At Least I Hope We Are

CHARTING FOR COMPLIANCE

� Regulatory basis for E&M visits

� Basic Elements of the E&M note

� Organizing your Thoughts

� Don’t be afraid to Code for the Work you do

� Think Like an Auditor

� Focus on the Problem

AMDA’s Coding Guidelines � 99309

� Moderately Complex Medical Decision Making

� Mulitple Diagnoses or management options (actual # not indicated by CMS

� Moderate amount and/or complexity of data

� Moderate Risk of complications and/or morbitidy/mortality

AMDA vignette - 99309

E&M Coding (Arkansas –Q1 09) Pinnacle Medicare Services

Most often, down-coding of services was due to a lower level of the complexity of medical decision making documented than was billed. In addition, billing a higher level of nursing facility code would not be expected if the patient is stable, recovering, or improving; there are no complaints; and the provider is making a routine monthly visit. These services should usually be billed as CPT 99307. According to the CPT definition of the code, to qualify for CPT 99308, the patient is usually responding inadequately to therapy or has developed a minor complication.

Other common problems noted on review:

- No records or the lack of documentation for the

performance of and/or necessity of services billed.

- Illegible documentation.

- Records lacking dates, patient’s name, and/or

signature of author.

- Incorrect date of service billed.

- Incorrect performing provider billed or unable to

identify the performing provider.

- Cloned, pre-printed notes that do not establish

medical necessity of service for patient receiving

service.

Cigna’s source for ‘Medical Necessity’

Visits to Comply With Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF and NF

Payment is made under the physician fee schedule by Medicare Part B for federally mandated visits. Following the initial visit by the physician, payment shall be made for federally mandated visits that monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.

Carriers shall not pay for more than one E/M visit performed by the

physician or qualified NPP for the same patient on the same date of service.

The federally mandated E/M visit may serve also as a medically

necessary E/M visit if the situation arises (i.e., the patient has health problems that need attention on the day the scheduled mandated physician E/M visit occurs).

The physician / qualified NPP shall bill only one E/M visit.

CFR

… or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

The volume of documentation should not be the primary influence upon which a specific level of service is billed.

Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

It would not be medically necessary…

CPT

MCPM

• Frequent and recurring "routine visits" by the same medical professional. •Seeing residents too often may indicate that the provider is billing for services that are not medically necessary.

•Questionable documentation for medical necessity of professional services. •Practitioners who are billing inappropriately may also enter, or fail to enter, important information on medical charts.

3+ Chronic Problems –

Doomed to 99307 &308????

Medical Necessity Other than some Medicare approved screening

services, Medical Necessity is the only criteria which drives a billable event.

The documentation in the medical record is the supportive evidence of that medical necessity.

The Medicare Policy Manual section 30.6.1 states, "Medical necessity is the overarching criteria for payment in addition to the individual requirements of the CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted."

PARK

Medical Decision Making

1. Dx/Management options- The number of possible diagnoses and/or management options that must be considered.

2. Data - Amount and complexity of medical records, lab work, diagnostic tests that must be reviewed or ordered in order to establish a diagnosis or treat an existing condition.

3. Risk - The risk of significant complications, morbidity and/or mortality as well as co-morbidities (which increase the complexity of the MDM) associated with the presenting problem(s), diagnostic procedures and/or possible management options.

PARK

Number of Diagnosis

CIGNA

Complexity of Data

CIGNA

Table of Risk

CIGNA

Type of Medical

Decision Making

CIGNA

CHIEF COMPLAINT: Fractured right hip. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old white female fell broke her right hip and had surgery while in the hospital. She tolerated the surgery well and is here in the nursing home for continued rehabilitation. PAST MEDICAL HISTORY: Significant also for: Diabetes. Peripheral vascular disease. Coronary artery disease. Hypertension.

PE: Assessment: 1. 821.0 Fractured Hip. Will order PT/OT. PLAN: Continue the current medicines and physical therapy.

Admission Visit � Audit Finding - 99306 to 99304

Patient admitted to NF following right hip surgery for continued rehabilitation.

Comp Hx & Comp. Exam with straight fwd to low complexity MDM. Plan includes continuation of current meds & PT.

What about better documenting….

It would raise the complexity of decision making. � DVT Prophylaxis? How long? What drugs? � 790.79 Anticoagulation Mgt? � Medication Mgt of multiple drugs? � 338.29 Pain Mgt? � 733.0 Osteoporosis Mgt? � 781.2 Direct PT to perform & report Balance Assessment –

falls prevention � Skin Care & Decubitus Prevention � What about cognition and/or dementia ? Testing? Mgt? � What caused this patient to fall? Syncope, balance, etc. � What complications can we expect in the elderly post hip

fracture? What is the morbidity and mortality rate? State it. What about weight loss and nutrition?

� Statement of increased risk of complications.

Subsequent Care Visits

CHIEF COMPLAINT: Cough, congestion. HISTORY OF PRESENT ILLNESS: This is an acute visit for Ms. xxx She has developed some cough and congestion. She was seen by a

pulmonary physician who ordered chest x-ray, also put her on Levaquin 500 mg every day x4 doses. When I went to see the patient, she was doing well, resting in bed. She did complain of some rhonchi and just not feeling very well. She has productive cough. She is on dialysis. Therefore she requires a decreased dose of the Levaquin. She does not appear to be septic. She is afebrile. No signs of tachypnea or accessory respiratory muscle use. However she is having this cough and congestion. She could easily be developing bronchitis versus early pneumonia. Awaiting the results of her chest x-ray. She still is going through loss of her husband who recently expired. She is having difficult time with this but seems to be adjusting reasonably well.

PAST MEDICAL HISTORY: Significant for: 1. End-stage renal disease. 2. History of DVT. 3. Hypertension. 4. Dyslipidemia. 5. GERD. 6. Anemia. 7. Osteoarthritis. 8. COPD. 9. Restless leg syndrome. MEDICATIONS: Reviewed

REVIEW OF SYSTEMS: General: Appetite has been fair. Eyes: No vision changes. Ears/Nose/Mouth/Throat: No hearing change, dysphagia, or change in dental status. Respiratory: Cough, congestion, no shortness of breath. Cardiac: No chest pains or palpitations. Gastrointestinal: No abdominal pain or change in bowel habits. PHYSICAL EXAM: Vital Signs/Constitutional: On exam, her blood pressure is 112/70. Afebrile. Pulse 77. Respiratory rate 20. Saturation 94%. General: The patient is in no obvious distress. Eyes: CONJUNCTIVAE AND LIDS: Conjunctivae and lids appear normal . Ears, Nose, Mouth, Throat: EXTERNAL / EARS AND NOSE: Overall appearance normal with no scars, lesions or masses. Respiratory: Mild rhonchi bilaterally. Cardiovascular: CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. PMI not displaced. No thrill. EDEMA / VARICOSITIES OF EXTREMITIES: No edema or varicosities

ASSESSMENT AND PLAN: 1. 490.00 bronchitis, unspecified. We will continue with the Levaquin as ordered. Hopefully she will have a good response to this. We will also add guaifenesin 1200 mg b.i.d. to help with phlegm production. Await the results of the chest x-ray. She does have mild rhonchi although improved with deep breath. Suspect she has bronchitis, possibly even early pneumonia however she is doing well with bronchitis. 2. 250.41 diabetes, with renal manifestations with 585.6 disease, end stage renal disease. Continue with dialysis. No signs of uremia. She does require decreased dose of Levaquin because of the end-stage renal disease. 3. 311.00 depression, secondary to the loss of her husband. Overall she seems to be doing reasonably well. LEVEL OF CARE: 99309.

What defines the medical necessity and Nature of Presenting Problem? Is the NPP stated in a way that would allow you to code this visit as a 99309? How else might we state the chief complaint? Does the History, Physical and Assessment document the NPP? How could these areas have been beefed up to better document medical necessity? What did the auditor find problematic in coding this visit at 99309 and why was it downcoded?

Auditors Findings

The auditor down coded this visit to a 99307. Patient had been seen 8 days before by the ECP doctor and seen by a pulmonary physician in between the current visit and the prior visit. The pulmonary physician ordered a CXR and Levaquin. Down coded on the basis of lack of medical necessity for the visit. However, the auditor felt that there was and Expanded history, a Detailed physical and Moderate medical decision making.

CODE STATUS: DNR. CHIEF COMPLAINT: Followup on dementia with failure to thrive, hypothyroidism, depression, and anxiety. HISTORY OF PRESENT ILLNESS: This is a follow-up visit note on Ms. zzzz. I am seeing her today to follow up on her advanced dementia, failure to thrive, and hypothyroidism. Overall, the patient seems to be doing well. Her appetite is doing good per the staff, although she does not drink very much. She appears to be slightly dehydrated this morning with a little bit of dry mouth. Therefore, I am going to encourage fluids for her. She has a history of renal insufficiency. She has no signs of uremia. She also has a history of hypothyroidism. She is on thyroid replacement. She has no signs or symptoms of hypo or hyperthyroidism. She requires assistance with all her ADLs because of her advanced dementia. She also has a history of hypertension. Her blood pressures are doing very well. Her systolic blood pressure usually runs in the 110s to 120s. The patient now is on hospice because of her advanced dementia with poor long-term prognosis. PAST MEDICAL HISTORY: Significant for:

•Hypertension. •Dementia. •Anxiety. •Hypothyroidism. •Renal insufficiency. MEDICATIONS: Reviewed.

REVIEW OF SYSTEMS: General: Appetite remains variable. Eyes: No vision changes. Ears/Nose/Mouth/Throat: No hearing change, dysphagia, or change in dental status. Respiratory: No upper respiratory infections, dyspnea, cough, hemoptysis or wheezing. Cardiac: No chest pains or palpitations. PHYSICAL EXAM: Vital Signs/Constitutional: Her blood pressure is 118/76. She is afebrile. Eyes: CONJUNCTIVAE AND LIDS: Conjunctivae and lids appear normal. Ears, Nose, Mouth, Throat: EXTERNAL / EARS AND NOSE: Overall appearance normal with no scars, lesions or masses. Respiratory: Normal respiratory effort. Normal to auscultation. Cardiovascular: CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. PMI not displaced. No thrill. EDEMA / VARICOSITIES OF EXTREMITIES: No edema or varicosities. DIAGNOSIS & ASSESSMENT: 1. 294.10 dementia in conditions classified elsewhere without behavioral disturbance. She has advanced dementia. We will continue to assist with her ADLs. Her long-term prognosis is limited. She now is on hospice. We will continue to monitor her. 2. 401.1 Hypertension: Her blood pressure is controlled without any medication. 3. 428.0 CHF: She is on Lasix 20 mg daily. She has no signs of failure. She appears to be a little bit volume depleted. We will discontinue the Lasix. 4. 244.9 Hypothyroidism: She is stable on the current dose of Synthroid. 5. 311 Depression: Doing well with the Zoloft. BILLING CODE: 99309

What defines the medical necessity and Nature of Presenting Problem?

Is the NPP stated in a way that would allow you to code this visit as a 99309?

How else might we state the chief complaint?

Does the History, Physical and Assessment document the NPP?

How could these areas have been beefed up to better document medical necessity?

What did the auditor find problematic in coding this visit at 99309 and why was it downcoded?

What defines the medical necessity and Nature of Presenting Problem?

Is the NPP stated in a way that would allow you to code this visit as a 99309?

How else might we state the chief complaint?

Does the History, Physical and Assessment document the NPP?

How could these areas have been beefed up to better document medical necessity?

What did the auditor find problematic in coding this visit at 99309 and why was it downcoded?

This claim was denied completely on the basis of lack of documented Medical Necessity. The auditor makes note of the fact that this patient had been seen 11 times in the time period 6-1-08 and 10-17-08. What would have been the outcome if the new problem of dehydration had been stated?

Medical Necessity ≡ Nature of Presenting Problem

Nature of Presenting Problem (NPP)

ADMISSION VISITS Associated CPT

Code

Verbose description of problem

1

Minor 99304

Problem runs definite and prescribed course, is transient in nature, and is not likely

to permanently alter health status; OR, has a good prognosis with management and

compliance.

2

Low 99304

Problem in which the risk of morbidity without treatment is low; there is little to no

risk of mortality without treatment; full recovery without functional impairment is

expected.

3

Low-Moderate 99304

Problem in which the risk of morbidity without treatment is low to moderate; there

is low to moderate risk of mortality without treatment; full recovery without

functional impairment is expected in most cases, with low probability of prolonged

functional impairment

4

Moderate 99305

Problem in which the risk of morbidity without treatment is moderate; there is

moderate risk of mortality without treatment; prognosis is uncertain, or there is an

increased probability of prolonged functional impairment.

5

Moderate – High 99305

Problem in which the risk of morbidity without treatment is moderate to high; there

is moderate risk of mortality without treatment; uncertain prognosis or increased

probability of prolonged functional impairment

6

High 99306

Problem in which the risk of morbidity without treatment is high to extreme; there

is moderate to High risk of mortality without treatment, or high probability of

severe prolonged functional impairment

SUBSEQUENT CARE VISITS

Verbose description of problem

1 Stable 99307 Usually, the patient is stable, recovering or improving

2 Inadequate

response

99308 Usually, the patient is responding inadequately to therapy or has

developed a minor complication

3 Unstable 99309 Usually, the patient is unstable or has developed a significant

complication or a significant new problem

4 Immediate

Attention

99310 The patient may be unstable or may have developed a significant new

problem requiring immediate physician attention

Practical E/M - S. R. Levinson 2nd Edition, 2008 – Nursing Home Template

Nursing Facility Care NF Assessments (3 of 3 required + Medical Necessity in Chief Complaint )

Codes Medical Necessity History Examination Type Decision

Complexity

Time

Basis

99304 Usually, the

problem(s) requiring

admission are of low

severity.

cc; HPI(4); ROS (2-9);

PFSH (1)

Detailed = 6 systems w/2

elements or 2+ systems

w/12 elements total

Straightforward

to Low

25

99305 Usually, the

problem(s) requiring

admission are of

moderate severity.

cc; HPI(4); ROS (10);

PFSH(3)

Comprehensive 9 systems

w/2+ elements

Moderate 35

99306 Usually, the

problem(s) requiring

admission are of high

severity.

cc; HPI(4); ROS (10);

PFSH(3)

Comprehensive 9 systems

w/2+ elements

High 45

99318 Usually, the patient is

stable, recovering or

improving.

cc; HPI(4); ROS (2-9);

PFSH (1)

Comprehensive 9 systems

w/2+ elements

Low/Moderate N/A

Subsequent Visits (2 of 3 elements required + Medical Necessity in CC))

Codes Medical Necessity History Examination Type Decision

Complexity

Time

Basis

99307 Usually, the patient is

stable, recovering or

improving.

cc; HPI (1-3) 1-5 elements Straightforward 10

99308 Pat responding

indqtly to thrpy or

has dvlpd a minor

complication.

cc; HPI (1-3); ROS(1) 6 systems w/2 elements or

2+ systems w/12 elements

total

Low 15

99309 Usly Pt. has

developed a

significant

complication or a

significant new

problem.

cc; HPI (4); ROS (2-

9); PFSH (1)

6-11 elements Moderate 25

99310 Pat may be unstable

or may have

developed a

significant new pblm

requiring immediate

physician attention.

cc; HPI (4); ROS

(10+); PFSH (3)

9 systems w/2+ elements

(Total of 18+ elements)

High 35

What’s happening

Good Words

Bad Words

Change in condition

Use “New Significant Problem or “change in condition” I’m here today to assess the patient’s recent elevated BP measurements Patient is complaining of new onset/recurrence of/worsening of/persistence of / pain @ (location)

• this is a review of recent high blood pressure readings … • This is a follow-up on p/c by RN about patient’s recent change … .

Patients condition still bad on subsequent visit

Patient continues to exhibit signs/symptoms of ____ and has shown no/minimum/limited improvement…. Remains unstable

Patient’s condition is unchanged or stable from last visit

Order some VS monitoring (note active vs passive voice)

Measure – I will have the nursing staff measure B/P q6 hr

Record – nurses are to record B/P q6 hr

Active vs. passive decision making

Report – I am instructing Nursing staff to report any abnormal B/P measurements to me (readings >150 mm Hg systolic)

Report – the B/P report form was reviewed during the visit

Active vs. passive voice

Determine – the purpose of today’s visit is to determine the cause of …as requested by .. Check on multiple medications and their potential for interactions and adverse reactions

It was determined by the (consultant) that..xyz.. should be changed. The requested change is being made

Good and bad words to use to describe reason for visit (regardless of what you do)

Assess or Reassess/re-evaluate Determine Measure Evaluate or Reevaluate Consider or Reconsider Verify Coordinate Examine Unstable Potentially life threatening Worsening condition New onset of Critically ill High risk of morbidity or mortality

Follow-up Check-up Review Stopped-by Ongoing

Some phases that might be helpful:

� “This patient is severely cognitively impaired and must

be seen frequently since he/she is unable to make his/her needs known.”

� “This patient is at moderate/high risk of medical complications due to (blank) and multiple co-morbid medical problems.”