Charting Basics & ICD Coding Quality Patient Care & Substantiated Billing

Mona Fahoum, ND

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Interview Basics

Listening Active and Reflective listening:

• Be quiet and let them talk• Allow silences• Share your thoughts (not your opinion)

• Reflect back what you hear to make sure you understand their symptoms & intent

• Then, you can construct goals with the patient, Measurable, Achievable goals that they buy into.

• WRITE THEM DOWN!!!!!

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Interview Basics• Remember you are the Doctor:

• You need to guide the history• You need to guide the exam• You need to guide the treatment• You are responsible medically, legally and ethically

to help this patient.• You are the most important person in the room.

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SOAP Notes

• Record of subjective and objective findings so you can track progress.

• Patients often don’t see progress, but you can say, “look, your pain went from a 7 to a 3”. They said it, not you.

• Safety in ruling out medical contraindications for certain modalities, medications, etc.

• Record of Illness (and wellness), treatment and procedures.

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SOAP Notes

From an Insurance Perspective:• If it’s not written down, it didn’t happen.• Marketing for you, educates others of

your education and role in healthcare.• Proof of services, medical necessity.• Proof you are treating within scope of

practice.• Proof your charges are ‘usual and

customary’ for the modalities you use.

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Intake Forms

Demographics:• Name, Address, Emergency Contact,

Birthdate, Email, Phone number(s)• Names and phone numbers of other

providers• How did they hear about you?• Allergies/Medications/Supplements• Why are they here?• Goals?

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Intake Forms

Insurance Information:• Insurance name, address, phone, ID #

and Group #. Primary insured’s name and birthdate.

• If PIP, claim adjuster name and number, Claim #, Other parties insurance info and/or attorney’s info if applicable

• Copy all cards, front and back• Also need a picture ID

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Intake Forms

Health History:• Current health issues/concerns• Daily activities/exercise/Risk factors• Past medical History• Family History• Review of Systems, spurs a way for you

to know contraindications before they happen

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Intake Forms

Informed Consent:• Purely for legal-ease.• Patient is releasing you from something

they didn’t tell you and also stating that they are voluntarily seeking you to be part of their healthcare.

• Good to put in scope of practice, contraindications, etc.

• May need specific Informed Consents as well.

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Intake Forms

Financial Policy:• If you don’t delineate this now, you will

pay later, not the client.• Put your office policies, cancellation

policies and billing policies so they know what is expected of them.

• Make sure they SIGN/DATE it before you treat them. F

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SOAP Guidelines

Not to punish you, but to create a standard context amongst practitioners for better patient care:

• Use only standard abbreviations, do not make up your own. If you do have some of your own symbols, PROVIDE A LEGEND, or you might not get paid.

• Patient name and date goes on EVERY page.• If you mess up, only do single line cross-out,

date and initial. No scribbles, no white-out, etc.

• Sign and date the bottom of every chart note.

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SOAP Guidelines

• Write legibly, if the adjuster can’t read it, you’re not getting paid.

• ALWAYS have a Chief Complaint (cc) and number them accordingly (cc1, cc2)

• NEVER, EVER put personal opinions in notes. These follow patients for a long time.

• Be very careful about psych analysis. If patient is using terms, put in “quotes”.

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SOAP Guidelines• Remember:

• Post-its and scrap paper are your friend, if it’s not ‘pronged’ in chart, it is not a part of the chart… don’t abuse this clinical pearl.

• OR, notepad/stickies on password protected computer can be your ‘brain’.

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SOAP notes

It’s similar in form, content and thoroughness to classical ND or Homeopathic case taking, but if you didn’t write it down, IT DIDN’T HAPPEN!

• Subjective: health concern(s) at time of visit from patient’s perspective.

• Objective: Practitioner’s observations, findings, measurable data.

• Assessment: Problem list, Differential, working Dx and Impression

• Plan: Treatments, prescriptions, labs and any instructions or counseling you have given to patient.

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Where does CPT fit in this?

• Basic components of CPT• History• Physical• Medical Decision Making

Makes sense: S, O, A&P

For a new patient you must have all three

For a return, you must have at least 2 of 3

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Subjective or HISTORY (component 1)

• Review the patient intake forms before first visit, will guide your visit and history taking.

• Prioritize CCs with patient, goal is to treat the most acute items first, they can always reschedule.

1. For Each CC:• Get the History of Present Illness (HPI)• Location, Quality, Severity (1-10), Duration,

Context, Status, Modifying Factors, Concomitants (associated factors)

• Med/supplement review

2. Review of Systems (Intake is handy here)3. Past Family and/or Social History (PFSH)

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Subjective or HISTORY (component 1)

• ROS:• Constitutional -- Genitourinary• Eyes -- MSK• ENT --

Integumentary• Cardiovascular -- Neurological• Respiratory -- Psychiatric• Gastrointestinal -- Endocrine• Allergy/Immune

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Objective or PHYSICAL EXAM(Component 2)

This must be pertinent to the diagnoses or other findings

Use all your senses and observational skills:

• Visualize: Trauma, swelling, inflammation, movement patterns…

• Auscultate: Listen for patterns, rates, etc.

• Palpation: location, depth, patterns• Quantify/Measure: mild, moderate,

severe• Type of pain elicited: sharp, dull, aching

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Objective or PHYSICAL EXAM(Component 2)

• Body areas: Head/face, Neck, Chest, Abdomen, Genitalia, Back, Extremities.

• More often though, described as Organ Systems:• Constitutional -- MSK• Eyes -- Integumentary• ENT -- Neurological• CV -- Psychiatric• Respiratory -- Endocrine• GI -- Heme/Lymph• GU --

Allergy/Immune

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Assessment & Plan or MDM(component 3)

• Assessment: problem list, DDx, Working Dx and Impression.

• Choose appropriate ICD-9 codes, remember we have up to 4/visit for billing purposes

• ANY DDx MUST BE WORKED UP, so be aware of what you’re writing!

• What is your thought process, what labs are you ordering, what did you find on labs, in records, in office testing…

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Assessment & Plan or MDM(component 3)

• Write down functional limitations in order of importance or previous abilities.

• Write down plan for how each Dx will be addressed, treated, management, labs

• Write down any Coordination of Care (COC), did you talk to Mom, husband, another doctor?

• Set goals with patient or give ‘homework’ as part of plan.

• Write down Future Plan or Follow-up date(s).

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Assessment & Plan or MDM(component 3)

• For Physical Medicine visits:• Treatment goes on Plan section

• Type, length• Modalities used, times on each• Specific points, Trigger points• Patient’s response, Quantify changes• Re-test ROM after Treatment

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Whoa! How does this all get done?• First visit needs to be a little longer, or

the treatment slightly shorter on the first visit.

• Use FOC for data gathering, treat only what is acute, patient homework, testing, etc.

• At follow-up, it’s a quick review, and treatment

• Re-evaluate at regular intervals• Always set up next appointment, or get

into a ‘tickler’ system.

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ICD-9 = Reimbursement

• Code what you see the patient for, and chart what you saw. In other words:

• Do what is medically necessary, completely document what you do and accurately code what you documented.

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To the Codes…

• Steps to proper diagnostic coding:1. Code the chief reason or most acute condition as the

primary (#1) diagnosis.

2. Use the alphabetical and tabular lists to get to the MOST specific code possible.

Just like a homeopathic repertory…

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For example

• Patient comes in with an annoying wart, but you find they have a a BP of 180/110 with a headache.• Chief complaint PPR was a wart, but your coding is going to

place the hypertensive reading in the #1 slot, then the headache, then the wart.

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Example, cont.

• You also need to get to the most specific ICD-9 code:• If this patient has no prior hypertension then Blood,

pressure, high, incidental reading, without diagnosis of hypertension or 796.2 is the code vs.

• Prior HTN would give you 401.9, for HTN(uncontrolled)(fluctuating)(systemic)

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Example, cont.

• Then I would code the headache, which is a symptom of the HTN:• Headache, or Headache, vascular, both have code 784.0

• Last would be the wart: Wart, common 078.19• Would I treat the wart today?

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Another example• You have to get to the most specific code: this may only

be 3 digits, 4 digits or the most specific 5 digits. (ICD-10 is 6 digits)

• Coryza = 460• Cough = 786.2• Abd pain, LUQ = 789.02 (789.0 gets you to Abd pain, the

2, gives the LUQ)

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Let’s look at this a little deeper

• 460=Acute nasopharyngitis [common cold]• Coryza (acute), Nasal catarrh, acute• Nasopharyngitis: NOS, acute, infective NOS• Rhinitis: acute, infective• EXCLUDES: nasopharyngitis, chronic (472.2)

• Pharyngitis: acute/NOS (462), chronic (472.1)• Rhinitis: allergic (477.0-477.9), chr/NOS (472.0)• Sore throat: acute/NOS (462), chronic (472.1)

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Let’s look at this a little deeper

• 786.2 = Cough• EXCLUDES cough:

• Psychogenic (306.1)• Smokers’ (491.0)• With hemorrhage (786.39)

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Let’s look at this a little deeper

• 789 Other symptoms involving the abdomen or pelvis, EXCLUDES symptoms referable to genital organs.• 789.0 Abdominal Pain• 0 unspecified site 5 periumbilic• 1 RUQ 6 epigastric• 2 LUQ 7 generalized• 3 RLQ 9 other specified site• 4 LLQ multiple sites F

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Next bit of detail…• You now know you are going to code them from most

important (or acute) to least, and you’re going to code to the highest specificity, now…

• You can only use a code once per visit (so bilateral issues, need to be charted)

• You have four spaces, so use them, IF YOUR CHART NOTES SUPPORT IT!!

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More Guidelines

• Signs and symptoms: Codes that describe symptoms and signs, as opposed to diagnoses are acceptable for reporting when a definitive diagnosis has not been established (or confirmed) by the provider.

• Headache (784.0) vs. Classical migraine without mention of intractable migraine (346.01)

• Or, diarrhea, infectious, presumed (009.3) vs. diarrhea, due to, Staphylococcus (008.41)

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More Guidelines

• You cannot code items that are already associated with a coded condition.• Premenstrual syndrome (625.4), don’t add

cramps, abd pain, bloating…it’s implied in primary code.

• Do code items that are not part of the stated condition.• PMS, but they also have constipation and abd

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More Guidelines

• Manifestations of one disease process, are secondary to the primary condition.

• For example: Peripheral neuropathy and a leg ulcer in a diabetic patient1. DM w/ neuro manifestations, controlled (250.60)

2. Polyneuropathy (357.2)

3. Ulcer, skin, lower extremity, calf (707.12) Fah

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More Guidelines• If you have an acute exacerbation of a chronic condition

and you are seeing them for both today:• The acute code is #1, followed by the chronic code• Example: Acute maxillary sinusitis (461.0) in a person

who suffers from chronic sinustis (473.9)

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General vs. Specific

• Can be a red flag for insurance companies:• Neck pain (723.1) every visit for the next two years says

your treatments aren’t very effective• Low back pain (724.2) vs. Degeneration of lumbar

intervetebral disc (722.52), if you have a diagnosis, use it!!

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V codes

• Love ‘em, but you have to know how to use them!

• “Supplementary Calssification of Factors Influencing Health Status and Contact with Health Services”

• Translation = exposures to illness, history of illnesses, physicals, counseling, congenital issues, screenings, outside factors in general

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V codes• V70, most common v-code for annual exams and

physicals• V70.0 Routine general medical exam at a healthcare facility• V70.3 other medical exam for admin

• Camp, school admission, sports, insurance, etc• V70.5 Health exams of defined subpopulations (armed

forces, pre-employment, etc.)

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V code Guidelines

• If ANNUAL is to be applied to an individual’s preventive insurance benefit (which is usually pre-deductible), you MUST put it in the #1 slot on the billing form.

• Other V codes are great, but be wary of putting the following codes in the #1 spot if you want to get paid…very few people have counseling or preventive service benefits outside their annual or possibly contraceptive care.

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Examples

• V72.32 Encounter for pap smear to confirm recent NL smear following initial ABNL smear

• V72.40 Preg exam/test, preg unconfirmed• V25.01 Prescription of OCP• V25.04 Counseling in natural family planning

to avoid pregnancy• MUST CHECK BENEFITS

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More Examples• V65.3 Dietary surveillance and counseling• V65.42 Counseling on substance use and abuse• V65.45 Counseling on other STDs• V69.2 High-risk Sexual behavior• V01.89 Exposure to parasitic disease• V75.1 Screening malaria

• For Next week, have a copy of the Audit Tool printed out for reference during webinar!!!!! F

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