FIRST EDITION

A comprehensive resource for clinical documentation experts

CLINICAL DOCUMENTATION REFERENCE GUIDE

II Clinical Documentation Reference Guide AAPC | 1-800-626-2633

DisclaimerDecisions should not be made based solely upon information within this reference guide. All judgments impacting career and/or an employer must be based upon individual circumstances including legal and ethical considerations, local condi-tions, payer policies within the geographic area, and new or pending government regulations, etc.

AAPC does not accept responsibility or liability for any adverse outcome from using this reference guide for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the individual’s misun-derstanding or misapplication of topics.

Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

AAPC has obtained permission from various individuals and companies to include their material in this reference guide. These agreements do not extend beyond this program. It may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of AAPC and the sources contained within.

No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording or taping) without the expressed written permission from AAPC and the sources contained within.

Medicare DisclaimerThis publication provides situational examples and explanations, of which many are taken from the Medicare perspective. The individual, however, should understand that while private payers typically take their lead regarding reimbursement rates from Medicare, it is not the only set of rules to follow.

While federal and private payers have different objectives (such as the age of the population covered) and use different contracting practices (such as fee schedules and coverage policies), the plans and providers set similar elements of the quality in common for all patients. Nevertheless, it is important to consult with individual private payers if you have ques-tions regarding coverage.

AMA DisclaimerCPT® copyright 2019 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for Medicare & Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.

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Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX

Chapter 1The Purpose of Clinical Documentation Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Quality of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Least Expected. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Financial Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Legal Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Routine Checks for Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Mastering the Documentation Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 2Implementation of a CDI Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Conduct Appropriate Training and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Enforcement of Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3Evaluation and Management Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

An Overview of the Anatomy of the Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1995 and 1997 Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 42021 Office or Other Outpatient Services Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

American Medical Association’s (AMA’s) 2021 Office/Outpatient E/M Codes: New Patient . . . . . . . . . . . . . . . . . . . . . . . 33

AMA 2021 Office/Outpatient E/M Codes: Established Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2021 AMA CPT® E/M Guidelines Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Time and Separate Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Office/Outpatient History and Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Medical Decision Making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2021 Level of Medical Decision Making (MDM) Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

MPFS 2020 Accepts CPT® MDM Guidelines for 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5Procedural Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Global Surgery Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Medicare Surgical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

VI Clinical Documentation Reference Guide AAPC | 1-800-626-2633

Global Surgery Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Monitor Op Reports for Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Chapter 6Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Medical Necessity and CMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Recovery Audit Contractors (RAC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

RAC Audit Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

CERT & RAC Common Documentation Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Medical Necessity Practice Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter 7Clinical Conditions and Diagnosis Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Use Both Alphabetic Index and Tabular List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Level of Detail in Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Excel With Auditing Advice for ICD-10-CM and CDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

How to Prepare for an Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Post-Audit Provider Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Chapter 8Incident-to Guidelines and Shared Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Incident-to Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Split/Shared Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Split/Shared Services vs. Incident-to Billing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 9Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Fast Facts About EMR Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Templates are NOT one-size-fits-all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

EMR Templates: A Boon or a Bane? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Copy and Paste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Ace EMR Documentation With These Guidelines and Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Concision Is Key: Document Efficiently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Keep a Separate Section for the CC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Don’t Just Correct – Perfect – Your EMR Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

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10 Tips for Keeping EMR Compliance Issues at Bay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Outsmart the Auto-Populate Feature in EMRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Guard Against These Top EMR Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter 10Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Clinical Documentation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for

Evaluation and Management Services.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

2. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

3. Centers for Medicare & Medicaid Services. 2019 MPFS Final Rule. Nov. 23, 2018, Federal Register, Vol.83, No. 226. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

4. Centers for Medicare & Medicaid Services. 2020 MPFS Final Rule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

5. Centers for Medicare & Medicaid Services. Electronic Health Records Provider. . . . . . . . . . . . . . . . . . . . . . . . . . 253

6. Centers for Medicare & Medicaid Services, FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

7. Centers for Medicare & Medicaid Services. National Physician Fee Schedule Relative Value Files. . . . . . . . . . . 260

8. Department of Health and Human Services, Office of Inspector General, OIG Compliance Program for Individual and Small Group Physician Practices. Oct. 5, 2000, Federal Register, Vol. 65, No. 194. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

9. Medicare Benefit Policy Manual, MCM, 60 - Services and Supplies Furnished Incident-To a Physician’s/NPP’s Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

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Introduction

Designed for all clinical documentation improvement (CDI) team members, this book will help you and your team better understand the role documentation plays in care management, coding, and billing. Proper documentation ensures quality patient care and optimal reimbursement through more accurate coding and compliance. Accurate documentation is also your one best defense in the event of litigation. The Clinical Documentation Reference Guide walks you through the minefield of common documentation pitfalls and teaches you the skills necessary to create, overhaul, or enhance your organization’s documentation improvement program to protect your reimbursement and operate ethically.

This extensive guide is filled with page after page of insights to guide you in devel-oping or expanding the qualities necessary to meet and manage clinical documen-tation. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complica-tions and comorbidities, and CDI for EMRs.

Prevent documentation deficiencies and keep your claims on track for optimal reimbursement with this expert guidance:

l Understand the legal aspects of documentation. l Anticipate and avoid documentation trouble spots. l Keep compliance issues at bay. l Learn proactive measures to eliminate documentation problems. l Work the coding mantra — specificity, specificity, specificity. l Avoid common documentation errors identified by CERT and RACs. l Know the facts about EMR templates — and the pitfalls of auto-populate

features. l Master documentation in the EMR with guidelines and tips. l Conquer CDI time-based coding for E/M.

Learn the all-important steps to ensure your records capture the work your providers perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the prac-tical and effective guidance in the Clinical Documentation Reference Guide to triumph over your toughest documentation challenges.

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CHAPTER 1

The Purpose of Clinical Documentation Improvement

The Quality of DocumentationQuality assurance in patient care is only evident if it is documented in the medical record. Quality services may have been provided; however, if this is not evident within the medical record, problems may arise.

For example, another provider (or the same provider several weeks later) will not necessarily know the details of the previous encounter. Providers can’t always rely on the patient to fill them in. For example, the provider may ask the patient what medications she is taking, and the patient responds, “I take the purple one in the morning.” If the provider has not documented the type of medication and proper dose in the patient’s record, he will have no idea what the patient is taking and whether she is taking it correctly.

If the provider instructs the patient on risks and benefits of a procedure and how to properly take medication but fails to document the instructions given and that the patient understood all the instructions, the provider has made himself vulnerable if the patient has any type of misadventure.

Records are scrutinized by multiple entities. Providers and facilities are being challenged to put their best foot forward in many ways. The only evidence the providers have of their veracity and the quality of care provided is the medical record.

Another reason for a quality assessment review of the clinical documentation is the number of requests for medical documentation from contractors paid by CMS for Hierarchical Condition Category (HCC) and Healthcare Effectiveness Data and Information Set (HEDIS) studies. These programs are abstracting data from the medical records for calculating risk adjustments based on the severity of diseases.

“The ultimate purpose of the CMS-HCC model is to promote fair payments to Medicare Advantage (MA) plans that reward efficiency and encourage high quality care for the chronically ill. Its use is intended to redirect money away from MA plans that disproportionately enroll the healthy, while providing the MA plans that care for the sickest patients the resources to do so” as stated in the Evaluation of the CMS-HCC Risk Adjustment Model.

Requests for medical records come from many sources, for different reasons other than reimbursement. For example:

l CMS contractors, HCC, HEDIS l Patients l Attorneys l Other providers l Workers’ compensation l Payers for precertification l Pre-employment applications l Military application l SSI applications

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The Purpose of Clinical Documentation Improvement CHAPTER 1

follow up to make sure the claim is not lost in the shuffle. These concerns must be tailored to each practice based on size and need.

Policies should be developed concerning typographical errors in transcription and the overutilization of EMR templates and pre-populated data. This task should be assigned to an individual who will monitor such use. A timeframe should be estab-lished for making corrections.

Policies for corrections of handwritten notes and policies concerning addendums must be systematically in place to facilitate the process of documentation improve-ment, producing clarity and accuracy.

Protocols for documentation are needed to establish policies for the practice’s use of abbreviations. Abbreviations and symbols can be an effective and efficient form of documentation if their meaning is well understood by the health provider who is using and/or reading them. Abbreviations should have clear definitions and be used practice wide for consistency in documenting and abstracting.

Frequently Asked Questions Question: What is medical record documentation?

Answer: Documentation provides a valuable account of a patient’s concerns, as described to the physician, and the physician’s assessment of, and findings about, the patient’s condition and resulting treatment plans.

Furthermore, because it is ultimately the physician’s responsibility to establish the cause and effect relationship of the disease process, a fully documented record provides him with the tools he needs to make that determination.

Providers are mandated by law and regulatory bodies to capture some form of record about an encounter with each patient. These notes provide a baseline from which any provider can build, review, and follow up on treatment plans.

Important: From this record, physicians determine or modify treatment plans, chart disease progression, and craft an entire case history.

The record allows the entire healthcare delivery team to provide quality patient care. Additionally, the fully documented patient record is the physician’s best chance of receiving complete reimbursement for services rendered on the patient’s behalf.

Question: How is documentation used in malpractice litigation?

Answer: Providers should regard documentation as a means of getting paid, but also as their best defense in a malpractice litigation. Poor record-keeping can mean the difference between a lawsuit that is indefensible and one that can be substanti-ated in court.

Pitfall: The biggest risk factor in a medical practice is insufficient or inaccurate documentation. Physicians that rarely keep accurate, comprehensive medical records place themselves at great risk of malpractice in negligence cases.

Providers would be well-served to document all patient encounters as though anticipating litigation. Providers should ask themselves: What information would be considered essential in a malpractice suit? How would we defend ourselves against negligence? Then document all cases accordingly.

NOTES

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Implementation of a CDI ProgramCHAPTER 2

Professionals who assist in ensuring the quality, accuracy, and integrity of the medical record are in great demand. Documentation improvement is far reaching and may involve several people or several departments within your organization to be a comprehensive, effective program. Designate an individual to oversee the documentation improvement process.

Assign a physician advocate and the compliance officer to assist with the manage-ment and enforcement of the policies. Including a physician advocate will help encourage the other providers to participate, assist with provider education, and build a stronger program with physician engagement and investment in the program.

Employ a coder or auditor to manage aspects of the documentation improvement process associated with coding, billing, and reimbursement. This teamwork uses the skills and expertise of the coding and auditing professionals when the CDI process overlaps. Involve all departments that play a role in the documentation process (nurses, data entry staff, etc.).

1. Assign one individual in each department the responsibility of working with the documentation specialist to assist in resolving documentation issues for that department.

2. Identify the practice or facility needs within each department.

3. Work with the highest risk area first, utilizing authoritative guidelines and instructions.

4. Develop policies and protocols that meet the needs of your practice that are effective but not overwhelming. For example, policies for:

l Adding late entries l Corrections to medical records l Timeliness of documentation l Who has the permission to input data in the EMR l Policies concerning the use of acronyms l Policies for risk prevention

5. Create templates that will assist with better detail and compliance with specialty-specific documentation mandates.

6. Review provider reports based on the quality and accuracy of information.

7. Schedule regular educational meetings for CDI team, providers, and staff.

8. Perform regular audits for monitoring.

9. Monitor the policies and procedures for effectiveness and change when needed.

NOTES

18 Clinical Documentation Reference Guide AAPC | 1-800-626-2633

Evaluation and Management Documentation CHAPTER 3

a documented CC which, if not documented as a separate statement, may be pulled from the HPI.

Tip: If the CC has not been documented, the visit is not billable.

The HPI is a description of the patient’s current problem or illness. Table 3.1 charts out the eight different elements of HPI:

Element Examples of Documentation Location Eye pain, shoulder pain Quality Yellow-thick sputum Severity Pain scale 5 out of 10 Duration For the past three weeks Timing This morning, yesterday Context Fell while riding bike Modifying factors Patient took pain meds Associated signs and symptoms Also, complains of itchy-watery eyes

Table 3.1: HPI Elements and Examples

The 1997 guidelines allow the provider the option of documenting four or more elements from the HPI, or the status of three chronic conditions for an extended HPI. CMS also allows the an extended HPI for the status of three chronic condi-tions in the 1995 guidelines as well.

The ROS is a review of the 14 body systems. Table 3.2 shows a list of the body systems with examples.

Body Systems Examples of Documentation Constitutional Weight loss, weakness, fever Eyes Itching, blurred vision Ears, nose, and throat Congestion, sore throat Cardiovascular Chest pain, flutter, fibrillation Respiratory Shortness of breath, cough Gastrointestinal Diarrhea, vomiting Genitourinary Dark urine, burning on urination Musculoskeletal Muscle pain and weakness, joint swelling Integumentary Rash, acne Neurological Syncope, tingling Psychiatric Stress, anxiety, depression Endocrine Increase in thirst, decreased appetite Hematologic/Lymphatic Bruising, swollen glands Allergy/Immune Medication allergies, itching, anaphylaxis

Table 3.2: Review of Body Systems and Examples

During the ROS, the provider asks the patient if they are experiencing any signs or symptoms in any of the body systems. Ancillary staff, physician assistants, nurse practitioners, and physicians can document the ROS.

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NOTES

CHAPTER 3 Evaluation and Management Documentation

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Options Selected

Minimal One self-limited or minor problem, eg, cold, insect bite, tinea corporis

Laboratory tests requiring venipuncture Chest X-rays EKG/EEG Urinalysis Ultrasound, eg, echo KOH prep

Rest Gargles Elastic bandages Superficial dressing

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected

Low Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension or non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain

Physiologic tests not under stress, eg, pulmonary function tests Non-cardiovascular imaging studies with contrast, eg, barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies

Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives

Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness

Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram cardiac cath Obtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis

Minor surgery with identified risk factors Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation

High One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, eg, 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 An abrupt change in neurologic status, eg, seizure, TIA, weakness, or sensory loss

Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography

Elective major surgery (open, percutaneous, or endoscopic with identified risk factors) Emergency major surgery (open, percutaneous, or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Table 3.6: Medical Decision Making Table of Risk

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Clinical Documentation Resources

1. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services.

https://www .cms .gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines .pdf

1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES

I. INTRODUCTION WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

the ability of the physician and other healthcare professionals to evaluate and

plan the patient’s immediate treatment, and to monitor his/her healthcare over time;

communication and continuity of care among physicians and other healthcare

professionals involved in the patient's care; accurate and timely claims review and payment;

appropriate utilization review and quality of care evaluations; and

collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary. WHAT DO PAYERS WANT AND WHY? Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

the site of service;

1

Clinical Documentation Reference Guide

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