Transcript of Making notes “authentic” and retaining quality Nancy M. Enos, FACMPE, CPC-I, CEMC, CPMA October...
- Slide 1
- Making notes authentic and retaining quality Nancy M. Enos,
FACMPE, CPC-I, CEMC, CPMA October 7, 2013 MGMA Annual Conference
San Diego, CA
- Slide 2
- Agenda Hot topics in E/M coding the OIG is watching high levels
of service Electronic Health Records and Physician Documentation-
Risk of copied and cloned notes The Chart Audit Process
- Slide 3
- 2012 OIG Work List E/M Trends in Coding of Claims OIG reviewed
evaluation and management (E/M) claims to identify trends in the
coding of E/M services from 2000-2009. Medicare paid $32 BILLION
for E/M services in 2009, representing 19% of ALL Medicare part B
payments. Providers are responsible for ensuring that the codes
they submit accurately reflect the services they provide. E/M codes
represent the type, setting, and complexity of services provided
and the patient status, such as new or established.
- Slide 4
- 2012 OIG Work List E/M improper documentation due to cloned
notes, identical documentation OIG will assess the extent to which
CMS made potentially inappropriate payments for E/M services due to
the consistency of E/M medical review determinations multiple E/M
services for the same providers and beneficiaries to identify
electronic health records (EHR) documentation practices associated
with potentially improper payments.
- Slide 5
- OIG Report released in May 2012 OIG released a report on Coding
Trends of Medicare Evaluation and Management Services The report
reflects OIGs and CMS continuing suspicions about the increase in
higher level billing indicating a need for physicians to audit
their E/M coding I hereby direct executive departments and agencies
to expand their use of Payment Recapture Audits, to the extent
permitted by law and where cost-effective. Daniel R. Levinson,
Inspector General
- Slide 6
- OIG Report From 2001 to 2010 Level 1 to 3 dropped 17% while
Level 4 and 5 increased 17% The OIG identified 1,700 providers who
billed level 4 or level 5 at least 95% of all E/M claims in 2010
OIG has sent the names of these high billing doctors to CMS, along
with a recommendation for review and possible recoupment.
http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf
- Slide 7
- OIG Report From 2001 to 2010 Level 1 to 3 dropped 17% while
Level 4 and 5 increased 17% The OIG identified 1,700 providers who
billed level 4 or level 5 at least 95% of all E/M claims in 2010
OIG has sent the names of these high billing doctors to CMS, along
with a recommendation for review and possible recoupment
http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf
- Slide 8
- Who are the 1,700? States California 17.1% New York 11.3%
Florida 9.6% Texas 6.7% Arizona 4.3% Michigan 3.8% Illinois 3.5%
Maryland 3.3% New Jersey 3.2% Pennsylvania 3.2% Specialties
Internal Medicine 19.8% Family Practice 12.2% Emergency Med. 9.9%
Nurse Practitioner 4.4% Ob-Gyn 4.3% Cardiovascular 4.0% Orthopedic
Surgery 3.9% Psychiatry 3.8% General Surgery 3.2% Ophthalmology
3.2%
- Slide 9
- Is the Increase Justified? Electronic Medical Records provide a
better way to capture patient acuity (more diagnosis codes) and
template guided E/M notes may document and support a higher level
of E/M Service Medical necessity is the key Completion of a
Comprehensive History, and a Comprehensive Examination, does not
justify a level 5 service if it is not medically reasonable and
necessary.
- Slide 10
- Correcting Undercoding The uptick may be a correction of
undercoding-many primary care doctors were overusing 99213 for
complex patients with multiple chronic diseases, because
handwriting a SOAP note for their follow up visits was time
consuming Ancillary staff can complete the Chief Complaint, Review
of Systems, Past, Family and Social History The provider MUST
validate these entries
- Slide 11
- Risks of Electronic Health Records Templates can assist Coders
adageIf it wasnt documented, it wasnt done Auditors adageif it
wasnt necessary, dont bill for it Auto-complete - check Review of
Systems (ROS) Were they all really reviewed? Was it necessary?
Physician training
- Slide 12
- Cloned Notes- History Does your EMR have templates that create
a Complete 14-point Review of Systems (ROS) automatically? Issues
and risks Each element of the ROS must be supported by the History
of Present Illness for medical necessity For instance, a patient
comes in to the Emergency Department for a hand injury Review of
systems includes Genitourinary system patient denies pregnancy,
dysmenorrhea and has a normal menstrual cycle
- Slide 13
- Cloned Notes- History Does your EMR have templates that create
a Complete 14-point Review of Systems (ROS) automatically? Issues
and risks Each element of the ROS must be supported by the History
of Present Illness for medical necessity For instance, a patient
comes in to the Emergency Department for a hand injury Review of
systems includes Genitourinary system patient denies pregnancy,
dysmennorhea and has a normal menstrual cycle Patient is an 87 year
old male
- Slide 14
- Validity of Data Systems that are documented in the HPI
(patient presents with a rash on the left arm) contradict the
systems documented in the ROS list (skin negative) Systems that are
documented in the ROS that make no sense for the patient (female
denies any erectile dysfunction) Systems that are documented in the
HPI and conflict with personal or family history (HPI pt is here
for full skin check, mother has malignant melanoma) and the Family
history is noncontributory.
- Slide 15
- Cloned notes-Physical Exam Automated Text for a Female exam or
Male exam Includes Organ systems and Body areas that are unrelated
to the reason for the visit Findings such as HEENT negative do not
indicate why the exam was done Neck-negative- what does this mean?
Musculoskeletal- neck, full range of motion Cardiovascular- neck,
no jugular venous distention Lymphatic- neck, no adenopathy
Neurological- neck, no stiffness or pain (meningitis)
- Slide 16
- Coding based on documentation or risk? According to the OIG, if
a visit is documented with a physical exam that is more extensive
than the problem described in the HPI- If the code level agrees
with the level of risk, the superfluous items in the PE are not a
problem If the code level is based on the extent of the
documentation in the physical exam, the visit may be overcoded
Example: Detailed History, Detailed Exam, Low MDM This should be
billed as 99213 based on risk
- Slide 17
- Risk Based Coding The most important element of the 3 key
components of History, Exam and Medical Decision Making is the MDM
A comprehensive history and comprehensive exam cannot be billed at
99215 if the MDM is at Low or Moderate Risk Unless, time is the
controlling factor and is documented greater than 50% of the
face-to-face encounter was spent in counseling and coordination of
care Total time of the visit was 45 minutes
- Slide 18
- Cloning and Fraud Providers who use EMR templates that create
identical records for multiple patients on the same date of service
will be reviewed for CLONING Using the same template for the same
ROS and Physical Exam, for every patient, regardless of the reason
for the visit, is considered CLONING Each entry should be AUTHENTIC
to the patient visit, on that date Copying/pasting from a previous
note is not allowed.
- Slide 19
- Medical Necessity Acuity is a good indicator of medical
necessity. The more diagnosis codes (as long as the problems were
addressed) the higher the severity Do you run reports by Diagnosis
code and view your E/M levels?
- Slide 20
- Auditing Processes- validating the authenticity of
Documentation
- Slide 21
- What to Audit Baseline Audit Identify areas in need of
increased documentation to maintain compliance Recommended 10-15
records per provider Random records but should reflect trends of
provider specific problem areas triggers or areas of concerns
Include Evaluation and Management and surgical encounters Use
reports to help decipher what types of services to review for your
physicians
- Slide 22
- Auditing the Records Audit based on information provided to
auditor Evaluated on information specific to the date of service
Records must be fused Evaluate documentation content and medical
necessity of visit Three notations of each performed audit:
Services billed Documentation level Medical necessity level
- Slide 23
- SOAP Notes Subjective (History) Describes the patients symptoms
and reason for visit Questions Presently experiencing Have
experienced Other signs/symptoms PFSH can be asked to help identify
possible risk factors APSO Exam HistoryMDM
- Slide 24
- SOAP Notes Objective (Examination) Hands on examination of the
patient by provider Includes: Vital signs, Eyes, Ears, Nose,
Throat, Neck, Cardiovascular, Chest, Respiratory, GI, GU,
Lymphatic, Musculoskeletal, Skin, Neurologic, Psychiatric APSO Exam
HistoryMDM
- Slide 25
- SOAP Notes Assessment (MDM) Patient diagnosis Other information
important to the diagnostic assessment APSO Exam HistoryMDM
- Slide 26
- SOAP Notes Plan (MDM) What the provider has developed for plan
of treatment, referrals, consultations, medications and
re-evaluations APSO Exam HistoryMDM
- Slide 27
- Counseling Documentation Counseling The physician spends a
majority of the visit talking with the patient, and due to this is
unable to fulfill all of the necessary components needed in order
to meet documentation guidelines. Test results consume the visit
Risks and benefits of a treatment are discussed Patient education
Multiple treatment options are discussed
- Slide 28
- Time Documentation Provider spends more than 50% of the visit
counseling the patient Example: I spent more then 50% of the visit
or a total of 45 minutes counseling the patient about their
depression. Document in patient medical record Time can not be used
with Emergency Department codes
- Slide 29
- Components E/M services are scored based on the documentation
of necessary components History - 1st component Examination - 2nd
component Medical Decision Making (MDM) 3rd component Contributing
factors Counseling, coordination of care, nature of presenting
problem, and time
- Slide 30
- History History of the medical record documentation should
include four areas: Chief Complaint History of Present Illness
Review of Systems Past, Family and Social History This area is
scored on the area of history documented with the least amount of
information.
- Slide 31
- Chief Complaint Chief Complaint is recommended of every medical
record. Concise statement that describes the problem/condition for
the patient encounter. Usually in the patients own words This is
usually documented by the nurse or medical assistant Beware of
routine reasons
- Slide 32
- Routine Reasons for visit Here to establish care Here for lab
results Here for MRI or radiology results Here for annual exam (and
an E/M code is reported) Here for routine recheck Ugh! Actually
used a word that says the visit is unnecessary! Share this list
with your Medical Assistants!
- Slide 33
- History of Present Illness - HPI HISTORY COMPONENT Must be
personally documented by the provider History of Present Illness
Patient symptoms and Chief Complaint What they are presently
experiencing Location Severity Timing Modifying Factors Quality
Context Duration Associated Signs & Symptom Brief 1-3 HPI
Elements OR status of 2>chronic or inactive conditions Extended
4< HPI elements OR status of 3< chronic or inactive
conditions
- Slide 34
- History of Present Illness (HPI) Location Severity Timing
Modifying Factors Quality Duration Context Associated Signs and
Symptoms HPI must be documented personally by the clinician.
- Slide 35
- First Component of HPI Brief History 1-3 Elements Extended
History 4 or more elements for 95/97 guidelines 3 or more
chronic/inactive for 97 guidelines Location Severity Timing
Modifying Factors Quality Context Duration Associated Signs &
Symptom Brief 1-3 HPI Elements OR status of 2>chronic or
inactive conditions Extended 4< HPI elements OR status of 3<
chronic or inactive conditions
- Slide 36
- Review of Systems HISTORY COMPONENT Review of Systems -ROS
Inventory of body systems obtained by questions from provider to
identify signs/and symptoms the patient may be experiencing or has
experienced. Constitutional ENT Eyes Cardiovascular Respiratory GI
GU Neurology Musculoskeletal Psychiatric Integumentary Endocrine
Hem/Lymph Allergy/Immunology All Others Negative NonePertinent to 1
system Extended 2-9 Systems Complete 10 systems or all neg
- Slide 37
- Review of Systems - ROS Constitutional Weight, fever, sweating
ENT Ears, Nose, Throat Eyes Glasses, vision problems,
Cardiovascular Heart, palpitations, chest pain GI Diarrhea,
vomiting GU Urinary, Male/Female problems Respiratory SOB, coughing
Musculoskeletal Joint pains, backaches, stiffness Psychiatric
Depression, anxiety, mood swings Integumentary Rashes, dryness,
hair, nails, lesions Endocrine Thyroid, excessive sweating
Hem/Lymph Easy bruising or bleeding, swollen glands
Allergy/Immunology Allergies to food, hepatitis. HIV Neurologic
Blackouts, seizures, memory loss, speech
- Slide 38
- No Double Dipping If you use a symptom or system in the History
of Present Illness, you cant use it in Review of Systems Example:
The patient woke up with a headache today Using headache as
location (HPI) and Neurologic (ROS) is not permitted
- Slide 39
- Past, Family, Social History - PFSH HISTORY COMPONENT PFSH Past
Medical, Family & Social History The provider asks the patient
information about past history of illnesses and diseases, social
history, and, family history of diseases and illness. Past Medical
History Family History Social History Established Patient None None
1 History Area 2 or 3 History Area Past Medical History Family
History Social History New Patient None None 1 or 2 History Area 3
History Areas
- Slide 40
- Past- prior illnesses, surgery, hospitalizations, allergies,
medications Family- age and cause of death of immediate family
members, or family members with diseases that are related to the
patients visit Social- lifestyle such a marital status, alcohol or
tobacco use, occupation, education, living situation, sexual
activity Past, Family, Social History - PFSH
- Slide 41
- History in Children Past History Specifics regarding birth
Family History Pregnancy of mother History of birth mother/father
Social History Parents alcohol or smoking habits Child care
settings
- Slide 42
- Unobtainable History Sometimes it is impossible to obtain a
history due to the status of the patient. Document why the history
was unobtainable How to score 1st view Omit the history as scorable
component 2nd view Allow a complete history Recommendation: Let
doctors decide and documented in your compliance manual
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- Examination An examination based on either the 1995 or 1997
documentation guidelines. 1995 examinations are based on the organ
systems and body areas. 1997 examinations are based on bullets
outlined through specific system examinations.
- Slide 44
- Examination Examination is the hands on examination performed
by the provider Unremarkable and non-contributory do not meet the
necessary requirements (Think no comment) Negative or normal meets
documentation guidelines If abnormal reason it is abnormal must be
documented
- Slide 45
- Template Risks for Physical Exam The biggest risk in EMR
documentation is the exam Using the same exam for every patient,
every visit, may lead to over- documentation of the exam Examples:
Patient is seen for a sore throat Comprehensive exam is documented,
mostly negative other than ears, nose, throat, respiratory and
constitutional Why is an exam done of unrelated systems?
- Slide 46
- 95 Examination Body areas and systems can be acceptable for all
levels of examination with the exception of the comprehensive level
Body areas: Head, neck, chest, abdomen, genitalia, back, each
extremity Body systems: Constitutional, eyes, ears, nose, throat,
mouth, cardiovascular, respiratory, GI, GU, musculoskeletal, skin,
neurologic, psychiatric, lymphatic
- Slide 47
- 95 Examination Body Areas BAHead, including the face BANeck:
neck (masses, symmetry, etc), thyroid BAChest (Breasts): inspection
breast, palpation breast/axillae BAAbdomen BAGenitalia, groin,
buttocks BABack, including spine BALeft upper extremity BARight
upper extremity BALeft lower extremity BARight lower extremity
- Slide 48
- 95 Examination Organ Systems=OS OSConstitutional 3 of the
following: sit/stand BP, sup BP, temp, pulse rate, respiratory,
height, weight or general appearance OSEyes conjunctivae/lids,
pupils/irises, optic discs OS Ears, Nose, Mouth/Throat External
exam ears/ nose, external auditory canal/tympanic membrane, hearing
assessment, nasal mucosa/septum/turbinates, lips/teeth/gums,
oropharynx OSRespiratory: Respiratory effort, chest percussion,
chest palpation, auscultation of lungs OSCardiovascular Palpation
heart, auscultation, exam of: carotid, femoral arteries, abdominal
aorta, pedal pulses, extremities OSGastrointestinalAbdominal,
lever/spleen, hernia, stool sample taken, anus, perineum, rectum
OSGenitourinary Male: scrotum, penis, DRE/prostate Female: pelvic,
ext genitalia, urethra, bladder, cervix, uterus, adnexa/parametria
OSMusculoskeletal Gait/station, digits/nails, examination of
jointst, bone, muscles, inspect & palpate, stability, ROM,
strength & tone OSSkin Inspection skin/ subcutaneous tissue,
palpation skin/ subcutaneous tissue OSNeurologic Crainal nerves,
deep tendon reflexes, sensation OSPsychiatric Judgment/ insight,
MSE: orientation, remote & recent memory, mood & affect OS
Hematologic/ lymphatic Neck, axillae, groin, other/immunologic
- Slide 49
- 95 Examination Problem Focused1 body area or 1 body system Exp
Problem Focused 2 - 7 body systems, no detail of any system
required Detailed 2 - 7 body systems with affected system in detail
Comprehensive 8 or more body system (not body areas) OR Problem
Focused1 body area or 1 body system Exp Problem Focused 2 - 4 body
systems or body areas Detailed 5 - 7 body systems or body areas
Comprehensive 8 or more body systems (not body areas)
- Slide 50
- 97 Examination General Multisystem Constitutional Measurement
of any three of the following seven vital signs: 1) sitting or
standing blood pressure, 2) supine blood pressure, 3} pulse rate
and regularity, 4) respiration, 5) temperature, 6) height, 7)
weight (may be measured and recorded by ancillary staff) General
appearance of patient e.g. development, nutrition, body habitus,
deformities, attention to grooming Neck Examination of neck e.g.
masses, overall appearance, symmetry, tracheal position, crepitus
Examination of thyroid e.g. enlargement, tenderness, mass Eyes
Inspection of conjunctivae and lids Examination of pupils and
irises e.g. reaction to light and accommodation, size, symmetry
Ophthalmoscopic examination of optic discs e.g. size, C/D ratio,
appearance and posterior segments e.g. vessel changes, exudates,
hemorrhages Ears, nose, External inspection of ears and nose mouth
& Otoscopic examination of external auditory canals and
tympanic membranes throat Assessment of hearing e.g. whispered
voice, finger rub, tuning fork Inspection of nasal mucosa, septum
and turbinates Inspection of lips, teeth and gums Examination of
oropharynx: oral mucosa, salivary glands, hard and soft palates,
tongue, tonsils and posterior pharynx
- Slide 51
- 97 Examination General Multisystem Respiratory Assessment of
respiratory effect e.g. intercostal retractions, use of accessory
muscles, diaphragmatic movement Percussion of chest e.g. dullness,
flatness, hyperresonance Palpation of chest e.g. tactile fremitus
Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs
Cardiovascular Palpation of heart e.g. location, size, thrills
Auscultation of heart with notation of abnormal sounds and murmurs
Examination of: Carotid arteries e.g. pulse, amplitude, bruits
Abdominal aorta e.g. size bruits Femoral arteries e.g. pulse,
amplitude, bruits Pedal pulses e.g. pulse amplitude Extremities for
edema and/or varieosities Chest (breasts) Inspection of breasts
e.g. symmetry, nipple discharge Palpation of breasts and axillae
e.g. masses or lumps, tenderness Gastrointestinal Examination of
abdomen with notation of (abdomen presence of masses or tenderness
Examination of liver and spleen Examination for presence or absence
of hernia Examination when indicated of anus, perineum and rectum,
including sphincter tone, presence of hemorrhoids, rectal masses
Obtain stool sample for occult blood test when indicated
- Slide 52
- 97 Examination General Multisystem Genitourinary Examination of
the scrota! Contents e.g. hydrocele, spermatocele, tenderness of
cord, (Male) testicular mass Examination of the penis Digital
rectal examination of prostate gland e.g. size symmetry,
nodularity, tenderness Genitourinary Pelvic examination (with or
without specimen collection for smears and cultures) including:
(Female) Examination of external genitalia e.g. general appearance,
hair distribution, lesions and Vagina e.g. general appearance,
estrogen effect, discharge lesions, pelvic support, cystocele,
rectocele Examination of the urethra e.g. masses, tenderness,
scarring Examination of the bladder e.g. fullness, masses
tenderness Cervix e.g.general appearance, lesions, discharge Uterus
e.g. size, contour, position, mobility, tenderness, consistency,
descent or support Adnexa/parametria e.g. masses, tenderness,
organomegaly, nodularity Lymphatics Palpation of lymph nodes in two
or more areas: Neck Axillae Groin Other
- Slide 53
- 97 Examination General Multisystem Musculoskeletal Examination
of gait and station Inspection and/or palpations of digits and
nails e.g. clubbing, cyanosis, inflammatory conditions, petechiae,
ischemia, infections, nodes Examination of joints, bones and
muscles of one or more of the following six areas: 1) head and
neck, 2) spine, ribs and pelvis, 3) right upper extremity 4) left
upper extremity, 5) right lower extremity, 6) left lower extremity.
The examination of a given area includes: Inspection and/or
palpation with notation of presence of any misalignment, asymmetry,
crepitation, defects, tenderness, masses, effusions Assessment of
range of motion with notation of any pain, creptitation or
contracture Assessment of stability with notation of any
dislocation (luxation), subluxation or laxity Assessment of muscle
strength and tone e.g. flaccid cog wheel, spastic with notation of
any atrophy or abnormal movements Skin Inspection of skin and
subcutaneous tissue e.g. rash, lesions, ulcers Palpation of skin
and subcutaneous tissue e.g. induration, subcutaneous nodules,
tightening Neurologic Test cranial nerves with notation of any
deficits Examination of deep tendon reflexes with notation of
pathological reflexes e.g. Babinski Examination of sensation e.g.
tough, pin, vibration, proprioception Psychiatric Description of
patient's judgement and insight Brief assessment of mental status
including: Orientation to time, place, and person Recent and remote
memory Mood and affect e.g. depression, anxiety, agitation
- Slide 54
- 97 Examination General Multisystem Problem FocusedOne to five
elements identified by a bullet Exp Prob FocusedAt least six
elements identified by a bullet DetailedAt least two elements
identified by a bullet from each six areas/systems OR at least
twelve elements identified by a bullet in two or more areas/systems
Comprehensive Performed all elements identified by a bullet and
document at least two elements by a bullet from each of nine
area/system
- Slide 55
- Medical Decision Making - MDM The medical decision making
portion of the documentation includes information that tells the
diagnosis of the patient and how the diagnosis or diagnoses will be
treated. Three areas of documentation: Diagnosis Complexity
Risk
- Slide 56
- MDM - Diagnosis Cannot get credit for mentioning a diagnosis
that may not be applicable to the days visit EMRs often list all
problems Some require an ICD-9 code to order a test, even if the
reason for the test is not addressed during the current encounter
Minimum of one diagnosis treated with a developed plan of care.
Diagnosis should have relevance to the treatment. Mentioning
diagnosis may be a secondary issue
- Slide 57
- Points # of Diagnoses or Management Options Problem Categories
(Multiplier) Self-limited/minor (stable, improved, or worsening)1
(max = 2) Established/stable/improved1 Established/worsening/not
responding to treatment2 New, no additional workup planned3 (max =
1) New, workup planned4 MDM - Diagnosis
- Slide 58
- What is additional work-up? Extensive procedures that do not
have the results on the date of service can be considered as
additional workup. These may include: MRI, CT, biopsies, nuclear
medicine testing, laboratory testing, etc
- Slide 59
- MDM Diagnosis Self Limited/Minor ? Improved ? Worsening? New
Problem, no work-up? New Problem, additional work-up? Self Limited
or minor (stable, improved, or worsening) (Max 2) 1x Established
problem, stable, improved1/dxx Established problem, worsening2/dxx
New problem; no additional work-up planned (Max 1)3x New problem;
additional work-up planned ie; referred, testing4x Total
- Slide 60
- MDM - Complexity of Data Points are assigned based on the
following: Review and/or order: clinical lab tests tests in
radiology section tests in medicine section Decision to obtain old
records and/or obtain history from someone other than patient
Review and summarization of old records and/or obtaining history
from someone other than patient and/or discussion of case with
another health care provider Independent visualization of image,
tracing or specimen itself (not simple review of report)
- Slide 61
- Ordering Test Providers are assigned pointed based on the
category of test ordered. One point per category ordered and not
based on the number of tests ordered Example: CBC and Strep tests
are ordered only one point for Review and/or order clinical lab
tests
- Slide 62
- Medical Record Requesting medical from the patients previous
provider. Must be documented Reviewing of the medical record
Guidelines require a brief summarization of the findings and not a
simple statement that they were reviewed
- Slide 63
- Independent Visualization Two points are given for every test
they interpret. If they interpret the test, they do not receive
points for ordering the test. Provider needs only to include a copy
of the findings with his/her interpretation to obtain credit.
- Slide 64
- MDM Complexity of Data Reviewed or Ordered Review and/or order
clinical lab tests 1 Review and/or tests in radiology section 1
Review and/or tests in medicine section 1 Decision to obtain old
records and/or obtain history from someone other than patient 1
Review and summarization of old records and/or obtaining history
from someone other than patient and/or discussion of case with
another health provider 2 Independent visualization of image,
tracing or specimen itself (not simple review of report 2
TOTAL
- Slide 65
- Labs, radiology, medicine? Discuss with another health
provider? Independent visualization? Review and/or order clinical
lab tests 1 1 Review and/or tests in radiology section 1 1 Review
and/or tests in medicine section 1 Decision to obtain old records
and/or obtain history from someone other than patient 1 Review and
summarization of old records and/or obtaining history from someone
other than patient and/or discussion of case with another health
provider 2 2 Independent visualization of image, tracing or
specimen itself (not simple review of report 2 TOTAL 4
- Slide 66
- Diagnosis1 or less234 or more Complexity1 or less234 or more
RiskMinimalLowModerateHigh Level Straight Forward LowModerateHigh
Medical Decision Making
- Slide 67
- MDM - Risk of Complications The level of risk must be assigned
to every patients medical record as the level of risk assigned
mirrors the medical necessity of the documentation. The level of
risk tells the reader of the note exactly what it implies: the
level of risk the provider has assumed in treating the patient on
this date of service.
- Slide 68
- Table of Risk There are three components to the table of risks:
Presenting problem Diagnostic procedures Management options
- Slide 69
- MDM - Presenting Problem Presenting Problem M I One
self-limited, minor problem e.g. cold, insect bite LOWLOW 2 or more
self limited or minor problems, 1 stable chronic, acute illness or
injury uncomplicated MODMOD One or more chronic illness with mild
exacerbation, 2 or more chronic illness, acute illness with
uncertain prognosis, acute complicated injury H I G H 1 or more
chronic illness with severe exacerbation, progression or side
effect of treatment, acute or chronic illness or injury that may
pose a threat to life or body function, abrupt change in
neurological status
- Slide 70
- MDM - Diagnostic Procedure Diagnostic Procedure Lab testing
requiring venipuncture, chest x-ray or US, EKG/EEG, KOH prep or UA
Physiological test not under stress, PFT, non cardiovascular image
study with contrast, superficial needle biopsy, clinical lab
requiring arterial puncture, skin biopsy Physiological test under
stress, diagnostic endoscopy with no identified risk factors, deep
needle or incision biopsy, cardio imaging study with contrast no
identified risk factors, obtain fluid from body cavity
Cardiovascular imaging studies with contrast with identified rsk
factors, cardiac electrophysiological test, diagnostic endoscopy
with identified risk factors, discography M I LOWLOW MODMOD H I G
H
- Slide 71
- MDM - Management Options Management Options Rest, gargles,
dressing, bandaid OTC drugs, PT or OT, IV fluids w/o additive.
Minor surgery no identified risk factors Minor surgery with
identified risk factors, elective major surgery with no
identifiable risk factors, prescription drug management,
therapeutic nuclear medicine, IV with additives, closed treatment
of fracture or dislocation w/o manipulation Elective major surgery
with identifiable risk factors, emergency major surgery, IV
controlled substances, drug therapy requiring intensive monitoring
for toxicity, decision not to resuscitate or de-escalate because of
poor prognosis M I LOWLOW MODMOD HIGHHIGH
- Slide 72
- Choosing the Level of Risk The highest level of risk in any one
category; presenting problem, diagnostic procedure or management
options determines the overall risk. Presenting ProblemDiagnostic
ProcedureManagement Options M I One self-limited, minor problem
e.g. cold, insect bite Lab testing requiring venipuncture, chest
x-ray or US, EKG/EEG, KOH prep or UA Rest, gargles, dressing, band
aid LOWLOW 2 or more self limited or minor problems, 1 stable
chronic, acute illness or injury uncomplicated Physiological test
not under stress, PFT, non cardiovascular image study with
contrast, superficial needle biopsy, clinical lab requiring
arterial puncture, skin biopsy OTC drugs, PT or OT, IV fluids w/o
additive. Minor surgery no identified risk factors MODMOD One or
more chronic illness with mild exacerbation, 2 or more chronic
illness, acute illness with uncertain prognosis, acute complicated
injury Physiological test under stress, diagnostic endoscopy with
no identified risk factors, deep needle or incision biopsy, cardio
imaging study with contrast no identified risk factors, obtain
fluid from body cavity Minor surgery with identified risk factors,
elective major surgery with no identifiable risk factors,
prescription drug management, therapeutic nuclear medicine, IV with
additives, closed treatment of fracture or dislocation w/o
manipulation H I G H 1 or more chronic illness with severe
exacerbation, progression or side effect of treatment, acute or
chronic illness or injury that may pose a threat to life or body
function, abrupt change in neurological status Cardiovascular
imaging studies with contrast with identified rsk factors, cardiac
electrophysiological test, diagnostic endoscopy with identified
risk factors, discography Elective major surgery with identifiable
risk factors, emergency major surgery, IV controlled substances,
drug therapy requiring intensive monitoring for toxicity, decision
not to resuscitate or de-escalate because of poor prognosis
- Slide 73
- MDM Level is determined with 2-3 or center level What is the
level Straight Forward, Low, Moderate, High Diagnosis1 or less234
or more Complexity1 or less234 or more RiskMinimalLowModerateHigh
Level Straight Forward LowModerateHigh Calculating the Level of
MDM
- Slide 74
- Score Sheet HISTORYMinimal Problem Focused Exp Problem Focused
DetailedComprehensive EXAMN/A Problem Focused Exp Problem Focused
DetailedComprehensive MDM N/A Straight Forward LowModerateHigh
LEVEL9921199212992139921499215 TIME 5 minutes10 minutes15 minutes25
minutes40 minutes Established Patient
- Slide 75
- Code Selection Nancy Enos, FACMPE CPMA CPC-I
- Slide 76
- Audit Feedback -Involve your EMR administrator Extent of
History, Exam, MDM Copy and paste capabilities- What does your
practice allow? Review of Systems Templates Physical exam Templates
Provider Education Re-Audit if the provider needs monitoring Use
the information gained to effect change!
- Slide 77
- Parting thoughts- Does your Electronic Medical Record suggest
the E/M Level of Code? Do your providers accept or reject the Level
of Service code? Are your providers trained (and proficient) to
correct or edit any smart text that is not authentic? Does your EMR
require a diagnosis code when a physician is entering orders? Do
you have annual compliance audits as a part of your practices
Compliance Program?
- Slide 78
- Nancy M Enos, FACMPE, CPMA, CPC-I, CEMC is an independent
consultant with the MGMA Health Care Consulting Group. Nancy was a
practice manager for 18 years before she joined LighthouseMD in
1995 as the Director of Physician Services and Compliance Officer.
In July 2008 Nancy established an independent consulting practice.
As an Approved PMCC Instructor by the American Academy of
Professional Coders, Nancy provides coding certification courses
and consultative service. Nancy frequently speaks on coding,
compliance and reimbursement issues. Nancy became an AAPC Certified
ICD-10 Instructor in June, 2013. Nancy is a Fellow of the American
College of Medical Practice Executives. She is a past Chair of the
Eastern Section MGMA and is a past President of MA/RI MGMA and
serves on the Section Council Steering Committee for MGMA. Email:
nancy@enosmedicalcoding.comnancy@enosmedicalcoding.com