Coding and Documentation Compliance Training

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Coding and Documentation Compliance Training

• Emergency Medicine Physicians
• UNC Chapel Hill School of Medicine

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Purpose of this course

• To assure appropriate billing through knowledge
  of guiding principles
• To build confidence in documenting evaluation and
  management (EM) services for accurate coding and
  reimbursement

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Compliance Offices Role

• Develop and assure adherence to faculty
  practices Compliance Plan
• Faculty, resident, nurse practitioner and staff
  education
• Medical record reviews (primarily
  physician-directed billing)
• Responses to audit requests from external
  agencies
• Investigate and resolve potential breaches in the
  Compliance Plan
• Research compliance-related issues

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Billing Professional Services

• Every billed service is assigned codes used for
  reimbursement, statistics, research and other
  purposes
• The complexity of the patient condition, as
  documented in the physician note, drives the
  level of evaluation and management service
  delivered, recorded and billed.

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Billing Professional Services

• A UNC Physicians Associates coder assigns codes
  for Emergency Medicine physicians based on the
  content of their notes.
• With the exception of the review of systems and
  past, family and social history, the medical
  students documentation may not be used or
  referenced in the physician note.

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Coding Systems

• Diagnosis
• International Classification of Diseases
  (ICD-9CM)
• World Health Organization
• Procedure
• Current Procedure Terminology (CPT)
• American Medical Association
• Supplemental supply and procedure codes
• Healthcare Common Procedure Coding System (HCPCS)
  
• Federal governmentbut used by many payers

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Medical necessity

• Only services that are medically necessary are
  billable
• Necessity for the work performed must be
  established in the physicians note

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Reimbursement

• Based upon the effort required to treat the
  individual at the time of presentation
• Five levels of evaluation and management (EM)
  services are designated for emergency department
  use

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EM Services AllowablesEmergency Department Codes
ED EMs Medicaid Medicare BCBS/SHP
99281 15.34 16.13 46.55
99282 25.39 26.69 58.35
99283 57.04 59.98 98.80
99284 89.08 93.68 168.44
99285 139.45 146.65 231.04
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EM Services AllowablesCritical Care Codes
Critical Care Medicaid Medicare BCBS/SHP
99291 (first 30-74 min) 191.12 200.93 332.69
99292 (ea. addl 30 min) 95.62 100.78 188.10
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EM code is determined by

1. Demonstration of medical necessity
2. Documentation of decision making complexity
3. Detail of history and physical exam included in
   the note

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Critical care

• When injury or illness acutely impairs one or
  more vital organ systems such that there is a
  probability of imminent or life-threatening
  deterioration
• Document system failure and the decision-making
  required to assess, manipulate and support vital
  system functions
• Record the amount of time spent providing
  critical care to the patient

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Five Emergency Department visit levels

• Medical decision making documentation is the key
  to selection of the code level
• Understanding how decision making is evaluated
  will help improve your documentation

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Medical Decision Making (MDM)Recording
complexity and effort
Based on 2 of these 3 components (detailed on
the following 3 pages)

• Number of diagnostic and/or management options
• Amount and complexity of data
• Risk of the illness, injury or treatment

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Recording your medical decision making
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Medical Decision Making 1. Diagnostic
Management Options

• Self-limited, minor
• Established problem, stable or improved
• Established problem worsening
• New problem, no additional workup planned
• New problem, additional workup planned

1 point
1 pt. ea
2 pts. ea
3 points
4 ea
Total (maximum of 4 points)
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Medical Decision Making 2. Amount and
Complexity of Data

• Review/order of 1)clinical lab 2) radiologic
  study 3)non-invasive diagnostic study
• Discussion of diagnostic study w/interpreting
  physician
• Independent review of diagnostic study
• Decision to obtain old records or get data from
  source other than patient
• Review/summary old med records or gathering data
  from source other than patient

1 point for each type
1 point
2 points
1 point
2 points
Total (maximum of 4 points)
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Medical Decision Making 3. Risk
Choose highest bulleted item from any of the
following three areas (see risk table, next page)
to determine level of risk due to

• Presenting problem
• Diagnostic procedures
• Management options

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3. Table of Risk (To print right click,
choose print, then current slide)
Risk Level Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected
Minimal (1) One self-limited or minor problem, eg, cold, insect bite, tinea corporis Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, eg, echocardiography KOH prep Rest Gargles Elastic bandages Superficial dressings
Low (2) Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension, 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 (3) 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 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 catheterization 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 (4) One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that 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, 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
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Medical Decision MakingConsiderations

• The existence of co-morbidities and underlying
  diseases is not considered in selecting a level
  of E/M service unless their presence
  significantly increases the complexity of the
  medical decision making.
• If it does, document it. Dont merely list it as
  an existing condition.

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Medical Decision MakingConsiderations

• Risk of the presenting problem is based on the
  risk related to the disease process anticipated
  between the present encounter and the recommended
  next inpatient or outpatient service by a
  physician

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MDM Calculation
Diag/.Mgmnt options 0-1 2 3 4
Amt/complexity of data 0-1 2 3 4
Overall risk Minimal Low Moderate High
Type of MDM Strghtfwd Low Moderate High
EM MDM Definition
99281 Straightforward
99282 Low
99283 Moderate Presenting problems are of moderate severity
99284 Moderate Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function
99285 High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function
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MDM Calculation
Diag/.Mgmnt options 0-1 2 3 4
Amt/complexity of data 0-1 2 3 4
Overall risk Minimal Low Moderate High
Type of MDM Strghtfwd Low Moderate High
EM MDM Definition
99281 Straightforward
99282 Low
99283 Moderate Presenting problems are of moderate severity
99284 Moderate Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function
99285 High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function
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Documentation requirements
The detail recorded in the history and exam
generally follows the complexity of the case. It
is required that both the history and exam meet
at least these requirements.
Level History and Exam MDM
99281 Problem focused (PF) Straightforward
99282 Expanded problem focused (EPF) Low
99283 Expanded problem focused (EPF) Moderate
99284 Detailed Moderate
99285 Comprehensive High
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Documenting the history and exam
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The Four Levels of History Exam
EM level HPI ROS PFSH Physical exam (95 guidelines) Level
99281 Brief (1-3) NA NA Limited exam of affected system or area Problem Focused
99282 Brief (1-3) Pertinent (at least one) NA Limited exam of affected system other symptomatic or related systems/areas Expanded Problem Focused
99283 Brief (1-3) Pertinent (at least one) NA Limited exam of affected system other symptomatic or related systems/areas Expanded Problem Focused
99284 Extended (4) Extended (2-9) Pertinent (1 of 3) Extended exam of affected areaother symptomatic Detailed
99285 Extended (4) Complete (10-14) Complete (3 of 3) 8 or more systems documented or a complete exam of a single organ system Comprehensive
History Components
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The History
History of Present Illness

• Location
• Quality
• Severity
• Duration

• Timing
• Context
• Modifying factors
• Associated signs symptoms

Brief 1-3 elements, Extended 4 or review of
3 chronic or inactive conditions
Review of Systems

• Constitutional symptoms
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary

• Musculoskeletal
• Integumentary (skin/breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

Pertinent lt2 Extended 2-9 Complete 10-14 or
all others negative
Past, Family and Social History

• Social
• Living arrangements
• Marital status
• Sexual history
• Occupational history
• Use of drugs/tobacco/alcohol
• Extent of education
• Current employment
• Other

• Past
• Current Medications
• Prior illnesses/injuries
• Dietary status
• Operations/hospitalizations
• Allergies
• Immunizations

Pertinent 1 of 3 areas Complete 3 of 3 (2
of 3 for estab.)

• Family
• Health status/cause of death of parent, sibling,
  children
• Diseases related to chief complaint, HPI, ROS
• Hereditary or high risk diseases

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The History

• Anyone, including students or the patient
  himself, may collect the review of systems and
  past, family and social history, however, the
  physician note must refer to reviewing those
  aspects of history to establish the use of those
  elements in the care of the patient.
• The physician must personally document the
  history of the present illness even if it appears
  in other providers notes.

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The Physical Exam

• A general multi-system examination or a single
  organ system may be performed by any physician
  regardless of specialty.
• The type (general multi-system or single organ
  system) and content of examination are selected
  by the examining physician.
• Note specific abnormal relevant negative
  findings of the affected or symptomatic
  area(s)--abnormal is insufficient.
• Describe abnormal or unexpected findings of
  asymptomatic areas or systems.
• Noting negative or normal is sufficient to
  document normal findings in unaffected areas.

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Examples of presentations at various levels

• patient with several uncomplicated insect bites.
• a 20-year-old student who presents with a painful
  sunburn with blister formation on the back.
• a well-appearing 8-year-old who has a fever,
  diarrhea and abdominal cramps, is tolerating oral
  fluids and is not vomiting
• a sexually active female complaining of vaginal
  discharge who is afebrile and denies experiencing
  abdominal or back pain

99281
99282
99283
99283
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Examples of presentations at various levels

• an elderly female who has fallen and is now
  complaining of pain in her right hip and is
  unable to walk.
• a patient with flank pain and hematuria
• a patient with a new onset of rapid heart rate
  requiring IV drugs
• a patient who presents with a sudden onset of
  "the worst headache of her life," and complains
  of a stiff neck, nausea, and inability to
  concentrate

99284
99284
99285
99285
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Medicare Teaching Physician Regulations
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The Medicare programs perspective on residents

• Resident services to Medicare beneficiaries are
  paid to the hospital through Part A based on the
  proportionate share of Medicare at the teaching
  hospital
• Teaching physicians are paid by Part B Medicare
  on a fee-for-service basis only when they provide
  a personal, face-to-face service in addition to
  the resident

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Proper Teaching Physician (TP) Documentation for
Medicare

• The resident note alone, the TP note alone or a
  combination of the two may be used to support the
  level of service billed.
• Documentation by a resident or any other party of
  the presence and participation of the TP is not
  sufficient (except in cases of some procedures in
  which the teaching physician is present for the
  entire time--never for ED visit services)
• Documentation may be dictated and typed,
  hand-written or computer-generated.

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Medicare requires attestation of teaching
physician involvement
For Emergency Department evaluation and
management services

• That the teaching physician performed the service
  or was physically present during the key or
  critical portions of all three components
  history, exam and decision making and
• The participation of the teaching physician in
  the management of the patient.

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Examples of Acceptable Teaching Physician Notes

• "I performed a history and physical examination
  of the patient and discussed his management with
  the resident. I reviewed the resident's note and
  agree with the documented findings and plan of
  care."
• "I was present with resident during the history
  and exam. I discussed the case with the resident
  and agree with the findings and plan as
  documented in the resident's note.

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Examples of Unacceptable Teaching Physician Notes

• "Seen and agree." followed by legible
  countersignature or identity
• "Patient seen and evaluated." followed by legible
  countersignature or identity and
• A legible countersignature or identity alone.

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Procedures

• Minor procedures of lt5 minutes
• TP must be present the entire time
• Surgical procedures
• TP must be present for the key portions and state
  those portions in the attestation
• In operating suite available to return
• Two overlapping procedures
• Key portions must happen at different times
• Must be available to return to either or
  designate another TP

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Time-based services

• Time-based procedures may be billed to Medicare
  on teaching physician time only. Record the
  actual amount of time in the note.
• Critical care
• Prolonged services
• Payers other than Medicare may be billed for
  resident time performing time-based services if
  the amount of time is documented

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North Carolina Medicaid Teaching Physician
Regulations
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NC Medicaid teaching physician (TP) requirements

• TP must be "immediately available" to the
  resident and patient by telephone or pager at the
  least
• For procedures, the TP must use "direct
  supervision" (available in the office suite)
• The degree of supervision is the responsibility
  of the TP and is based on the skill, level of
  training and experience of the resident as well
  as the patient's condition.
• Written documentation in the medical record for
  Medicaid patients must clearly designate the
  supervising physician and be signed by that
  physician.

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Where To Get Help

• www.med.unc.edu/compliance/
• UNC PA Professional Charges Coders for Emergency
  Medicine
• Cindy Wyrick, CPC, 966-9051
• Rhonda Peck, CPC, 962-8391
• Jana Rakes, CPC, 843-6096
• Deresa Stroud, CPC, 843-3135
• School of Medicine Compliance Office 843-8638
• Heather Scott, CPC, Compliance Officer
• Keishonna Carter, CPC, Compliance Review Analyst
• Nirmal Gulati, CPC, Compliance Auditor
• Lateefah Ruff, CPC, Office Assistant
• Confidential Help Line 800-362-2921 for reporting
  potential compliance problems
• The AMAs Current Procedural Terminology (CPT)
  Manual