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  • Demystifying Medical Documentation

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    This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.

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    This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5K views37 pages

    Demystifying Medical Documentation

    Uploaded by

    adultmedicalconsultants
    This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 37

    Medical

    Templates
    Demystifying Medical Documentation

    Created by The Lung Doctor for e-Medtools


    A Quick Review of
    Medical Documentation
    Requirements

    Created by The Lung Doctor for e-Medtools


    Patient Encounters
    The Centers for Medicare and Medicaid
    Services (CMS) has published definitions and
    documentation guidelines for the key
    components of a medical encounter note,
    using CPT codes.

    Created by The Lung Doctor for e-Medtools


    Key Components of Documentation
    History Key components in
    selecting the level of
    Exam E/M services

    Medical Decision Making


    Counseling
    Coordination of Care
    Nature of Presenting Problem
    Time
    1997Guidelines
    1997 Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services
    http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
    http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

    Created by The Lung Doctor for e-Medtools


    The History

    Created by The Lung Doctor for e-Medtools


    History Components and Levels
    HPI ROS PFSH Type of History
    Brief N/A N/A Problem Focused

    Brief Problem N/A Expanded


    pertinent Problem Focused
    Extended Extended Pertinent Detailed

    Extended Complete Complete Comprehensive

    New patient evaluations MUST have at least a Detailed History

    Created by The Lung Doctor for e-Medtools


    History of Present Illness
    EVERY encounter MUST contain a Chief Complaint!
    ™ Preferentially stated in patients’ words
    Elements of HPI
    Location
    Quality Brief
    Brief
    Severity Contains1-3
    Contains 1-3elements
    elementslisted
    listed
    Duration Extended
    Extended
    Timing Contains≥≥44elements
    Contains elements
    ORdiscusses
    OR discusses33chronic
    chronicor orinactive
    inactiveconditions
    conditions
    Context
    Modifying factors
    Associated Signs and Symptoms

    Created by The Lung Doctor for e-Medtools


    Review of Systems
    Constitutional Symptoms
    ProblemPertinent
    Problem Pertinent
    Eyes
    Documentsresponses
    Documents responsestotothe
    thesystem
    system
    Ears, Nose, Mouth, Throat directlyrelated
    relatedto
    tothe
    thepresenting
    presenting
    directly
    Cardiovascular problem
    problem
    Respiratory
    Gastrointestinal Extended
    Extended
    Documentspositive
    Documents positiveand
    andnegative
    negative
    Musculoskeletal
    responsesto
    responses to2-9
    2-9systems
    systemsrelated
    relatedto
    to
    Integumentary (Skin, Breast) theproblem
    problem
    the
    Neurological
    Psychiatric Complete
    Complete
    Endocrine Documentsall
    Documents allpositive
    positiveand andnegative
    negative
    responsesto
    responses tosystems
    systemsrelated
    relatedtotothe
    the
    Hematologic/Lymphatic
    presentingproblem
    presenting problemAND ANDall allother
    other
    Allergy/Immunologic systems(10
    (10orormore
    moretotal)
    total)
    systems

    Created by The Lung Doctor for e-Medtools


    Past, Family and Social History
    Past Medical History
    ™ Illnesses, Operations, Injuries and Treatments

    Family Medical History


    ™ Include heritable diseases and those that place the patient at increased risk

    Social History
    ™ An age appropriate review of past and current activities
    Pertinent
    Pertinent
    Documentatatleast
    Document least11item
    itemfrom
    fromANYANYofofthe
    the33areas
    areas
    ItItmust
    mustbe
    bedirectly
    directlyrelated
    relatedtotothe
    theproblems
    problemsidentified
    identifiedininthe
    theHPI
    HPI

    Complete
    All initial inpatient services require a Complete PFSH
    Document at least 1 item from EACH of the 3 areas
    Created by The Lung Doctor for e-Medtools
    The Exam

    Created by The Lung Doctor for e-Medtools


    Recognized Single Organ Systems
    Cardiovascular
    Ears, Nose, Mouth, Throat
    Detailed
    Detailed
    Eyes Anextended
    An extendedexam
    examof ofthe
    theaffected
    affectedbody
    bodyarea
    area
    Genitourinary (Female) ororgans/organ
    or organs/organsystem
    systemandandanother
    another
    symptomaticor
    symptomatic orrelated
    relatedarea
    area
    Genitourinary (Male)
    Hematologic/Lymphatic/Immunologic
    Musculoskeletal Comprehensive
    Neurologic A general multi-system exam
    A complete exam of an organ system and
    Psychiatric other related body areas or organ systems
    Respiratory
    Skin
    Mostlevels
    Most levelsrequire
    requireaaminimum
    minimumof
    ofaaDetailed
    DetailedExam
    Exam

    Created by The Lung Doctor for e-Medtools


    Multi-organ System Exam
    Detailed
    ≥3 vital signs
    ƒ BP, sitting or standing
    ƒ BP, supine
    ƒ Pulse, rate and regularity
    ƒ Respirations
    ƒ Temperature
    ƒ Height
    ƒ Weight
    ≥2 elements* of at least 6 organ systems or body areas examined
    OR ≥1 element of at least 12 organ systems

    Comprehensive
    ≥2 elements* in at least 9 organ systems or body areas

    *Referto
    *Refer to1997
    1997Guidelines
    Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services

    Created by The Lung Doctor for e-Medtools


    Single Organ System Exam
    Detailed
    ™ Document ≥12 elements* (NOT Eye and Psychiatric exams)
    ™ Eye and Psych exams document ≥9 elements

    Comprehensive
    ™ Document ALL elements*

    *Referto
    *Refer to1997
    1997Guidelines
    Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services

    Created by The Lung Doctor for e-Medtools


    Elements of Individual Organ Systems
    Constitutional Cardiovascular
    ¾ Vital signs ¾ Palpation of heart
    ¾ General appearance of patient ¾ Auscultation
    ¾ Nutrition, Body habitus, Development, Deformities,
    Grooming ¾ Carotid artery exam
    Eyes ¾ Abdominal aorta exam
    ¾ Inspection of conjunctivae and lids ¾ Femoral arteries exam
    ¾ Exam of pupils and irises ¾ Pedal pulses exam
    ¾ Ophthalmoscopic exam of optic discs ¾ Extremities for edema or varicosities
    Ears, Nose, Mouth and Throat Chest (Breasts)
    ¾ External inspection of ears and nose ¾ Inspection
    ¾ Otoscopic exam ¾ Palpation
    ¾ Assessment of hearing Gastrointestinal
    ¾ Inspection of nasal mucosa, septum, ¾ Abdominal exam
    and turbinates ¾ Liver and spleen exam
    ¾ Inspection of lips, teeth and gums ¾ Hernia presence or absence
    ¾ Exam of oropharynx ¾ Anus, perineum, rectum exam
    Neck ¾ Stool for occult blood
    ¾ Exam of neck
    ¾ Thyroid
    1997Guidelines
    Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services
    Respiratory 1997
    ¾ Assessment of effort
    ¾ Percussion of chest
    ¾ Auscultation
    ¾ Palpation of chest
    Created by The Lung Doctor for e-Medtools
    Exam elements, continued
    Lymphatic Psychiatric
    ¾ Neck ¾ Judgment and insight
    ¾ Axilla ¾ Orientation to person, time, place
    ¾ Groin ¾ Memory, recent and remote
    ¾ Other ¾ Mood and affect
    Musculoskeletal Genitourinary
    ¾ Gait and station
    ¾ Inspection, palpation digits and nails Male
    ¾ Exam of bones, joints, muscles AND 1 ¾ Scrotal contents
    or more ¾ Penis
    ¾ Inspection or palpation ¾ Digital rectal exam of prostate gland
    ¾ Range of motion and
    presence/absence of pain
    ¾ Stability Female
    ¾ Muscle strength and tone ¾ External genitalia
    Skin ¾ Urethra
    ¾ Inspection ¾ Bladder exam
    ¾ Palpation ¾ Cervix
    Neurologic ¾ Uterus
    ¾ Cranial nerves ¾ Adnexa/parametria
    ¾ Deep tendon reflexes
    ¾ Sensation 1997Guidelines
    1997 Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services

    Created by The Lung Doctor for e-Medtools


    Medical Decision
    Making

    Created by The Lung Doctor for e-Medtools


    Elements of Medical Decision Making
    • Number of diagnoses or Management Options
    • Amount or Complexity of data to be reviewed
    • Risk of Complications, Morbidity or Mortality

    Created by The Lung Doctor for e-Medtools


    Complexity of Medical Decision Making
    Number of Amount or Risk of Complexity of
    Diagnoses Complexity of Data Complications Decision Making
    Or Management to be Reviewed Morbidity or
    Options Mortality
    Minimal Minimal or None Minimal Straightforward
    Limited Limited Low Low
    Multiple Moderate Moderate Moderate
    Extensive Extensive High High
    1997Guidelines
    Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services
    22out
    outofof33elements
    elementsmust
    mustbe
    bemet
    met 1997

    Created by The Lung Doctor for e-Medtools


    Worksheets
    Calculating Documentation Levels
    Adaptedfrom
    Adapted from
    HGSAdministratorsDocumentation
    HGSAdministrators DocumentationWorksheet
    Worksheet
    CMSMedicare
    MedicarePart
    PartBB
    CMS

    Created by The Lung Doctor for e-Medtools


    History
    HPI: Status of chronic conditions □ □
    1-2 3
    □1 condition □2 conditions □3 conditions

    HPI elements □ □
    □Location □Severity □Timing □Modifying factors Brief Extended
    1-3 4 or more
    □Quality □Duration □Context □Associated signs & symptoms
    Review of Systems □ □ □ □
    □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes None Pertinent to Extended Complete
    Problem 2-9
    □CV □MS □Neuro □Aller/Immun □Resp □Psych 1 system Systems
    10 or more
    Systems
    □All others negative
    PFSH □ □ □
    □Past History □Family History □Social History None Pertinent Complete
    1 2 or 3
    Problem Expanded Detailed Comprehensive
    Focused Problem
    Focused

    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Examination
    Body Areas □ □ □ □
    □Head, Face □Chest, Breasts, Axilla 1 Up to 7 Up to 7 8 or more
    Body Area Body Areas Body Body Areas
    □Abdomen □Neck □Back, Spine or or Areas or
    □Genitalia, Groin, Buttocks □Each Extremity System Systems or Systems
    Systems
    Organ Systems
    □Constitutional □ENT □Resp □MS □GI □Skin
    □GU □Psych □CV □Eyes □Heme/Lymph □Neuro
    Problem Expanded Detailed Comprehensive
    Focused Problem
    Focused
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Medical Decision Making
    Reminder:
    There are 3 components used to determine the complexity of medical decision making
    • Number of diagnoses or Management Options
    • Amount or Complexity of data to be reviewed
    • Risk of Complications, Morbidity or Mortality

    Created by The Lung Doctor for e-Medtools


    Number of Diagnoses or Treatment Options
    Complexity of Medical Decision Making
    A B x C = D
    Problem status Number Points Result
    Self-limited or minor Max = 2 1
    Established problem (to examiner) 1
    Stable or improved

    Established problem (to examiner) 2


    Worsening

    New problem (to examiner) Max = 1 3


    No additional workup planned

    New problem (to examiner) 4


    Additional workup planned

    Total
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted
    Created by The Lung Doctor for e-Medtools
    Amount and/or Complexity of Data Reviewed
    Complexity of Medical Decision Making
    Reviewed Data Points Result
    Clinical lab tests reviewed and/or ordered
    1
    Review and/or order of tests from radiology section of CPT
    1
    Review and/or order of tests from medicine section of CPT
    1
    Discussion of test results with performing physician
    1
    Decision to obtain history from source other than patient
    1
    Review and summarization of history obtained from source other than patient
    2
    Independent visualization of image, tracing or specimen (NOT reviewing report)
    2
    TOTAL
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Guide to Determining Risk of Complications
    Complexity of Medical Decision Making
    Risk Presenting Problem Dx Procedure Ordered Management Options Selected
    Minimal -1 self-limited or minor problem -Venipuncture -Rest
    -X-rays -Gargles
    -EKG -Elastic bandages
    -EEG
    -Urinalysis
    -ECHO

    Low -2 or more self-limited or minor problems -Physiologic tests NOT under stress i.e., PFTs -OTC drugs
    -1 stable, well- controlled chronic illness -Noncardiovascular imaging studies + contrast -Minor surgery without identified risk factors
    -Acute uncomplicated illness or injury Barium enema -Physical therapy
    -Superficial needle biopsies -Occupational therapy
    -Clinical lab tests requiring arterial puncture -IV fluids without additives
    -Skin biopsies

    Moderate -Mild exacerbation of 1 or more chronic -Physiologic tests under stress -Minor surgery WITH identified risk factors
    illnesses Cardiac stress test -Elective major surgery with NO identified risk factors
    -2 or more stable, chronic illnesses Cardiopulmonary exercise test -Prescription drug management
    -Previously undiagnosed NEW problem with -Diagnostic endoscopies with NO risk factors -Therapeutic nuclear medicine
    uncertain prognosis (i.e., breast lump) -Deep needle or incisional biopsy -IV fluids with additives
    -Acute illness with systemic symptoms -Cardiovascular imaging studies with contrast -Closed treatment of fracture
    -Acute complicated injury NO identifiable risk factors
    Cardiac catheterization
    -Obtaining body cavity fluid
    Thoracentesis

    High -Severe exacerbation or progression of -Cardiovascular imaging studies + Risk factors -Elective surgery + Risk factors
    1 or more chronic illnesses -Cardiac electro-physiologic tests -Emergency Major surgery
    -Acute or chronic illness or injury that -Diagnostic endoscopies + Risk factors -Parenteral controlled substances
    threatens life or limb -Discography -Drug therapy requiring intensive monitoring
    -Abrupt change in neurologic status -Decision to not resuscitate or to de-escalate care
    due to poor prognosis

    Thehighest
    highestlevel
    levelininANY
    ANYcategory
    categorydetermines
    determinesthe
    theoverall
    overallrisk
    risk 1997Guidelines
    Guidelinesfor
    forEvaluation
    Evaluation&&Management
    ManagementServices
    Services
    The 1997

    Created by The Lung Doctor for e-Medtools


    Final Determination
    Complexity of Medical Decision Making
    Number of ≤1 2 3 ≥4
    A diagnoses or Minimal Limited Multiple Extensive
    treatment options
    Highest risk Minimal Low Moderate High
    B

    Amount and ≤1 2 3 ≥4
    C complexity of Minimal or Low Limited Multiple Extensive
    data reviewed

    Type of decision making Straightforward Low Moderate High


    Complexity Complexity Complexity

    Circlethe
    theappropriate
    appropriatedescriptions
    descriptionsfor
    forRows
    RowsA,A,B,B,CC
    Circle
    TheColumn with22oror33circles
    Columnwith circlesdetermines
    determinesthe
    thefinal
    finalComplexity
    ComplexityofofMedical
    MedicalDecision
    DecisionMaking
    Making
    The
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Determining Overall Service Levels

    Created by The Lung Doctor for e-Medtools


    Inpatient Encounters
    Initial Hospital Encounter Subsequent Inpatient
    Or Observation Or Follow up
    Requires 3 components within shaded area Requires 2 components
    History D or C C C PF EPF D
    Examination D or C C C PF EPF D
    Complexity of SF/L M H SF/L M H
    medical decision
    LEVEL I II III I II III
    Init Hosp Care
    99221 99222 99223 99231 99232 99233
    Observation 99261 99262 99263
    99218 99219 99220

    C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
    C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low

    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Outpatient,
    Consults (Outpatient, Inpatient) and ER
    New Office / Consult / ER Established Office
    Requires 3 components within shaded area Requires 2 components
    History PF EPF D C C Minimal PF EPF D C
    problem
    ER: PF ER: EPF ER: EPF ER: D ER: C that may
    not
    Examination PF EPF D C C require PF EPF D C
    ER: PF ER: EPF ER: EPF ER: D ER: C presence
    of
    Complexity SF SF L M H physician SF L M H
    of medical ER: SF ER: L ER: M ER: M ER: H
    decision
    LEVEL I II III IV V I II III IV V
    New Pt 99-201 -202 -203 -204 -205 99211 -212 -213 -214 -215
    Outpt Consult 99-241 -242 -243 -244 -245
    Inpt Consult 99-251 -252 -253 -254 -255
    ER 99-281 --282 -283 -284 -285
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Documenting Time
    As a Determinant of Level of Service
    “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%)
    the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis,
    risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”

    Does documentation reveal total time?


    Time: Face to face in outpatient setting
    □Yes □No
    Unit/floor in inpatient setting
    Does documentation describe the content of
    counseling or coordinating care □Yes □No

    Does documentation reveal that more than half


    the time was counseling or coordinating care? □Yes □No

    Documentation of Time requires that ALL of the answers to the above questions are YES
    Adaptedfrom
    fromCMS
    CMSMedicare
    MedicarePart
    PartBB HGSAdministrators
    HGSAdministratorsDocumentation
    DocumentationWorksheet
    Worksheet
    Adapted

    Created by The Lung Doctor for e-Medtools


    Summary Examples
    Documentation Requirements

    Created by The Lung Doctor for e-Medtools


    Initial Hospital Care
    Must meet ALL criteria

    99223
    ƒ Comprehensive History and Exam
    ƒ High complexity Medical decision making
    99222
    ƒ Comprehensive History and Exam
    ƒ Moderate complexity Medical decision making
    99221
    ƒ Detailed OR Comprehensive History and Exam
    ƒ Straightforward or Low Complexity Medical decision making

    Created by The Lung Doctor for e-Medtools


    Initial Inpatient Consultation
    Must meet ALL criteria
    99255
    ƒ Comprehensive History AND Exam
    ƒ High complexity medical decision making
    99254
    ƒ Comprehensive History AND Exam
    ƒ Moderate complexity medical decision making
    99253
    ƒ Detailed History AND Exam
    ƒ Low complexity medical decision making

    Created by The Lung Doctor for e-Medtools


    New Outpatient Encounter
    Not a Consult
    Must meet ALL criteria
    99205
    ™ Comprehensive History and Exam
    ™ High complexity medical decision making

    99204
    ™ Comprehensive History and Exam
    ™ Moderate complexity medical decision making

    99203
    ™ Detailed History and Exam
    ™ Low complexity medical decision making

    Created by The Lung Doctor for e-Medtools


    New Outpatient Consult
    Must meet all criteria
    99245
    ™ Comprehensive History
    ™ Comprehensive Exam
    ™ High complexity medical decision making
    99244
    ™ Comprehensive History
    ™ Comprehensive Exam
    ™ Moderate complexity medical decision making
    99243
    ™ Detailed History
    ™ Detailed Exam
    ™ Low complexity medical decision making

    Created by The Lung Doctor for e-Medtools


    Established Outpatient Encounter
    Must meet 2 out of 3 criteria
    99215
    ™ Comprehensive History
    ™ Comprehensive Exam
    ™ High complexity medical decision making
    99214
    ™ Detailed History
    ™ Detailed Exam
    ™ Moderate complexity medical decision making
    99213
    ™ Expanded Problem Focused History
    ™ Expanded Problem Focused Exam
    ™ Low complexity medical decision making

    Created by The Lung Doctor for e-Medtools


    We hope you found this presentation helpful!
    Remember to thank all the patient and knowledgeable billing and coding
    specialists who make themselves available to answer your questions in
    more detail!

    Created by The Lung Doctor for e-Medtools

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