DOCUMENTATION COMPARISONBy:

Betsy L. Priest

AA, CCS-P

AHIMA Approved ICD-10-CM/PCS Trainer

DOCUMENTATION

Documentation is key for all visits in an outpatient setting.

Incorrect or incomplete documentation can result in:DenialsTake backsMedical Necessity issuesIncreased AuditsIncomplete medical picture of the patient

DENIALS

Denials can happen for numerous reasons.

They are based off of the billing codes submitted.

You can appeal these denials if the documentation supports the codes that were submitted for billing.

Once the appeal has started there should be no updates to the medical record before sending them out.

If it is not documented, it did not happen.

TAKE BACKS

When a payer thinks they over paid you for services rendered, they will do a take back.

Take backs are also based off of the codes submitted for billing as well as other payer driven initiatives.

Take backs can also be appealed.

Documentation needs to support the codes submitted.

MEDICAL NECESSITY REVIEWS

Medical necessity reviews are done on pre-determined sets of diagnosis codes.

Usually the record is requested at random due to the diagnosis billed.

Documentation needs to support the diagnosis billed.

** Claims can always be denied based simply on the procedure billed and what diagnosis is attached if that procedure is not accepted with certain diagnosis codes. (See LCDs and LMRPs to determine if a diagnosis code is accepted with certain procedures)

INCOMPLETE MEDICAL PICTURE OF THE PATIENT

Your documentation needs to tell a story.

Who is the patient?What is wrong with the patient?Why are they in your office?Where is the visit taking place (done by registration/check in and E/Ms)?What is the outcome of the visit?

INCREASED REVIEWS

If your practice and/or provider are consistently reviewed and found to be wrong in your billing, your practice may be subject to more reviews.

Payers like to save money. If they find that the documentation does not support their reviews, they will be back.

Reviews and audits can be helpful.

Use them to teach the providers and fix your denials.

PROCEDURE CODING

When ICD-10 is implemented on Oct 1, 2015, CPT will still be used to report all procedures completed in the out patient setting.

CPT includes actual procedures as well as office visits and counseling services.

While the information needed to support the procedures has not changed, the information needed to support the diagnosis codes attached has.

We will look at different examples and scenarios today but for definitive answers always look to the LCDs and LMRPs for specific procedures.

EVALUATION AND MANAGEMENT

Evaluation and Management codes are the most widely used procedure codes in an outpatient setting.

All types of practices can use them. PCPs, Specialists and even Hospitalists and providers that round on inpatients for their Part B billing.

All Evaluation and Management codes are built based on the same criteria. All of this criteria “builds” and E/M code.

BUILDING AN E/M CODE

There are 3 components to an E/M codeHistory

1.Chief Complaint/HPI

2.Review of Systems

3.Past family, medical and social historyExam

1.Simply the actual examination of the patientMedical Decision Making

1.Number of diagnosis and/or management options that must be considered

2.The amount and/or complexity of medical records reviewed (labs, x-rays, consult notes, etc.)

3.The risk of the complications, morbidity and/or mortality

HISTORY COMPONENT

The history component is built on:

HPI – History of presenting illness

1.Part of a valid HPI is a good chief complaint. Chief complaint should not include subjective information or question marks.

2.Chief complaint is the reason the patient is in today

3.Chief complaint should not simply say “follow up”, what is the visit a follow up for?ROS - Review of Systems

1.Can be captured in the body of the HPI

2.Can be captured by nursing staff if reviewed by providerPFSH –Past Family and social history –

1.Includes smoking status, past surgeries, family illnesses, etc.

EXAM COMPONENT

Exam is usually done by the provider.

This is an exam of pertinent body systems to the problem at hand.

Made up of “bullets” or points.

1.3 vitals is 1 point

2.Appearance (constitutional) is one point

Any other system is an additional point.

EXAM BULLETS

  Normal EXAM Abnormal   Normal EXAM Abnormal   Normal EXAM Abnormal  

Skin  Inspect  

Resp

  Resp Effort  

GU (male)

  Penis      Palpate     Palpation Chest     Scrotum/Testicles    

Eye

  Conjuctiva/lids     Percussion     Prostate    

  Pupils/Irises     Auscultation Lungs  

GU (female)

  Ext. Genital & Vag    

  Fundi  

CV

  Palpation Heart     Urethra    

ENMT

  Ext ears/Nose     Auscultation

Heart     Bladder    

  TM's/ EAC's     Abdominal Aorta     Cervix      Hearing     Femoral Arteries     Uterus    

  Nasal Muc/Sep     Pedal Pulses     Adnexa    

  Lips/Dentition     Edema/Var Veins  

BR  Inspection    

  Oropharynx     Carotid Arteries     Palpation    

Neck  Neck  

ABD

  Palpation  

MUSC-SKEL

  Digits/Nails      Thyroid     Liver/Spleen     Gait/Station    

Lym (need 2 or more areas)

  Neck     Hernias Absent     Joints/Bone/Muscle    

  Groin     Rectum/Perineum     Head/Neck

Must include at least 1 of the following for a

"bullet"-ROM, Stability, Insp/Palp,

Musc Tone

  Axilla     Stool Heme     Spine/rib/Pelvis

  Other  

PSY

  Judge/Insight     RUE

Neu

  Sensation     Orientation     LUE

  DTR's     Memory     RLE

  Cranial Nerves     Mood & Affect     LLE

MEDICAL DECISION MAKING COMPONENT

Medical decision making is thought of as the most important component. It drives the E/M code to the appropriate level.

It also supports the medical necessity of the visit itself.

Medical Decision Making includes:Number of diagnosis Management options that must be consideredComplexity of medical records that need to be reviewed (if applicable)The risk of the patient

1.Complications

2.Comorbidity

3.Diagnostic procedures

4.Possible management options

NUMBER OF DIAGNOSIS

Number of Diagnosis Points & Management Options1pt (2pts max)Self Limiting or minor problem1 pt eachEstablished problem stable/improving2 pts eachEstablished problem worsening, not responding to treatment3 pts (3pts max)New problem, no additional workup planned4 + pts eachNew problem, additional workup planned

RISK OF THE PATIENT

E/MS BY TIME

You can also assign an E/M based on time.Make sure total time is documentedMust state in note that at least 50% of total visit time was spent on counseling and/or coordination of careAdequate documentation must be there to support coding by time.Adequate does not mean that all E/M components must be met. It simply means that you need to give an overview in the note to outline what was discussed.

PREVENTIVE E/MS

Preventive visits (H&Ps) do not follow the E/M components even though they are considered an E/M.

Preventive visits are based on the patient’s age and whether they are new or established

Preventive visits and an office visit E/M can be billed on the same DOS if there is a significantly different problem than the preventive alone.This would NOT be stable chronic conditions or refilling a medication for a problem.

PROCEDURE CPTS

The remainder of the CPTs are actual procedures.

These are a little more straight forward in their coding.

You simply code what was done to the patient while in the office.

While you must document what was done in entirety, denials are usually based on LCDs and LMRPs.

MEDICAL NECESSITY

In order to bill for any CPT there must be medical necessity.

Some examples:

69210 – Cerumen Removal (with a tool) needs to have the diagnosis 380.4 (Impacted Cerumen) attached. All other diagnosis codes will make this deny.

99407 – Tobacco Cessation Counseling (10 mins) needs to have the diagnosis code 305.1 (Tobacco abuse) attached. All other codes will make this deny.

MEDICAL NECESSITY, CONT.

In the inpatient setting you can code probable, rule outs and suspected conditions in order to order tests and do other diagnostics.

In the outpatient setting none of these are allowed.

In ICD-9 that left coders using vague symptom codes and non-specific diagnosis codes that could cause denials.

In ICD-10 there are many codes that can outline these types of visits.

“ENCOUNTER FOR” CODES

In place of using only vague symptom codes, you can also add “Encounter for” codes. These should be used in addition to the symptom code to better explain what is going on during the visit.

Some examples are:

Z11.*** - Encounter for screening for infectious and parasitic diseases

Z12.*** - Encounter for screening for malignant neoplasm

Z13.1 – Encounter for screening for diabetes mellitus

These should never be used alone. But these grouped with the symptom codes should assist in gathering the most specific information for the patient’s care.

CODE SELECTIONSpecialty

Number of ICD-9 codes

Number of ICD-10 codes

ICD-10-CM Comments

Infectious disease 1,270 1,056Chapter 1, ICD-10-CM codes actually fewer by 250 codes

Hematology 123 238 Chapter 3, begins with category D50

Endocrinology 335 675Chapter 4, total includes metabolic and nutritional diseases

Neurology 459 591Chapter 6, increase is modest despite more site-specific diagnoses

Ophthalmology 795 2,432Chapter 7, total is 3x, but that is mainly because of the left/right detail for the eye, and left/right plus upper/lower detail for the eyelid

Cardiology 230 266Chapter 9, first half of the chapter, categories I00-I50

Pulmonology 255 336Chapter 10, increase is modest despite more site-specific diagnoses

Gastroenterology 596 706Chapter 11, total includes diseases of the teeth and oral cavity, GI diagnoses start with category K20

Dermatology 204 768Chapter 12, increase in total mostly because of site specific detail, especially in skin ulcer codes, where site and stage are all included in one code

Urology 389 591Chapter 14, includes reproductive system as well as urinary system diagnoses

Pediatrics 702 1,207Includes the newborn conditions (chapter 16) and the congenital anomalies (chapter 17)

SEVENTH CHARACTER EXTENSIONS

Many code sets have a 7th character extension.

These are already built into the code so they are not forgotten.

These tell a more detailed story about the diagnosis you are treating.

In S01 – Injury chapter, there are 3.

A – Initial Encounter

D – Subsequent Encounter

S – Sequela

SEVENTH CHARACTER EXTENSIONS, CONT.

There are even more in the fracture chapter (S62)

They are:A - initial encounter for closed fracture B - initial encounter for open fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela

SEVENTH CHARACTER DEFINED Initial: used while the patient is receiving active treatment

for the injury, illness or surgery. (follow up from a surgery or Emergency Room visit)

Subsequent: used while the patient is in the recovery stage of treatment for that same injury, illness or surgery. (cast change or removal, medication adjustment, and other after care or follow up visits)

Sequela: used for complications of the same injury, illness or surgery. (scar formation after a burn is an example)

***When using Sequela you need to list both the complication as well as the initial injury. The “S” extension would go on the injury code, not the complication. The complication would be the first diagnosis and the injury would be the 2nd.

UNDERDOSING

Underdosing is a new concept in ICD-10. It refers to taking less of a medication than is prescribed by the provider or manufacturer’s instructions.

The codes for underdosing (T36.***-T50.***) should never be the only code, or the first code.

If the patient has a relapse or exacerbation due to the underdosing, the medical condition should also be coded.

In addition to the underdosing codes, there are also codes to list the intent if known. You can use the non-compliance codes (Z91.12* or Z91.13*) or complication of care codes (Y63.61, Y63.8-Y63.9) in addition to the underdosing code for the intent itself.

SPECIFICITY

There will be times when there are no choices for an “unspecified” code.

An example of this is GERD. There is no unspecified, but a lot of times you may not know if your patient has esophagitis or not.

When this happens, it is perfectly fine to pick the least specific code available. Just remember to go back in and update if and

when you get the more specific diagnosis.

QUESTIONS????