Do What Your Patients Need Document What You Did Get Paid Appropriately

1
Do What Your Patients NeedDocument What You
DidGet Paid Appropriately

• David T. Walsworth, MD, FAAFP
• Assistant Professor
• Associate Chair for Clinical Affairs
• Department of Family Practice
• Michigan State University College of Human
  Medicine

2
Outline

• Introduction to Documentation
• Documentation Formats
• Documentation Guidelines
• New or Established?
• Location of Service
• CPT Coding
• Teaching Physician Documentation
• Student Documentation
• References

3
What is Documentation?

• Medical record documentation is required to
  record pertinent facts, findings, and
  observations about an individuals 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.

HCFA, 1995
4
The Medical Record Facilitates

• the ability of the physician and other health
  care professionals to evaluate and plan the
  patients immediate treatment, and to monitor
  his/her health care over time
• communication and continuity of care among
  physicians and other health care professionals
  involved in the patients care

HCFA, 1995
5
The Medical Record Facilitates

• 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.

HCFA, 1995
6
What Do Payers Want 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
• the medical necessity and appropriateness of the
  diagnostic and/or therapeutic services provided
  and/or
• that services provided have been accurately
  reported.

HCFA, 1995
7
Quality Markers

• Every page contains the two patient identifiers
• The record includes appropriate personal and
  biographical data
• The record is legible to some other than the
  author
• Significant illnesses and conditions are included
  in the problem list
• Medication allergies and adverse reactions are
  prominently noted

• If the patient has been seen three or more times,
  the record includes an appropriate past medical
  history as well as notes about smoking, alcohol
  use and substance abuse
• The history and exam are appropriate for
  presenting complaints
• Lab work and other studies are ordered as
  appropriate

Edsall Moore, 1995
8
Quality Markers

• Working diagnoses are consistent with findings
• Treatment plans are consistent with diagnoses
• Follow-up care is noted as appropriate, with time
  of return specified or noted as prn
• Unresolved problems are addressed in subsequent
  visits
• Consultants used appropriately and their reports
  are included in the record

• Reports filed with the record are initialed or
  marked electronically to signify that the
  physician has reviewed them
• There is no evidence that the patient is placed
  at inappropriate risk
• The record includes an immunization record or
  history
• The record includes evidence that appropriate
  preventive services have been offered

Edsall Moore, 1995
9
What Was is No More

• Once, the documentation for a child with a right
  otitis media treated with Amoxicillin was
• ROM Amox
• Now the documentation for the same visit consumes
  most, if not all of the page!

Outline
10
Documentation Formats

• SOAP
• Subjective
• Objective
• Assessment
• Plan

• SOAPIER
• Subjective
• Objective
• Assessment
• Plan
• Instructions
• Education
• Return to Office

11
Documentation Formats

• SNOCAMP
• Subjective
• Nature of the Presenting Problem
• Objective
• Counseling and Coordination of Care
• Medical Decision Making

• SOOOAAP
• Subjective
• Objective
• Opinion
• Options
• Advice
• Agreed Plan

Edsall, R. K. Moore, 1995(a)
Teichman, P, 2000
12
SNOOOCAMAAPIER?

• Subjective
• Nature of the Presenting Problem
• Objective
• Opinion
• Options
• Counseling Coordination
• Advice

• Medical Decision Making
• Assessment
• Agreed Plan
• Instructions
• Education
• Return to Office

Outline
13
Documentation Components

• Subjective
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past, Family, Social History (PFSH)
• Review of Systems (ROS)
• Objective
• Physical Examination (PE)
• Diagnostic Studies
• Assessment Plan
• Medical Decision Making
• Orders

14
Chief Complaint (CC)

• The reason the patient is seeking care
• Reason for visit
• Reason for admission
• Reason for continued admission
• Should be in the patients own words whenever
  possible

HCFA, 1995
15
History of Present Illness (HPI)

• HPI Elements
• Location
• Quality
• Severity
• Duration
• Timing
• Context (Provocative)
• Modifying Factors (Palliative)
• Associated Signs Symptoms

• Status of chronic diseases
• Complications
• Progression of disease
• Self-care results
• Medical compliance
• Side effects of treatment

HCFA, 1995
16
Past, Family, Social History (PFSH)

• Past History
• Illnesses
• Injuries
• Surgeries
• Medications
• Allergies
• Advanced Directives

• Family History
• Illnesses
• Adverse reactions
• Social History
• Occupation
• Habits
• Sexual
• Substance
• Religious restrictions

HCFA, 1995
17
Review of Systems (ROS)

• Constitution
• Eyes
• ENT/Mouth
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal

• Skin/Breasts
• Neurologic
• Psychiatric
• Endocrine
• Hematologic / Lymphatic
• Allergic / Immunologic

HCFA, 1995
18
1995 Physical Examination (PE)

• Body Areas
• Head (Including face)
• Neck
• Chest (Including breasts axillae)
• Abdomen
• Genitalia / Groin / Buttocks
• Back (Including spine)
• Each Extremity
• Right Upper
• Left Upper
• Right Lower
• Left Lower

• Organ Systems
• Constitutional
• Eyes
• ENT / Mouth
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic / Lymphatic / Immunologic

HCFA, 1995
19
1997 Physical Examination (PE)General
Multisystem Examination

• Constitutional
• Measurement of three or more of the following
  seven vital signs
• Sitting or standing BP
• Supine BP
• Pulse rate regularity
• Respiratory rate
• Temperature
• Height
• Weight
• General appearance of patient

• Eyes
• Inspection of conjunctivae and lids
• Examination of pupils and irises
• Ophthalmoscopic examination of optic discs and
  posterior segments

HCFA, 1997
20
1997 Physical Examination (PE)General
Multisystem Examination

• Ears, Nose, Mouth Throat
• External inspection of ears and nose
• Otoscopic examination of external auditory canals
  and tympanic membranes
• Assessment of hearing
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx oral mucosa, salivary
  glands, hard and soft palates, tongue, tonsils
  and posterior pharynx

• Neck
• Examination of neck
• Examination of thyroid
• Respiratory
• Assessment of respiratory effort
• Percussion of chest
• Palpation of chest
• Auscultation of lungs

HCFA, 1997
21
1997 Physical Examination (PE)General
Multisystem Examination

• Cardiovascular
• Palpation of heart
• Auscultation of heart
• Examination of
• Carotid arteries
• Abdominal aorta
• Femoral arteries
• Pedal pulses
• Extremities for edema and/or varicosities

• Chest (Breasts)
• Inspection of breasts
• Palpation of breasts and axillae
• Gastrointestinal
• Examination of abdomen
• Examination of liver and spleen
• Examination of anus, perineum and rectum,
  including sphincter tone, presence of
  hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when
  indicated

HCFA, 1997
22
1997 Physical Examination (PE)General
Multisystem Examination

• Male Genitourinary
• Examination of the scrotal contents
• Examination of the penis
• Digital rectal examination of prostate gland

• Female Genitourinary
• Pelvic examination with or without collection for
  smears and cultures
• Examination of external genetalia and vagina
• Examination of urethra
• Examination of bladder
• Examination of cervix
• Examination of uterus
• Examination of adnexa and parametria

HCFA, 1997
23
1997 Physical Examination (PE)General
Multisystem Examination

• Lymphatic
• Palpation of lymph nodes in two or more areas
• Neck
• Axillae
• Groin
• Other
• Musculoskeletal
• Examination of gait and station
• Inspection and/or palpation of digits and nails
• Examination of joint(s), bone(s) and muscle(s) of
  one or more of the following six areas
• Head and neck
• Spine, ribs and pelvis
• Right upper extremity
• Left upper extremity
• Right lower extremity
• Left lower extremity

• Musculoskeletal, continued
• The examination of a given area includes
• Inspection and/or palpation with notation of
  presence of any misalignment, asymmetry,
  crepitation, defects, tenderness, masses,
  effusions
• Assessment of range of motion with notation of
  any pain, crepitation, or contracture
• Assessment of stability with notation of any
  dislocation , subluxation or laxity
• Assessment fo muscle strength and tone

HCFA, 1997
24
1997 Physical Examination (PE)General
Multisystem Examination

• Skin
• Inspection of skin and subcutaneous tissue
• Palpation of skin and subcutaneous tissue
• Neurologic
• Test cranial nerves with notation of any deficits
• Examination of deep tendon reflexes with notation
  of pathologic reflexes
• Examination of sensation

• Psychiatric
• Description of patients judgment and insight
• Brief assessment of mental status, including
• Orientation to time, place and person
• Recent and remote memory
• Mood and affect

HCFA, 1997
25
1997 Physical Examination (PE)

• As you can see the following statements are true
• Each bullet may not be clinically relevant for
  each patient encounter
• Other items may need to be done and recorded to
  document the quality of your care
• Remember
• Do what the patient needs
• Document what you did

26
1997 Physical Examination (PE)

• In addition to the General Multisystem
  Examination, there are eleven System Specific
  Examinations that can be used by any physician
• Cardiovascular
• Ear, Nose and Throat
• Eye
• Genitourinary (Male and Female)
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin

HCFA, 1997
Outline
27
New or Established?
Hill, 2003
Outline
28
Location of Service

• Office or Other Outpatient Location
• Inpatient Hospital
• Observation Services (Inpatient or Outpatient)
• Consultation Services
• Inpatient
• Outpatient
• Critical Care Services
• Newborn Services
• Emergency Department Services
• Nursing Facility Services
• Domiciliary, Rest Home or Custodial Care Services
• Home Services

Outline
29
CPT Coding - Overview

• The What of documentation
• An effort to condense the value of a
  patient-physician interaction into a single 5
  digit code (99,999 possibilities)

30
CPT Coding History Chief Complaint

• Required for all Evaluation and Management
  encounters
• The reason that the patient presents for care,
  was admitted, still requires inpatient or other
  facility care
• Why the patient requires home care

31
CPT Coding History History of the Presenting
Illness (HPI)

• HPI Elements
• Location
• Quality
• Severity
• Duration
• Timing
• Context
• Modifying Factors
• Associated Signs Symptoms

• HPI Types
• Brief
• 1-3 HPI Elements
• Extended
• gt 4 HPI Elements
• Status of gt 3 Chronic Problems

32
CPT Coding History Review of Systems (ROS)

• Systems for Review
• Constitution
• Ears, Nose, Mouth Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Musculoskeletal
• Intagumentary (Skin Breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic / Lymphatic
• Allergic / Immunologic

• ROS Levels
• None
• 2-9 Systems Reviewed
• gt 10 Systems Reviewed

33
CPT Coding History Past, Family Social
History (PFSH)

• Past History
• Illnesses
• Medications
• Allergies
• Surgeries
• Significant Injuries
• Significant Hospitalizations and Treatments

• Family History
• Significant Illnesses
• Heritable Conditions
• Social History
• Occupation
• Exercise
• Sexual History
• Substance Use
• Exposures

34
CPT Coding HistoryInitial Services / New
Patients
35
CPT Coding HistorySubsequent Services /
Established Patients
36
1995 Physical Examination (PE)

• Body Areas
• Head (Including face)
• Neck
• Chest (Including breasts axillae)
• Abdomen
• Genitalia / Groin / Buttocks
• Back (Including spine)
• Each Extremity
• Right Upper
• Left Upper
• Right Lower
• Left Lower

• Organ Systems
• Constitutional
• Eyes
• ENT / Mouth
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic / Lymphatic / Immunologic

HCFA, 1995
37
CPT Coding 1995 Physical Examination
38
1997 Physical Examination (PE)General
Multisystem Examination

• Constitutional
• Measurement of three or more of the following
  seven vital signs
• Sitting or standing BP
• Supine BP
• Pulse rate regularity
• Respiratory rate
• Temperature
• Height
• Weight
• General appearance of patient

• Eyes
• Inspection of conjunctivae and lids
• Examination of pupils and irises
• Ophthalmoscopic examination of optic discs and
  posterior segments

HCFA, 1997
39
1997 Physical Examination (PE)General
Multisystem Examination

• Ears, Nose, Mouth Throat
• External inspection of ears and nose
• Otoscopic examination of external auditory canals
  and tympanic membranes
• Assessment of hearing
• Inspection of nasal mucosa, septum and turbinates
• Inspection of lips, teeth and gums
• Examination of oropharynx oral mucosa, salivary
  glands, hard and soft palates, tongue, tonsils
  and posterior pharynx

• Neck
• Examination of neck
• Examination of thyroid
• Respiratory
• Assessment of respiratory effort
• Percussion of chest
• Palpation of chest
• Auscultation of lungs

HCFA, 1997
40
1997 Physical Examination (PE)General
Multisystem Examination

• Cardiovascular
• Palpation of heart
• Auscultation of heart
• Examination of
• Carotid arteries
• Abdominal aorta
• Femoral arteries
• Pedal pulses
• Extremities for edema and/or varicosities

• Chest (Breasts)
• Inspection of breasts
• Palpation of breasts and axillae
• Gastrointestinal
• Examination of abdomen
• Examination of liver and spleen
• Examination of anus, perineum and rectum,
  including sphincter tone, presence of
  hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when
  indicated

HCFA, 1997
41
1997 Physical Examination (PE)General
Multisystem Examination

• Male Genitourinary
• Examination of the scrotal contents
• Examination of the penis
• Digital rectal examination of prostate gland

• Female Genitourinary
• Pelvic examination with or without collection for
  smears and cultures
• Examination of external genetalia and vagina
• Examination of urethra
• Examination of bladder
• Examination of cervix
• Examination of uterus
• Examination of adnexa and parametria

HCFA, 1997
42
1997 Physical Examination (PE)General
Multisystem Examination

• Lymphatic
• Palpation of lymph nodes in two or more areas
• Neck
• Axillae
• Groin
• Other
• Musculoskeletal
• Examination of gait and station
• Inspection and/or palpation of digits and nails
• Examination of joint(s), bone(s) and muscle(s) of
  one or more of the following six areas
• Head and neck
• Spine, ribs and pelvis
• Right upper extremity
• Left upper extremity
• Right lower extremity
• Left lower extremity

• Musculoskeletal, continued
• The examination of a given area includes
• Inspection and/or palpation with notation of
  presence of any misalignment, asymmetry,
  crepitation, defects, tenderness, masses,
  effusions
• Assessment of range of motion with notation of
  any pain, crepitation, or contracture
• Assessment of stability with notation of any
  dislocation , subluxation or laxity
• Assessment fo muscle strength and tone

HCFA, 1997
43
1997 Physical Examination (PE)General
Multisystem Examination

• Skin
• Inspection of skin and subcutaneous tissue
• Palpation of skin and subcutaneous tissue
• Neurologic
• Test cranial nerves with notation of any deficits
• Examination of deep tendon reflexes with notation
  of pathologic reflexes
• Examination of sensation

• Psychiatric
• Description of patients judgment and insight
• Brief assessment of mental status, including
• Orientation to time, place and person
• Recent and remote memory
• Mood and affect

HCFA, 1997
44
CPT Coding 1995 Physical Examination
45
CPT Coding Medical Decision Making Diagnoses
Score
46
CPT Coding Medical Decision Making
Diagnostics Score
47
CPT Coding Medical Decision Making Risk Score
48
CPT Coding Medical Decision Making
49
CPT Coding Final Code Selection

• 9920x Office or Other Outpatient Services New
  Patients
• 9924x Office or Other Outpatient Consultation
• 9925x Initial Inpatient Consultation

50
CPT Coding Final Code Selection

• 9921x Office or Other Outpatient Services
  Established Patients

Outline
51
Teaching Physician Documentation

• GC Inpatient, procedures, other locations,
  level 4 and 5 outpatient visits, all outpatient
  visits if there is no GE letter on file with your
  Medicare intermediary listing your location
• Requires personal evaluation of patient by
  teaching physician
• Key components can be in resident/fellow and/or
  teaching physician documentation
• Requires documentation of the following
• Personal evaluation of the patient
• Review of resident/fellow documentation
• How teaching physician impacted care
• Legible signature of teaching physician note

52
Teaching Physician Documentation

• GE Used only by practices that have a GE letter
  on file with their Medicare intermediary listing
  each office practice - for level 1-3 outpatient
  visits, prenatal care, prevention visits
• Requires discussion of patient care by teaching
  physician and resident/fellow
• Key components can be in resident/fellow and/or
  teaching physician documentation
• Requires documentation of the following
• Discussion of care
• Review of resident/fellow documentation
• How teaching physician impacted care
• Legible signature of teaching physician note

Outline
53
Student Documentation

• The only documentation by medical students that
  may be used by the teaching physician is their
  documentation of the Review of Systems (ROS) and
  Past, Family, Social History (PFSH).

Chapelle, K., et. al., 2000
Outline
54
References

• AMA, 2005. AMA Physician ICD-9-CM 2006, Volumes
  1 2. AMA Press.
• AMA, 2005. CPT 2006 Professional Edition. AMA
  Press.
• Chapelle, G, et. al., 2000. Off The Charts
  Teaching Students in Compliance with HCFA
  Guidelines. Family Practice Management. May,
  2000.
• Edsall, R K Moore, 1995(a). A Documentation
  Toolbox. Family Practice Management. May, 1995.
  pp. 35-43.
• Edsall, R K Moore, 1995(b). Exam
  Documentation Charting Within the Guidelines.
  Family Practice Management. March, 1995. pp.
  53-59.
• Edsall, R K Moore, 1995(c). Thinking on Paper
  Guidelines for Documenting Medical Decision
  Making. Family Practice Management. April,
  1995.
• HCFA (now CMS), 1995. 1995 Documentation
  Guidelines for Evaluation Management Services.
• HCFA (now CMS), 1997. 1997 Documentation
  Guidelines for Evaluation Management Services.
• Henry, L, 1998. Three Documentation Tools That
  Work. Family Practice Management. January,
  1998. pp. 29-36.
• Hill, E., 2003. Understanding When to Use the
  New Patient E/M Codes. Family Practice
  Management. September, 2003
• Moore, K L Henry, 1997(a). Exam Documentation
  Just Got Harder. Family Practice Management.
  October, 1997.
• Moore, K L Henry, 1997(b). More Help With Exam
  Documentation. Family Practice Management.
  November/December, 1997.
• Owen, A K Moore, 1995. Dont Read This
  Article! Have We Got Your Attention? Good. Now
  Join Us for a Scenic Tour of HCFAs New
  Documentation Guidelines for History. Family
  Practice Management. February, 1995. pp. 47-53.
• Teichman, P, 2000. Documentation Tips For
  Reducing Malpractice Risk. Family Practice
  Management. March, 2000.

Outline