any secondary disease process) �Under-dosing, over-dosing, adverse affect � Encounter type, when indicated (injury, complications) (initial, subsequent, sequela) � Do not select codes from the problem list if not addressed in the visit. www. codingnetwork. com © 2016 The Coding Network, LLC

Linkage Documentation Tips There are several preferred ways to state the cause and effect between a condition and the complication code. � “due to” � “secondary to” “diabetic” Examples: � • � “External ear disorder due to gout” � “PVD secondary to Diabetes” � “Diabetic Retinopathy” www. codingnetwork. com © 2016 The Coding Network, LLC

Use Additional Code For ICD-10 -CM, for respiratory and cardiology: - Use additional code to identify: � Exposure to environmental tobacco smoke (Z 77. 22) � History of tobacco use (Z 87. 891) � Occupational exposure to environmental tobacco smoke (Z 57. 31) � Tobacco dependence (F 17 -) (- means needs additional digit) � Tobacco use (Z 72. 0) www. codingnetwork. com © 2016 The Coding Network, LLC

Nicotine Dependence: F 17 Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders Identify the product: �Cigarettes �Chewing tobacco �Other �Unspecified Identify the status: �Uncomplicated �In remission �Withdrawal �With other nicotine-induced disorders �With unspecified nicotine-induced disorders www. codingnetwork. com © 2016 The Coding Network, LLC

Obesity Use additional code to identify BMI if known(Z 68. -) �E 66. 9 Obesity unspecified �E 66. 01 Morbid (severe) obesity due to excess calories (default in Index) �E 66. 09 Other obesity due to excess calories �E 66. 3 Overweight �E 66. 8 Other obesity �E 66. 1 Drug induced obesity Use additional code for adverse affect, if applicable, to identify drug www. codingnetwork. com © 2016 The Coding Network, LLC

Guideline: Application of 7 th Character � 7 th character used in certain chapters (e. g. , Obstetrics, Injury, Musculoskeletal, and External Cause chapters) �Must always be used in the 7 th character position Common examples include: A B S Initial encounter Subsequent encounter Sequela www. codingnetwork. com © 2016 The Coding Network, LLC

Chapter 19 �Initial encounter The patient is receiving active treatment for the injury � Surgical treatment � Emergency department encounter Injury, Poisoning, other consequences of External Causes � Evaluation and continuing treatment by the same or a different physician � Assignment of the 7 th character is based on whether the patient is undergoing active treatment and not whether the Provider is seeing the patient for the first time. www. codingnetwork. com © 2016 The Coding Network, LLC

�Subsequent encounter Chapter 19 After patient received active treatment of injury and receiving routine care during healing or recovery phase � Cast change or removal � Removal of external or internal fixation device � Medication adjustment � Other aftercare and follow-up visits following injury treatment. www. codingnetwork. com © 2016 The Coding Network, LLC

Chapter 19 � Sequela Complications or conditions that arise as a direct result of an injury � Scar formation after burn Use both the injury code that precipitated sequela and code for sequela S added only to injury code, not sequela code. S identifies injury responsible for sequela. Specific type of sequela (like scar) sequenced first, followed by injury code. www. codingnetwork. com © 2016 The Coding Network, LLC

Coding Example: Sequela Scenario: Patient suffered a third degree burn of the left hand after accidentally touching a hot stove in his kitchen. He has a painful scar as a result of the burn L 90. 5 Scar conditions and fibrosis of skin T 23. 302 S Burn of third degree of left hand, unspecified site, subsequent encounter X 15. XXXS Contact with hot stove (kitchen) Y 92. 010 Kitchen of single-family (private) house as the place of occurrence of the external cause www. codingnetwork. com © 2016 The Coding Network, LLC

E&M MODIFIERS GLOBAL SURGERY CONCEPT 113 www. codingnetwork. com © 2016 The Coding Network, LLC

MODIFIERS Modifiers are two-digit additions to CPT codes to indicate that a performed service or procedure has been altered by a specific circumstance but not changed in its definition or code. Some modifiers impact reimbursement while others simply convey information. 114 www. codingnetwork. com © 2016 The Coding Network, LLC

EVALUATION AND MANAGEMENT MODIFIERS - 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period. v. Used to indicate that an E&M service performed during the postoperative period is unrelated to the original procedure. v. The diagnosis for the E&M service must support the fact that the service was unrelated. v v. If the service is unrelated, Medicare will pay for the E&M service with the 24 modifier. 115 www. codingnetwork. com © 2016 The Coding Network, LLC

EVALUATION AND MANAGEMENT MODIFIERS Significant, Separately Identifiable Evaluation and Management Service - 25 by the Same Physician on the Same Day of the Procedure or Other Service. v Reflects that the day of a minor surgical procedure, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual operative and postoperative care associated with the procedure that was performed. v The term “separately identifiable service” means an additional service that is not part of the surgery or procedure. The E&M service must require additional history, exam, knowledge, skill, work, time, and risk above and beyond that of the surgery or procedure and its pre- and postprocedure components. Moreover, the E&M service should be able to stand alone from the same-day procedure. 116 www. codingnetwork. com © 2016 The Coding Network, LLC

v A significant, separately identifiable E&M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E&M service to be reported. v The E & M service may be prompted by the symptom or condition for which the procedure and/or service was provided. Different diagnoses are not required for reporting of the E & M service on the same date. 117 www. codingnetwork. com © 2016 The Coding Network, LLC

NCCI POLICY v If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. 118 www. codingnetwork. com © 2016 The Coding Network, LLC

Administration of vaccines/injections �Documentation for the injection should include the drug, dose, route, anatomic site, and signature and credentials of the administering provider. �When coding for injections, the following documentation is required: Anatomic site, medication given, dosage ordered and given, route of administration, signature of staff providing the service. www. codingnetwork. com © 2016 The Coding Network, LLC

Documentation for Diagnostic Services �Diagnostic tests may only be ordered by the “treating physician/practitioner. ” �The treating physician should clearly indicate ALL tests to be performed in the patient’s medical records – simply stating “ordered x-rays” or “requested labs” is not acceptable. �The medical records MUST support the medical necessity of ordering the service. �Ordering providers MUST also maintain documentation of the order and medical necessity in the beneficiary’s medical record. (CGS Medicare) www. codingnetwork. com © 2016 The Coding Network, LLC

QUESTIONS? www. codingnetwork. com © 2016 The Coding Network, LLC