Clinical Documentation TipsReflection of Acuity &

Medical Necessity

“I Bill for It”

ObjectivesUnderstand the elements of synergies in

clinical documentation impacting physicians and hospitals

Understand relationship between specificity in documentation and patient acuity

Learn how patient acuity and comorbid conditions drives medical necessity and E & M assignment

Appreciate the “pitfalls” and “traps” of documentation that contribute to denials and downcoding of E & M

History of Present IllnessHPI is chronological description of the

development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

Focus upon present illness!

HPIHPI → 8 elements

LocationQualitySeverityDurationTimingContextModifying factorsAssociated signs and symptoms

HPI that are really “HPI’s”Mrs. Jones, a 75 year old patient

presented to the Emergency Room with abdominal pain lower left quadrant of three days duration, suddenly worse last night, with associated shortness of breath, took Maalox, didn’t help. Pain described as at 10 on a pains scale of 10. Pain now 7 out of 10 after receiving Morphine in the ER.

Right to the PointHPI- The patient presented from the Personal

Care Home with a two day history of worsening shortness of breath and nonproductive cough. She started using oxygen at home but this got progressively worse , particularly when ambulating, and she came to the Emergency Room this morning and was found to be in acute respiratory distress.

Right to the Point

She was evaluated and found to have acute hypoxemic respiratory failure, congestive heart failure with possible pneumonia. She was stabilized somewhat in the Emergency Room but is still short of breath, more so that at her usual baseline. She is being admitted for further evaluation and treatment.

Assessment & PlanThis is a 75 year old-female with 1) Acute

congestive heart failure, acute left ventricular systolic dysfunction with probable chronic left ventricular systolic dysfunction. We are going to admit her, give her fluid restrictions, intravenous Lasix for diuresis and pulmonary toilet. Will monitor closely.

Assessment & Plan1) Chronic obstructive pulmonary disease

exacerbation with acute on chronic respiratory failure and hypoxia and hypercapnia and acute respiratory acidosis. We are going to give her oxygen and pulmonary toilet with Duoneb treatment. Will diurese her as noted above. Will cover empirically for infection with Avelox, 400 mg, IV daily. Monitor closely and call in pulmonology service and cardiology service if clinical conditions worsen.

Assessment & Plan Continued3) Diabetes mellitus, Type II controlled, and

will continue her on Lantus and start her regular insulin sliding scale and monitor

4) Hypertension, will continue current medications and monitor

History of breast cancer. Status post lumpectomy, apparently stable.

5) History of long QT syndrome. She does have an implantable defibrillator. Will rule out MI per protocol and monitor closely(Total time for H & P examination one

hour)

Role of HPIHPI drivers:

Extent of PFSH, ROS and physical exam performed

Medical necessity for amount work performed and documented

Medical necessity for E & M assignmentMedical necessity of an Evaluation and

Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements.

Speaking of Medical NecessityFederal law requires that all expenses paid

by Medicare, including expenses for Evaluation and Management services, are medically reasonable and necessary.

1862(a)(1)(a) of the Social Security Act, Title XVIIINo payment can be made for items and

services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Applies to physician and hospital

Synergy of Clinical DocumentationPhysician Responsible for patient designation

assignmentInpatient versus Outpatient Service

The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting.

Documentation of AcuityFactors to be considered when making the

decision to admit include such things as:The severity of the signs and symptoms exhibited by

the patient;The medical predictability of something adverse

happening to the patient;The need for diagnostic studies that appropriately

are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and

The availability of diagnostic procedures at the time when and at the location where the patient presents.

Medical NecessityMedical necessity of a 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.

Less Complex diagnoses potentially warrant a lower level of E & M

Medical ComplexitySigns, Symptoms &

Nonspecific DiagnosesSpecific Diagnoses

Chest Pain/Acute Coronary Syndrome

Hypoxemia/Acute Respiratory Distress

Nausea and VomitingCHFPostobstructive

Pneumonia with right lower lobe cancer inoperable

Non ST MI with unstable angina

Acute hypoxemic respiratory failure

Food poisoning with severe dehydration

Acute on chronic systolic left sided heart failure

Suspected gram-negative pneumonia in a patient with known inoperable RLL cancer

Medical NecessityMedical necessity of E/M services is

generally expressed in two ways: frequency of services and intensity of service (CPT level).

Medicare’s determination of medical necessity is separate from its determination that the E/M service was rendered as billed.

Medical NecessityMedicare determines medical necessity largely

through the experience and judgment of clinician coders along with the limited tools provided in CPT and by CMS.

At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs

Elements of 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

diagnoses/ problems addressed through history, physical and medical decision-making.

Common Documentation Deficiency

Progress Note9/13 10:10 AM- Patient had no new complaints,

stable overnight. VS stable, Labs WNL.Assessment and Plan: Continue Present

ManagementDeficiency

Not Clear Face-to-Face EncounterAbsence of Diagnoses

No Billable E & M service

Elements of Medical NecessityThe 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).

Complexity Does MatterLess Complex More Complex

Acute respiratory distress

CHFCHF worsening

COPD exacerbation

COPD exacerbation with hypoxemia

Acute respiratory failureAcute systolic CHFAcute on chronic systolic

CHFAcute respiratory failure

with COPD exacCOPD exacerbation with

chronic respiratory failure

Complexity Does MatterLess Complex More Complex

Acute renal insufficiency

Chronic hypoxemiaCardiac arrhythmiaAcute renal failure

Chronic renal failure

Hypoalbuminemia

Acute renal failureChronic respiratory failureAtrial fibrillationAcute tubular

necrosis/acute interstitial nephritis

Chronic renal failure stage IV

Protein calorie malnutrition

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Medical Decision MakingMedical decision making refers to the complexity of

establishing a diagnosis and/or selecting a management option as measured by:

The number of possible diagnoses and/or the number of management options that must be considered;

The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

The risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

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Medical Decision MakingMDM consists of 4 levels

Straight Forward ComplexityLow ComplexityModerate ComplexityHigh Complexity

General Rule of Thumb is inpatient encounter should equate to Moderate or High Complexity

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Amount & Complexity of DataThe amount and complexity of data to be

reviewed is based on the types of diagnostic testing ordered or reviewed.

A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed

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Number of Diagnoses & Management Options

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.

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Documentation TipsDG: For each encounter, an assessment, clinical

impression, or diagnosis should (must)be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.

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Documentation Tips

For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnoses or as "possible,” "probable,” or "rule out” (R/O) diagnoses.

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Best Strategy DocumentationChief Complaint: Chest PainHPI- Eighty-five year old female patient

unassigned presented to the ER with abdominal pain 8 out 10 radiating to the chest, associated shortness of breath, worse at night and after eating a large meal. Patient states pain was waxing and waning for last few days, became intolerable this morning, not relieved by Maalox, prompted her to seek medical attention in the Emergency Room.

Best Strategy DocumentationAssessment & Plan

1. Chest pain- possible MI but less likely given the fact the patient does not have any risk factors for MI other than age. Will still initiate the ROMI protocol to ensure we don’t get caught in situation of blind obedience

2. Abdominal pain- likely mesenteric ischemia in light of the fact patient’s abdominal pain is worse after eating a large meal. Will order mesenteric duplex ultrasound and CT scan with contrast to evaluate status of vasculature. Will consult surgery for their recommendations of further work-up. IV pain meds as needed and NPO for now.

Practical Documentation TipsWhen documenting MDM, a list of established

diagnoses or potential diagnoses is insufficient for coding purposes without additional indications in the record of meaningful and necessary evaluation for each problem.

Practitioners should record relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which evaluation and management is clearly demonstrated

Tip- stability of chronic conditions should be documented as well as discussion of relationship to abnormal diagnostic results to established or provisional diagnoses.

Documentation ApproachTell Documentation Show Documentation

Assessment:Dizziness and headache

TIA- Acute sinusitis

HypertensionHyperlipidemiaGoutHistory of breast cancer

Assessment: Dizziness and headache

TIA- with patient describing an episode of slurred speech and difficulty finding words and weakness of left arm, this may be a TIA, will order a follow-up CT as initial in ER was indeterminate.

Hypertension- BP reading in the ER indicated hypertensive urgency, 205/120, perhaps BP elevation contributing to patient’s dizziness and headache. Will monitor and step up her anti-hypertension meds

Clinical Case StudyHPI: Mrs. Cold Weather presented to

the Emergency Room with shortness of breath of three days duration, complains of chest pain at the same time of shortness of breath, waxing and waning, stabbing at some time, 8 out of 10, not relieved by her usual nitro.

PFH: Ischemic cardiomyopathy, hypertension, EF 10-15%

Clinical Case Study Continued….PSH: quite smoking 20 years ago, lives with

her husband who is in good health for his agePast Surgical History; Non-contributoryLabs: BNP 2276, cardiac enzymes and

Troponin mildly elevatedChest X-ray shows cardiomegaly with

pulmonary vascular congestion

Clinical Case Study Continued….Clinical Impression:

Chest pain and shortness of breath rule out MI, rule out MI protocol

Elevated BNP- will start IV Lasix IV 80 mg, monitor output, chest X-ray PM,

Reduced EF- left ventricular systolic dysfunction

Chronic renal insufficiency

Clinical Case Study Continued….Clinical Impression: Mrs. Cold Weather with

history of ischemic cardiomyopathy and end stage renal disease presents with chest pain and shortness of breathPossible MI, will follow MI protocolPossible Acute systolic CHF, likely chronic

in nature also, continue to diurese. Will contact patient’s regular cardiologist

End stage renal disease- will need monitor renal function closely and diurese carefully

Table of RiskThe risk of significant complications,

morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.

DG: 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.

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Severity Risk RamificationsPDX: HypotensionSecondary DX

Congestive Heart Failure

Chronic Renal Failure

HyperkalemiaHyperlipidemiaHypercholesteremia

PDX: Acute Systolic CHF

Secondary DXChronic Renal

Failure End Stage with fluid overload

Hyperkalemia HyperlipidemiaHypercholesteremia

Financial RamificationsPDX HypotensionMS-DRG 316Other Circulatory

System Diagnoses without CC/MCC

Relative Weight .6147Approximate

Reimbursement =$4302.90 (Blended rate= $7,000)

PDX Acute Systolic CHF

MS-DRG 291Heart Failure and

Shock with MCCRelative Weight

1.4943Approximate

Reimbursement = $10,4601 (Blended rate = $7,000)

APR-DRG RamificationsPDX HypotensionAPR-DRG 207

Other Circulatory System DX

SOI 1/ROM 1Relative

weight .4850Reimbursement

$3,395 (blended rate $7,000)

PDX Acute Systolic CHF

APR-DRG 194Heart FailureSOI 3/ROM 1Relative weight

1.1222Reimbursement

$7,855.40 (blended rate $7,000)

Now a Word from our SponsorProgress note Day #2No events overnight, patient has no

complaints, appears comfortablePneumonia-will start IV antibiotic, order WBCCOPD exacerbation-will start Duonebs, IV

steroids, pulmonary toilet, will encourage smoke cessation

Hypertension –will monitor

New & ImprovedProgress Note Day # 3No events overnight, patient has no

complaints, appears comfortablePneumonia-will start IV antibiotic, order WBCCOPD exacerbation-will start Duonebs, IV

steroids, pulmonary toilet, will encourage smoke cessation

Hypertension, will monitor

Principles of Documentation

The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making as it relates to the patient's chief complaint for the encounter.

Principles of DocumentationThe patient's progress, including response to

treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented

Importance of Proper and Accurate Documentation

Services billed to the Medicare program are the sole responsibility of the Medicare provider.

Your documentation needs to be unique, specific, and should accurately reflect the services you are billing.

Importance of Proper and Accurate Documentation

Documentation not only must reflect necessity and the services provided but also must be consistent among the providers involved in an episode of care.

Medicare payment for services may be denied if the supporting documentation is not thorough.

Clinical Thought ProcessesProgress note Day #2CC- shortness of breath

HPI- patient still complaining of shortness of breath but only when he first gets up in morning Pneumonia-improving, WBC trending down to 16 from

24, bands 8, still has fever and x-ray slow clearing, will continue IV antibiotics, follow labs,

COPD exacerbation-slowly improving, lungs still junky, easily short of breath with minimal exertion, will continue Duonebs, IV steroids, pulmonary toilet, will encourage smoke cessation

Clinical Thought ProcessesProgress note Day #3CC- shortness of breath

HPI- patient still complaining of shortness of breath but no episodes in last 12 hours Pneumonia-improving, WBC almost back to within upper limits

of normal, morning labs show WBC 12 from initial 24, bands 2, fever has just about cleared, x-ray slow clearing, will step down to PO antbx, anticipate discharge tomorrow.

COPD exacerbation-resolving, responded well to hospital course of therapy. Patient agrees to smoking cessation counseling outpatient.

Nature of Presenting ProblemEnsure the nature of the patient’s

presentation corresponds to CPT’s contributory factors of the nature of the presenting problem and/or patient’s status descriptions for the code reported.

Nature of Presenting ProblemFor instance:

99231 – “Usually the patient is stable, recovering or improving.”

99232 – “Usually the patient is responding inadequately to therapy or has developed a minor complication.”

99233 – “Usually the patient is unstable or has developed a significant complication or a significant new problem.”

There Must Be a Better Way!

The Five Step ProcessDetermine that the service is medically necessaryProvide the service needed in order to properly

meet the patient’s needs. Document the service provided. Select the most appropriate CPT/HCPCS code for

the medically necessary service that was provided and properly documented.

Submit the service to Medicare that was medically necessary and documented.

Questions about this presentation? Contact Glenn Krauss at glennkrauss@earthlink.net