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8/3/2011
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Presented by:Brenda Edwards, CPC, CPMA, CPC‐I, CEMC
AAPCCA Board of Directors1
DocumentationAuditingAuditingResults
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HANDWRITTEN
LegibilityDICTATED
Conciseg y
Personalized
EMR
Concise
Personalized
Timely?
Lengthy, cloned notes
Shared record3
Paper Electronic
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Review of SystemsConstitutional
Denies: fatigue, malaise, excessive weight changeEyes
Denies: double vision, blurred vision, vision loss, floatersCardiovascular
Denies: chest pain, palpitations, irregular heart beats, syncope, dyspnea on exertionRespiratory
Denies: shortness of breath, wheezing, cough
Physical ExaminationConstitutional well nourished, seems more confused today, alert, oriented to person, place and time, no acute distress
Eyes conjunctiva normal, sclerae nonicteric
Neck no masses or tenderness
Denies: shortness of breath, wheezing, coughNeurologic
Denies: tingling, memory difficulties, seizures, tremors, loss of balanceEndocrine
Denies: polyuria, polydipsia, significant hypoglycemia, significant hyperglycemia
Neck no masses or tenderness
Respiratory breathing unlabored, clear to auscultation
Cardiovascular regular rate and rhythm, no murmurs present
Skin no rashes or lesions present
Neurologic cranial nerves II-XII grossly intact
Psychiatric judgement and insight intact, confused, memory difficulties, normal mood and appropriate affect 7
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Passwords and
authenticationFree text narrative
“Under coded” by
t
Better coding
Learning curve
EMR
computer
Amended Records
Tracking Improved charge
Customize clinical care
mechanism
Template carrying forward Savings in
processes and staff cost
Paperless office
charge capture
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Double standard•“If it isn’t documented it, isn’t done, and therefore not billable”
•“If it is documented did you really do
Irrelevant information = search for pertinent findings•Time saving or over dictating?
•“If it is documented, did you really do the work”?
Think in categories instead of Medical‐legal standpointpersonal opinion•Clicking boxes instead of writing what they think and feel based on observations
•Nearly identical documentation on large numbers of patient records
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Chart Review/AuditChart Review/Audit
AuditReviewA tAssessmentWhatever makes your physicians comfortable (or equally uncomfortable)
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Current OIG work planAnnual internal work planAnnual internal work plan
How to perform auditsUnder attorney client privilegeFrequency
Specific providersNewOutliersTeaching Facility SpecialtyPayer mix
FrequencyQuantity LocationSpecific codes or services
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Upcoding
Lack of checks and balances
Opportunities
Threats
Financial impact over time
Lack of qualified coding staff
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Threats
Services 2‐3 months prior
to review Charge tickets
d l
Remittance advices
Medical records
Appointment schedule Patient
account detail
Internal documentsAbbreviation listProvider signaturesSpecific policies
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Codes reported on charge ticket
Compare date of service• Medical record to encounter form
• Encounter form to claim
• Claim to remittance d i C i t f
DocumentCompare progress
advice Consistency of codes
Compare submitted charges to allowed Document
DiscrepanciesCompare progress
notecharges to allowed charges• Date claim paid versus date of service
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Date of service CPT‐4®
ICD9 and HCPCS
ModifiersHandwritten
template
dictated or
EMR
Patientidentifiers•Minimum of 2•Front and back
Identity, authentication by performing
provider
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Review chart Review chart
Familiarize • Forms, H&P, Problem List, Drawings
Review chart organizationReview chart organization
Coding criteriacriteria• Time• Critical care• IP/OP• Office procedure
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Have you seen this drawing?
“A new patient has…not received professional services from the physician or another physician of f p y p y fthe same specialty who belongs to the same group practice within the past three years.”
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Photo: Kaptain Kobold23
Required IT IS NOT Required •Exception‐ subsequent inpatient hospital visits
•Concise •Patient’s own words
IT IS NOT •“F/U”•“Right lower extremity”•“He swallowed something”•“Patient here for routine check”
•“Patient seen in f/u for other”“N l i t t thi ti ”•“No complaints at this time”
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Patient presents with 2 day history of cough Has Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school district). No fevers.
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• Area of bodyLocation
• Dull, sharp, stabbingQuality
• Scale of 1‐10, mild, significant, moderateSeverity
• When symptoms first occurredDuration
• Intermittent, continuousTiming
• Associated with a specific activity Context
• What relieve symptoms, circumstances surrounding a certain activityModifying factors
• Associated with the presenting problemAssociated signs or symptoms 26
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“The HPI can only be performed by the physician or non‐physician practitioner and that the only way another staff member can d i d l i if h h i ki di i document it adequately is if he or she is taking dictation or scribing” (Part B News, 6/11/07)
The physician must do the work and document it themselves, simply reviewing the documentation obtained and indicating “I have reviewed the HPI and agree with above” is not acceptable.
If the history cannot be obtained from the patient or other If the history cannot be obtained from the patient or other source, document why and code the visit appropriately.
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Two types of HPI
Brief requires documentation of 1‐3 elements
Extended requires documentation of 4+ elements or as changed in the 1997
d l d fguidelines, documentation of the status of 3 chronic conditions
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Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He is unable to sleep much; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school di t i t) N fdistrict). No fevers.
Elements: Duration, Modifying Factor, Context,Associated Sign and Symptom
Type of History HPIProblem Focused (99201, 99213) Brief (1-3)Expanded Focused (99202, 99213 Brief (1-3)Detailed (99203, 99214) Extended (4+)Comprehensive(99204, 99205,99215) Extended (4+)
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Typically weakest documentationTemplates or forms acceptable
Patient’s responses to signs/symptoms experiencingComplete ROS must document any positive and Complete ROS, must document any positive and problem pertinent negatives “All other systems negative” for remaining
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Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday (bus driver for y y (the school district). No fevers.
ROSP bl F d (99201 99213) N/A
Systems Reviewed: ConstitutionalENT
Problem Focused (99201, 99213) N/AExpanded Focused (99202, 99213 Problem Pertinent(1)Detailed (99203, 99214) Extended (2-9)Comprehensive (99204, 99205,99215) Complete (10+)
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Past
Family •Health of parents, siblings or children, hereditary diseases that put the patient at risk (blood relatives)
Social •Age appropriate review of past and
Past
•Allergies, current meds, immunization, surgeries, previous illness, age appropriate feedings
current activities •Marital status•Employment•Drug, alcohol, and tobacco use
•Education•Sexual history
Family &/or Social History
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Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school district). No fevers.
PFSH
Social History: Employment
N/A (99201, 99213)N/A (99202, 99213Pertinent (99203, 99214) (1-3)Complete (99204, 99205,99215) (3)
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Which Set of Guidelines?
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Expanded Problem Focused – limited exam of 2‐7 body areas or organ
systems
Detailed Exam –extended exam of 2‐
7 body areas or systems
(5 7?)
Problem Focused ─a limited
examination of the affected body area or organ system.
y(2‐4?) (5‐7?)
Comprehensive Exam – 8 of 12
systems
Difference between limited and extended exam has never been
clarified in writing
1995 Exam
Guidelines
or organ system.
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Temperature: 99.6, BP: 120/72 Patient is 42 year old white male in no acute distress. HEENT: Exam reveals no edema or effusion noted.Cardiovascular: RRR, no murmursRespiratory: Palpation normal. Expiratory wheeze bilaterally;
improves occasionally with deep coughAbdomen: Negative
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Temperature: 99.6, BP: 120/72 Patient is 42 year old white male in no acute distress. HEENT: Exam reveals no edema or effusion noted.Cardiovascular: RRR, no murmursRespiratory: Palpation normal. Expiratory wheeze bilaterally;
improves occasionally with deep coughAbdomen: Negative
1997 Guidelines
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1995 Organ Systems 1995 Expanded Examination
1997 Examination Guidelines
Expanded4 systems examined
ExpandedLimited exam of affected
3 bulletsProblem focused exam4 systems examined Limited exam of affected
body area or organ system and other related systems
Problem focused exam
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Tie It All Together
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MDM should be the primary factor in determining the level of serviceof service
History and physical •Match the severity of the problem(s)
•Complexity of decision‐making
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“Medical 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 E&M service when a lower level of service is warranted.”
MCM Section 15501 A
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Chest x‐ray ordered to rule out pneumoniaCBC ordered due to fatigueCBC ordered due to fatigue
Impression: No infiltrates found on x‐ray; upper respiratory infection. Z‐pack for 5 days given as well as prescription for Tussin Pearls. Will see back next week if not improvingnext week if not improving.
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What is Additional Work‐Up?
Artist: Caroline Shotton43
A B C D
Problem Categories Number Points Score
Self limit or minor (stable improved or Max 2 1Self-limit or minor (stable, improved, or worsening)
Max= 2 1
Established problem: stable, improved 1
Established problem:worsening
2
New problem no additional work up 3 3?New problem, no additional work-up planned
3 3
New problem: additional work-up planned
4 4
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Table of Riskb f i i•Number of prescriptions
•Assessment of risk•Presenting problemDi ti d•Diagnostic procedures
•Prescription drug management
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Level of established patient office visit=Level of new patient office visit=Level of consult visit=
History Problem Focused
Expanded Detailed Comprehensive
Exam Problem Focused
Expanded Detailed Comprehensive
Level of consult visit=
?Focused
MDM Straight Forward
Low Moderate High?46
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Quantify the data• Visuals
Deliver results in‐person
Use as educational opportunity
Communicating Results
Project confidence
Provide resources
and solutions
Involve staff in
educational sessionsProvide
coding specifics in writing
Approach from the
positive, not the punitive
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Chart Review
Patient #DOS Auditor CPT: CPT
Progress Note Auditor1 12 23 34 4
HISTORY ELEMENTHistory of Present Illness
Chief Complaint:Location:Quality:Severity:Duration:Timing:Context:Modifying Factors:
Signs & Symptoms:
Review of SystemsConstitutional IntegumentaryEyes NeurologicalEars, Nose, Mouth, Throat Psychiatric
Cardiovascular EndocrineRespiratory HematologicGastrointestinal Allergic/ImmunologicGast o test a e g c/ u o og cGenitourinary LymphaticMusculoskeletal All others negative
HistoryPast:Family:Social:
EXAMINATION ELEMENTBody Areas Organ Systems:
Head Constitutional GenitourinaryNeck Eyes MusculoskeletalChest Ears, Nose, Throat Integumentary
Abdomen Cardiovascular NeurologicalGenitalia, Groin, Buttocks Respiratory Psychiatric
Back Gastrointestinal Hematology/Lympahtic/ImmunologyEach extremity
1995 Guidelines:1997 Guidelines:
MEDICAL DECISION MAKINGDiagnoses/Mgmt Options:Data Reviewed:Risk to Patient:
CONCLUSION
KaMMCO
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80%
90%
100%
50%
60%
70%
Data Comparison within a Practice
20%
30%
40%
50%
60%
70%
10%
20%
30%
40%
50%
0.00% 1.19% 91.90% 5.87% 1.04%2.14% 14.89% 66.13% 15.79% 1.04%3.95% 6.33% 55.23% 31.64% 2.86%
99211 99212 99213 99214 992150%
10%
Dr. MGMA*Medicare*
0%
0%
Dr. MGMA*Medicare*
0.19% 3.05% 41.73% 46.56% 8.46%2.14% 14.89% 66.13% 15.79% 1.04%3.95% 6.33% 55.23% 31.64% 2.86%
99211 99212 99213 99214 99215
A B
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Data Comparison of different periods2004 2007
80%
90%
100%
0%
10%
20%
30%
40%
50%
60%
70%
0.00% 4.80% 93.43% 1.77% 0.00%1.05% 2.09% 26.46% 69.98% 0.42%2.14% 14.89% 66.13% 15.79% 1.04%4.09% 7.35% 57.75% 28.17% 2.64%
99211 99212 99213 99214 992150%
Dr. A 1/2004-12/2004Dr. A 1/2007-7/2007MGMA*Medicare*
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0.6
0.7
0.8
0.2
0.3
0.4
0.5
0.6
PhysicianNational Trend
0
0.1
99201 99202 99203 99204 99205
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80%
90%
ABC Family PracticeE&M Office Visit Trend Compared to Family Practice Physicians
1/2004 - 12/2004
10%
20%
30%
40%
50%
60%
70%
0%
Dr. A 0.65% 87.95% 9.45% 1.30% 0.65% 0.02% 19.98% 74.95% 1.61% 3.44%Dr. B 2.35% 35.88% 58.82% 2.94% 0.00% 0.24% 7.78% 66.38% 25.39% 0.21%Dr. C 0.64% 4.49% 76.92% 17.31% 0.64% 0.00% 3.70% 85.82% 10.05% 0.43%
MGMA 9.24% 38.66% 40.05% 10.47% 1.58% 1.87% 18.60% 65.61% 12.90% 1.02%
Medicare 2.79% 21.34% 42.91% 25.93% 7.02% 3.96% 9.75% 60.82% 23.03% 2.44%
99201 99202 99203 99204 99205 99211 99212 99213 99214 99215
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A ccurat ely C od ed , 8 , 57%
Over C od ed / B il led , 5, 3 6 %
U nd er C o ded / B illed , 1, 7%
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Establish a method for monitoring trends and tracking progress
Ongoing Monitoring
Provide feedback to
physicians on a regular basis
Document all actions taken to
honor your compliance
plan
Request second opinions if necessary
Request involvement from your compliance committee
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Ongoing Monitoring
Chart Audit Trend Analysis
90%
30%
40%
50%
60%
70%
80%
Dr. A
0%
10%
20%
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
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Challenges•Higher presenting problem lacking documentation•Requirements for consultations not met •Quantity of documentation inconsistent with presenting problem
•Weak review of system•Misuse of templates and poor form design•Unfamiliar with documentation guidelines•Emotional coding•Payment reactive coding•Illegible documentation•Services documented but not performed•Services not documented but performed•Provider disinterest
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Thank you for participating today
Happy trails to youAs you review your records…
(sung to the tune of Happy Trails)67
