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Evaluation and Management Services –Amping up the Documentation for 2016

October 29, 2015

The purpose of this publication is to accompany a lecture prepared and presented by GILLCOMPLIANCE SOLUTIONS, LLC. It is supplemental and is not a substitute for the CPT® or theICD-10-CM coding manuals. There is no guarantee that the use of this presentation willprevent differences of opinion with providers or carriers in reimbursement disputes.

There is no implied or expressed warranty regarding the content of this publication orpresentation due to the constant changing regulations, laws and policies. It is further notedthat any and all liability arising from the use of materials or information in this publicationand/or presentation is the sole responsibility of the participant and their respectiveemployers, who by his or her purchase of this publication and/or attendance at apresentation evidences agreement to hold harmless the aforementioned party.

This publication is intended to be used as a teaching tool accompanying the oralpresentation only. Presentation material may not be distributed without written permissionby Gill Compliance Solutions, LLC.

Disclaimer

• ICD-10 clinical documentation strategies for providers

• Evaluation & management criteria, EMR’s and assessing risk

• Time based services to override E/M components

• Ancillary staff, scribing and EMR’s

• “Incident to” and shared services with consideration to regulatoryconstraints based on place of service

• Industry news and trends

• Questions?

Today’s Agenda

ICD-10 Moving Forward

CMS is not conducting any audits for 1-year followingimplementation

• A valid I-10 code is required on all claims as of October 1, 2015

• Claims will not be denied under the Part B physician feeschedule solely on I-10 codes for 12-months afterimplementation

CMS Audit Expectations

CMS Guidance:https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

CMS Guidance Clarifications:https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

Reverse audit

• Pull history for top ICD-9 codes by specialty

• Use top 10-20 ICD-9 code for each specialty

• Match claim history to ICD-9 utilization

• Pull claims to validate ICD-9 and documentation

• Evaluate current documentation and attempt mapping to ICD-10

• Develop structured feedback onadditional documentation neededto reach level of detail matching ICD-10 conventions

• Develop visual tools to assist providers with dictation or manualEMR entry

Audit/Education Strategies for Providers

Evaluation & Management

Purpose of Good Documentation

• The documentation of each patient encounter should include:

‒ The reason for the encounter and relevant history

‒ Physical examination findings and prior diagnostic

‒ Test results

‒ Assessment, clinical impression, or diagnosis

‒ Medical plan of care

‒ The date and legible identity of the observer

General Principles

CMS on Signatures:

• Notes should clearly identify authorship and provide clarity as to whomprovided which elements of note or service

• All notes should contain an official electronic authentication from provider andshould be done before billing is performed. Notes as “incomplete”, “unsigned”or “unreviewed” are not considered complete and authenticated

• For electronic records; Pending or Revised does not qualify as “authenticated”per CMS

• Handwritten signatures must be legible per CMS guidelines

• The record may contain a printed signature below the illegible signature andthis may be accepted

Signature log:

- Identifies the author associated with initials or illegible signature

- Include with requested documentation

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

Authentication Rules

New & Established Office Visits

New Patient Office and Consultations:• Must have documentation in all three categories of history, exam,

and medical decision making to meet level of service

OR

• May satisfy criteria by documentation of time when counselingand/or coordination of care is greater than 50% of the total time taken

Definition of a “New Patient”• CMS Definition:

“One who has not received a face-to-face evaluation and management service or procedure froma physician, or colleague of the same specialty (or subspecialty; AMA 2012) who belongs to thesame group practice within the past 3 years. New patient status does not apply to admissions,critical care services or ER.”

• Based on Payor credentialing

• Mid-levels are non-designated (specialty) in most states

Established Patients:• Must have documentation in at least two categoriesof history,

exam and medical decision making

OR


Initial & Subsequent Visits

Initial Hospital or Observation:• Must have documentation in all three categories of history, exam, and medical decision making to

meet level of service

OR

• May satisfy criteria by documentation of time when counseling and/or coordination of care is greaterthan 50% of the total time taken

• If provider is the principal physician of record for Initial Inpatient Hospital Day, then the “-AI”modifier should be appended when billed

• Providers not furnishing the initial observation, but furnish consultations or additional evaluationservices to a patient who is receiving hospital outpatient observation services should bill theappropriate outpatient service code, see CMS observation rules

Note:

‒ The “-AI” modifier is not used for Observation Services OR subsequent visits

‒ Other physicians who perform initial evaluations and are not the principal physician of recordshould not us the “-AI” modifier

Subsequent:• Must have documentation in at least two categoriesof history,

exam and medical decision making

OR


Chief Complaint / Reason for Visit

Every visit should clearly indicate a “reason for visit or “chief complaint”:• The reason for visit and CC should correlate with the HPI, PE, and AP. If multiple problems are

being addressed, these should be summarized and included within the history of present illness(i.e. interval history).

• CMS: A CC is a concise statement that describes the symptom, problem, condition, diagnosis, orreason for the patient encounter. The CC is usually stated in the patient’s own words. Forexample, patient complains of upset stomach, aching joints, and fatigue. The medical recordshould clearly reflect the CC/reason for visit. CMS AUDIT FOCUS!

Noridian Provider Outreach and Education, April 2011:

Medical records must be complete, legible and include the following information:

‒ Reason for encounter, relevant history, findings, test results and date of service

‒ Assessment and impression of diagnosis

‒ A clear, concise reflection of patients condition

‒ Plan of care with date and legible identity of observer

History Components - HPI

HPI tips for EACH visit:• HPI should clearly show development of problem since last visit

OR

• If new problem should be clearly identifiable as new issue

Noridian E/M Workshop August 2014:

Q An RN or NP obtained the HPI and documents it. The physician then goes over theinformation with the patient to verify it, can the MD say, "I verified the HPI with thepatient. Please see RN/NP documentation above?”

A If that scenario takes place, the information will not be accepted if reviewed.The MD mustgather and document the HPI themselves.The ROS and PFSH can be recorded by other staffand the physician then reviews and confirms the information.

HPI, Physical Exam and A&P correlation:• Condition(s)/diagnosis(es) presenting at appointment should be addressed in the HPI, physical

exam, and A&P

‒ HPI should flow to physical exam and A&P

‒ Physical exam should address systems/areas that presenting diagnosis(es) falls under along with any other system/area that presenting diagnosis(es) may affect

‒ A&P should trickle down from HPI and physical exam. Each condition/diagnosis should have an individual A&P

History Components - HPI

History Components:• Made of three sub-sections:

1. HPI (history of present illness)

2. ROS (review of systems)

3. PFSH (past, family & social history)

History of Present Illness:Combination of ELEMENTS or summary of 3 chronic conditions relevant to chief complaint or reason for visit

• Location: Where is the problem (diffuse, localized, unilateral, bilateral, body area)

• Quality: Description of pain or problem (stabbing, tingling, green)

• Severity: Problem improved, stable, or worsening (on a scale of 1-10, more or less)

• Duration: Length of time problem has been present (started 3 days ago, since last visit)

• Timing: Regularity of occurrence or measures when or at what frequency problem/symptom occurs(at night, intermittently, lasted 20 minutes)

• Modifier Factors: Anything attempted to make the problem better or worse (better “when heatapplied”, improved “with Advil”, worse “when standing,”)

• Context: How did the problem occur (fell off curb, lifting an object)

• Associated sign and symptoms:Other symptoms or exacerbating symptoms (nausea w/ vomiting)

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

History Components - ROS

Review of Systems (History):• An oral account (by patient or guardian) of signs and symptoms the patient is or has experienced

• There are three levels of ROS recognized by the E/M guidelines:

- Problem Pertinent ROS : Requires review of ONE system related to current problem(s)

- Extended ROS: Requires review of TWO to NINE systems

- Complete ROS: Requires review of at least 10 systems (CMS suggests 14)

Complete review of systems:• If a complete (comprehensive) system review ismedically necessary, CMS accepts the following

documentation:

"At least ten organ systems must be reviewed. Those systems with positive or pertinent negativeresponses must be individually documented. For the remaining systems, a notation indicating allother systems are negative is permissible. In the absence of such a notation, at least ten systemsmust be individually documented."

• 14 PT inventory recommended for high level visits

- Phases such as “pertinent positives noted in HPI, 14 systems reviewed and all othersnegative”. This gives clear specificity to the review being performed.

- CMS DG: If the physician is unable to obtain a history from the patient or other source, therecord should describe the patient’s condition or other circumstance which precludesobtaining a history.

History Components - ROS

CMS Medicare Claims Processing Manual Chapter 12

D. Use of Highest Levels of Evaluation and Management Codes

Contractors must advise physicians that to bill the highest levels of visit codes, the servicesfurnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, thehistory must meet CPT’s definition of a comprehensive history).The comprehensive history must include a review of all the systems and a complete past(medical and surgical) family and social history obtained at that visit. In the case of anestablished patient, it is acceptable for a physician to review the existing record and update itto reflect only changes in the patient’s medical, family, and social history from the lastencounter, but the physician must review the entire history for it to be considered acomprehensive history.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

History Components - PFSH

PFSH Components:• Past history: Medications and/or patient’s past experiences with illnesses, operations, injuries

and treatments

• Family history: A review of medical events in the patient’s family, including diseases that arehereditary or presents a risk factor for the patient

• Social history: An age appropriate review of past and current activities

Past, Family, and Social History:• Documentation in all three history areas is required in comprehensive levels of service for new

out-patient encounters, initial hospital encounters, and initial skilled nursing facility encounters.

• History areas given as unremarkable ornoncontributory can be considered insufficientinformation by many payers. CMS recommends giving greater clarity as to the informationreviewed, with pertinence to the patient’s conditions or complaint, and found to be negative

Noridian E/M Workshop June 2011:

Q Is it appropriate to indicate “non-contributory” when completing the family history if theinformation obtained is not germane to the clinical problems at hand?

A Something specific should be provided in the family history. When it is not relevant to thechief complaint, it can be limited to the first-degree relatives (mother, father, sister,brother).

Examination 1995 Guidelines

Exam LevelProblemFocused

(level 1 new, 2established)

ExpandedProblemFocused

(level 2 new, 3established)

Detailed(level 3 new, 4established)

Comprehensive(level 4 & 5 new, 5

established)

Body AreasHead, including faceGenitalia, groin, buttocksBack, Including spineChest (axillae/breast)Each extremityAbdomen

OR 1 body area orsystem

2-4 body areasand/or systems

5-7 body areaand/or system

8+ organ systems(Body areas may bedocumented but 8

or more organsystems is required)

Organ systemsConstitutional,Musculoskeletal,Eyes, Skin, ENMT, Neuro,Cardiovascular, Psych,Respiratory, GI,Hem/lymph/imm, GU

Examination - CMS

Exam Given as Unremarkable:CMS carriers’ manual:

Q When using the 1995 documentation guidelines for the physical exam, is it appropriate toindicate “unremarkable” if an organ system has normal findings?

A If an organ system has been examined and the physician/NPP has normal findings, then CMSprefers your documentation show the system had been examined by using the statement normalfindings or describe findings specifically.

Noridian “A/B Referrals and Proper Documentation”, April 2011:

• Examination is only one of three components to determine level of service and may be leastimportant

Caution on Exam Templates:MCR Program Integrity Manual, chapter 3, section 3.3.2.1.1.

“Some templates provide limited options and/or space for the collection of information such as

by using “check boxes”, predefined answers, limited space to enter information, etc. CMS

discourages the use of such templates. Claim review experience shows that that limited space

templates often fail to capture sufficient detailed clinical information to demonstrate the work

performed”.

Complexity Point System

Problem to Exam Number x points = Result

Self limiting or minor;(Stable, improving or worsening) __ x 1 =

Established problem(to examiner);Stable, improving __ x 1 =

Established problem(to examiner);worsening __ x 2 =

New problem (to examiner);no additional workup planned __ x 3 =

New problem (to examiner);additional workup planned __ x 4 =

A. Number of Diagnoses or Treatment Options

Complexity Point System

Data to be Reviewed Points

Review and/or order clinical lab tests 1

Review and/or order tests in radiology section of CPT 1

Review and/or order tests in medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from someone other thanpatient

1

Review and summarize old records and/or obtain hx from someone other thanpatient and/or discuss case with another health care provider

2

Independent visualization of image, tracing or specimen itself (not simply reviewof report)

2

Total Points =

B. Amount and Complexity of Data to be Reviewed

C. Risk of Complications and MortalityComplexity Point System

Low

Level of Risk

Minimal

Moderate

High

�Lab testing requiring venipuncture �Rest�Chest X-rays �Gargles�EKG/EEG �Superficial dressings�Urinalysis or KOH prep �Elastic bandages�Ultrasound, e.g. echo

�Over-the-counter drugs�Minor surgery with no identified risk factors�Physical therapy�Occupational therapy

�Superficial needle biopsies �IV fluids without additives�Clinical lab tests requiring arterial puncture�Skin biopsies

�Minor surgery with identified risk factors

�Two or more stable chronic illnesses �Prescription drug management�Deep needle biopsy �Therapeutic nuclear medicine

�IV fluids with additives

�Cardiac electrophysiological tests

�Parenteral controlled substances

�Discography

Management Options

Selected�One self-limited or minor problems, e.g.

cold, insect bite, tinea corporis

�Two or more self-limited or minor

problems�One stable chronic illness, e.g. well-

controlled HTN, DM, BPH

�Physiological tests not under stress, e.g.

pulmonary function studies�Non-cardiovascular imaging studies with

contrast, e.g. barium enema�Acute uncomplicated illness or injury, e.g.cystitis, allergic rhinitis, simple sprain

Presenting Problem(s)Diagnostic Procedure(s)

Ordered

�An abrupt change in neurological status,

e.g. seizure, TIA, weakness, or sensory loss

�Decision not to resuscitate or de-escalate

care because of poor prognosis

�Obtain fluid from body cavity, e.g. lumbar

puncture, thoracentesis

�Acute complicated injury, e.g. head injury

with brief loss of consciousness

�One or more chronic illnesses with severeexacerbation, progression, or side effects of

treatment

�Cardiovascular imaging studies withcontrast with identified risk factors

�Elective major surgery (open, perc, or endo)with no identified risk factors

�Physiological tests under stress, e.g. cardiac

stress test, fetal stress test

�Closed treatment of fracture or dislocation

without manipulation

�Diagnostic endoscopies with no identified

risk factors

�Cardiovascular imaging studies with

contrast and no identified risk factors, e.g.

cardiac cath, arteriogram

�One or more chronic illnesses with mild

exacerbation, progression, or side effects oftreatment

�Undiagnosed new problem with uncertain

prognosis, e.g. breast lump�Acute illness with systemic symptoms, e.g.

pyelonephritis, pneumonitis, colitis

�Diagnostic endoscopies with identified risk

factors

�Elective major surgery (open, perc, or endo)with identified risk factors

�Acute or chronic illnesses or injuries that

may pose a threat to life or bodily function,

e.g. multiple trauma, acute MI, pulmonary

embolus, respiratory distress, psych illness

�Emergency major surgery (open, perc, or

endo)

�Drug therapy requiring intensive monitoring

for toxicity

Complexity Summary

Must have 2 of the 3 components to satisfy any given level of complexity

Type of DecisionStraight-Forward

LowComplex

ModerateComplex

HighComplex

A Number of diagnoses ortreatment options

1 2 3 4

B Amount and complexityof data 1 2 3 4

C Highest risk Minimal Low Moderate High

Assessment/Plan - CMS Publication

Documenting the Number of Diagnoses and Management Options:

For each encounter, an assessment, clinical impression, and diagnosis should be documented

• Presenting problem(s) of an established diagnosis(es) should reflect whether theproblem is:

‒ Improved, well controlled, resolving, or resolved; or

‒ Inadequately controlled, worsening , or failing to change as expected

• For presenting problem(s) without an established diagnosis, the assessment or clinicalimpression may be stated in the form of differential diagnoses or as “possible,”“probable,” or “rule out;” in which case the ICD-9-CM codes for billing would bereflective of signs/symptoms

The initiation of, or changes in treatment should be documented. Treatment may include awide range of management options including, but not limited to: patient instructions, nursinginstructions, therapies, and medications.

Problems that are improving or resolving are less complex than those problems that areworsening or failing to change as expected.

http://www.cms.gov/MLMProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

Visit Complexity - Noridian

Determine the nature of presenting problem• Self-limited or minor, low severity, moderate severity or high severity

• If the visit does not necessitate the detail of documentation required to meet a high levelCPT code

- A lower level of service should be billed

• Bill the code based on what is documented - do not include additional components in therecord for the sole purpose of meeting a specific level CPT code

E/M Misconceptions• Simply because a patient has a complex medical history or multiple chronic conditions, this

does not support billing a high level of E/M service

- All elements of history, examination and complexity of decision making must be met

- Listing chronic conditions with no other associated information is considered pastmedical history

- Stating a chronic condition and “to continue the same medication” is not generallyseen as an active plan

- Typically these are not a presenting/pertinent problem supported in the review ofsystems and physical examination

Medical Decision Making

Self-Limited/Minor Problems:

• CPT defines a self-limited or minor problem as “a problem that runs a definite andprescribed course, is transient in nature, and is not likely to permanently alter healthstatus, OR has a good prognosis with management/compliance”.

• In order to comply with this CPT definition, unless the provider documents riskfactors specific to the patient (e.g., co-morbidities or other extenuatingcircumstances) that indicate a specific increased risk of altering the health status ofthe patient or of worsening his or her prognosis, any self-limited or minor problemsshould be considered “self-limited or minor” in determining the level for diagnoses /management options and level of risk in medical decision-making. Simply statingpotential risk factors or circumstances common to all patients with the problem willnot justify considering the problem beyond a self-limited/minor problem.

Clinical Example:

22-year-old male (patient of Dr. A, seen by Dr. B) presents for 2-day history of coughand congestion. Patient is otherwise healthy, without any other positive findings notedin Review of Systems for ENT and Respiratory organ systems or past medical, family, orsocial history. Provider performed exam and diagnosed patient with a URI andconservative treatment.

Summary of Criteria – New PatientNew Patient CPT

Codes (3 of 3required)

History Exam Decision

99201 (10 min) 1 HPI1 body area or organ

systemsStraightforward

99202 (20 min) 2-3 HPI, 1 ROS2-4 body area or organ


99203 (30 min)

4 or more elements orstatus of 3 chronic

conditions; 2 to 9 ROS;and 1 PFSH

5-7 Body areas or organsystems

Low

99204 (45 min)


conditions; 10 to 14ROS; and 3 PFSH

8 or more organ systems Moderate

99205 (60 min)



8 or more organ systems High

Summary of Criteria – Established Patient

Established CPT

Code (2 of 3 required)History Exam Decision

99211 (5 min)1 HPI 1 body area or organ


99212 (10 min)

(1 stable condition or selflimiting problem)

1 HPI 1 body area or organsystems

Straightforward

99213 (15 min)

(2 stable conditions or acuteuncomplicated illness or

injury)

2-3 HPIand 1 ROS

2-4 Body areas or organsystems

Low

99214 (25 min)

(worsening problem,undiagnosed new problem, or

several existing problems)


conditions; 2 to 9 ROS;and 1 PFSH

5-7 body areas or organsystems

Moderate

99215 (40 min) (one or morechronic illness w/severe

exacerbation, life threatening)



8 or more organsystems

High

99211

Appropriate Use:• Carrier specific code

• Must have MD orders to validate service (e.g. MD must document “medicalnecessity” for hypertensive patient to come in for BP check)

• Nurse should document: date of visit, reason for visit (as per doctors orders),necessary vitals and updated condition

• Code requires patient presence

Misuse:

• Doctor giving patient orders over the phone

• Calls for Rx refills

• Calls to reschedule patients

• Faxing medical records

• Recording lab results or relaying results over the phone

Initial Hospital/OBS Service

Initial Hospital

ObservationRequires 3 of 3

99221 (30)

99218 (30)

99234 (40)

99222 (50)

99219(50)

99235 (50)

99223 (70)

99220 (70)

99236 (55)

History

Detailed4 + HPI or status of 3

chronic conditions2-9 ROS 1 PFSH

Comprehensive4 + HPI or status of 3

chronic conditions10/14 ROS

3 PFSH

Comprehensive4+ HPI or status of

3 chronic conditions10/14 ROS

3 PFSH

ExamDetailed

5-7 Body areas ororgan systems

Comprehensive8 organ systems

Comprehensive8 organ systems

MedicalDecision

Low Moderate High

Subsequent Hospital/OBS Services

Sub Hospital

Sub ObservationRequires 2 of 3

99231 (15)

99224 (15)

99232 (25)

99225 (25)

99233 (35)

99226 (35)

HistoryProblem Focused

1-3 HPI

Expanded ProblemFocused

1-3 HPI1 ROS

Detailed4+ or 3 chronic

condition2-9 ROS1 PFSH

ExamProblem Focused1 body area or organ

system

Expanded ProblemFocused

2-4 body area or organsystems

Detailed5-7 body area or organ

systems

MedicalDecision

Straightforward/Low

Moderate High

Subsequent Hospital Service - CMS

• CPT code 99231 usually requires documentation to support that thepatient is stable, recovering or improving

• CPT code 99232 usually requires documentation to support that thepatient is responding inadequately to therapy or has developed a minorcomplication. Such minor complications might include careful monitoringof co-morbid conditions requiring continuous active management

• CPT code 99233 usually requires documentation to support that thepatient is unstable or has a significant new problem or complication

Initial Hospital Service

CMS Transmittal 2282, August 26, 2011:

“In situations where the minimum key component work and/or medical necessityrequirements for initial hospital care services are not met, subsequent hospital care CPTcodes (99231 and 99232) could potentially meet requirements to be reported for an E/M.Medicare contractors shall not find fault with providers who report a subsequent hospitalcare code (99231 and 99232) in cases where the medical record appropriatelydemonstrates that the work and medical necessity requirements are met for reporting asubsequent hospital care code (under the level selected), even though the reported codeis for the provider's first E/M service to the inpatient during the hospital stay.”

Noridian E/M Workshop August 2014:

Q When all three key components are not present on initial inpatient visits, would itbe appropriate to bill a subsequent inpatient visit?

A If a reported code is for the provider’s first E/M service to the inpatient during thehospital stay, providers may submit a subsequent hospital care CPT code (99231 or99232) when the medical record appropriately demonstrates that the work andmedical necessity requirements are met for reporting a subsequent hospital care code(under the level selected).

Time Based Services

Discharge Services

Discharge Services:• 99238 Discharge Day Management under 30 minutes

• 99239 Discharge Day Management over 30 minutes

• Time MUST be included in the medical record to justify 99239

• Face-to-face care must be documented in the discharges summary for the date the dischargeservice is billed

CMS Discharge Q&A:

Q What information does the physician need to show in the medical record to support aface-to-face visit for the discharge management? Several of our physicians indicate"stable", "stable and improved, "no vomiting, tolerating diet." Would these statementsshow a face-to-face service?

A No, the statements listed could have been obtained from a nursing note or chart. They donot support a face-to-face service. The medical record should show notations on an exam ifone was performed, or other observations that could have only been obtained if thephysician were present. Some examples could include, "patient is stable and states they arefeeling well and want to go home," or "reviewed plan with patient and he had no questions.

Time Based Billing

Counseling/Coordination of Care:

• Documentation should reflect the following three components:

‒ Total time

‒ Counseling time

‒ Content of counseling or coordination of care

• The note must specify the nature of the counseling in order for the level of serviceto be based on time. Phrases such as "counseled patient on the following topics"or “we discussed…" are recommended when documenting by time and to meetCMS criteria.

• When time based coding for level of service, counseling/coordination of caremust dominate more than 50% of the total encounter time.

Noridian E/M Workshop August 2014

Q When billing by time, do we have to state more than 50% of the time wasspent when no exam was performed?

A Yes, and if counseling was a dominant portion of the visit, documentationmust state what was counseled, the patient's response(s) and any additionalinformation pertinent to the visit.

Established Patient Times

• 99211 = 5

• 99212 = 10

• 99213 = 15

• 99214 = 25

• 99215 = 40

Example of C & CC

• Patient returns for MRI results anddiscussion of treatment regarding herbreast cancer. We discussed the role ofchemotherapy and benefits of thecurrent clinical trials. Patientunderstands side effects and consentsto start treatment next week. Spent atotal of 20 minutes with the patient,over half of which was counseling ontreatment options.

• 99213 based on time.

Clinical Example

Counseling and Coordination of Care

Prolonged Services:

• Prolonged services codes may be possible when extra time does not =counseling or coordination of care.

• Documentation of face-to-face time (outpatient) +99354-99355 Office orOutpatient Prolonged Service

Clinical Example:

Patient presents for F/U visit for seizure disorder and requires a translator forcommunication. Provider documents level 4 visit with a detailed history and moderatedecision (average time 25 minutes). Due to communication difficulties, patient visit took60 minutes. This was clearly documented in the record.

• 99214 time = 25 minutes

• Excess of 35 minutes spent with the patient; 60 (Total) -25 (99214) = 35additional minutes

• May bill 99214 and 99354 to account for additional face-to-face time

Prolonged Services

Ancillary Staff and Scribing

Ancillary Staff Documentation

CMS clearly defines what history sections within the patient record thatmay be completed by someone other than the provider:

“The ROS and/or PFSH may be recorded by ancillary staff or on a formcompleted by the patient. To document that the Physician reviewed theinformation, there must be a notation supplementing or confirming theinformation recorded by others.”

http://www.cms.gov/MLMProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

Ancillary Staff Documentation

Per CMS, only the physician or non-physician practitioner who is conducting theevaluation and management visit can perform the history of present illness (HPI) andchief complaint (CC). This is physician work and shall not be relegated to ancillary staff.

• Noridian Healthcare Solutions reminds providers that E/M codes are valued asincluding all elements of work to be performed by the physician or non-physician practitioner when “physician” criteria are met. Although ancillary staffmay question the patient regarding the CC, that does not meet criteria fordocumentation of the HPI. The information gathered by ancillary staff (i.e.Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used aspreliminary information but needs to be confirmed and completed by thephysician.

• Reviewing information obtained by ancillary staff and writing a declarativesentence does not suffice for the HPI. An example of unacceptable HPIdocumentation would be “I have reviewed the HPI and agree with above.”

https://www.noridianmedicare.com/partb/train/education_center/evaluation_and_management_clarification.html

Documentation should include:• Who performed the service and who recorded the service

Scribe’s documentation should include:• Name, title and signature of the scribe

• Name of the practitioner providing the service

• Sample Scribe attestation: "Entered by _____________________, acting as scribe for Dr./PA/NP_________________________________." Signature________________ Date_______________

Practitioner’s documentation should include:• Affirmation the practitioner personally performed the services documented

• Confirmation he/she reviewed and confirmed the accuracy of the information in the medical record

• Acceptable practitioner signature

• Sample Practitioner attestation: "The documentation recorded by the scribe accurately reflects theservice I personally performed and the decisions made byme." Signature______________________ Date_______________________Time________________

Per CMS, the evaluation and management encounter is a face-to-face service; therefore there must beevidence that the practitioner personally saw the patient, reviewed and confirmed any documentationtranscribed by the scribe.

http://www.acep.org/Physician-Resources/Practice-Resources/Administration/Financial-Issues-/-Reimbursement/Scribe-FAQ/

Scribe Documentation Requirements

Shared Services and‘incident to’

Shared/Split Visits with Mid-levels

CMS Regulation on SPLIT/SHARED E/M SERVICE

• Medically Necessary Encounter

• A split/shared E/M visit is defined as a medically necessary encounter with apatient where the physician and a qualified non-physician practitioner (NPP) eachpersonally perform a substantive portion of an E/M visit face-to-face with thesame patient on the same date of service. A substantive portion of an E/M visitinvolves all or some portion of the history, exam or medical decision making keycomponents of an E/M service. The physician and the qualified NPP must be inthe same group practice or be employed by the same employer.

• The split/shared E/M visit applies only to selected E/M visit**s and settings (i.e.,hospital, office and non facility clinic visits (incident-to), and prolonged visitsassociated with these E/M visit codes).

• The split/shared E/M policy does not apply to critical care services, or procedures.A split/shared E/M visit cannot be reported in the SNF/NF settings.

• **Due to consultation codes no longer being accepted by CMS, they are no longera part of the SS exclusions.. even if a consultation is performed and billed underthe 99221-99223 CPT codes.

Shared Services- Noridian Communication

September 14, 2012

Q For an inpatient shared-service between a NPP and MD, how does Noridian define“substantive” for purposes of medical decision-making? If both NPP and MD see thepatient (face-to-face), the NPP documents the note and the MD documents portions ofthe A/P, would this qualify as substantive?

A I reviewed your questions with our Medical Review (MR) department. If the patient isseen face-to-face by both the nurse practitioner(NP) or physician assistant (PA) as well asthe doctor, the NP or PA may document the note and the doctor may document theportions of the assessment and plan. Also, if this is indeed a shared service, it should bedocumented that it is a shared service. MR suggested that you review this evaluation andmanagement fact sheet.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Evaluation_Management_Fact_Sheet_ICN905363.pdf

Split/Shared Discharge - Noridian

Q Can a physician and a non-physician practitioner (NPP) perform the discharge as ashared/split visit?

A The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM)Publication 100-04, Chapter 12, Section 30.6.9.2, discusses hospital discharge services.The service may be performed as a shared/split visit.The documentation must show aface-to-face encounter with both parties. If there is no face-to-face encounter with thephysician, the service must be billed under the Non Physician Practitioner's (NPP)provider number.

Section 30.6.9.2 B, discusses the discharge visit and states, "Only the attendingphysician of record reports the discharge day management service. Physicians orqualified non-physician practitioners, other than the attending physician, who havebeen managing concurrent health care problems not primarily managed by theattending physician, and who are not acting on behalf of the attending physician shalluse Subsequent Hospital Care (CPT code range 99231 - 99233) for a final visit.”

Incident-to Services

For POS 11 (clinic), billing incident-to services are payable if all of the 3conditions are met:

① Services must be provided by a caregiver whom you directly supervise, and who representsa direct financial expense to you (such as a “W-2” or leased employee, or an independentcontractor).

② Services must be provided under “direct” supervision meaning you must be present in theimmediate office suite to render assistance if needed. If you are a solo practitioner, youmust directly supervise the care. If you are in a group, any physician member of the groupmay be present in the office to supervise.

③ Diagnosis must be established by the provider (or group) with active involvement. Ifdiagnosis is new, the service should be billed under the NPP’s NPI, not the physician.

Reimbursement:

• Services billed “incident-to” a physician are paid at 100% vs. 85% of the PFS fee schedule

• Incident-to is NOT applicable for POS 22 (check with your MAC!)

Industry News

OIG –CMS and Its contractors have adopted few program integrity

practices to address vulnerabilities in EHR’s

Recommendations to CMS Contractors

• Provide guidance to its contractors on detecting fraud associated with EHRs

• Direct contractors to use providers’ audit logs totrack and validate information

OIG/MACIncident-to Services

Physicians: Incident-to Services

We will review physician billing for “incident-to” services to determine whetherpayment for such services had a higher error rate than that for non-incident-toservices. We will also assess CMS’s ability to monitor services billed as “incident-to.”Medicare Part B pays for certain services billed by physicians that are performed bynon-physicians incident to a physician office visit. A 2009 OIG review found that whenMedicare allowed physicians’ billings for more than 24 hours of services in a day, halfof the services were not performed by a physician. We also found that unqualifiednon-physicians performed 21 percent of the services that physicians did not performpersonally. Incident-to services represent a program vulnerability in that they do notappear in claims data and can be identified only by reviewing the medical record.They may also be vulnerable to overutilization and expose Medicare beneficiaries tocare that does not meet professional standards of quality.

CMSGlobal Days – Changes in 2017

Global Transition:

CMS has finalized its proposal to transition all 10 and 90 day global periods to “0”days beginning 2017. The AMA has strongly opposed the transition yet CMS feels thepost-operative portion of the RVU is overvalued. Although CMS has not madecomment to billing procedures due to this change, we anticipate all E/M’s to beseparately billable yet linked by diagnosis code (ICD-9/ICD-10) to track related visits.

Noridian Medical Review

High error rates for Evaluation and Management Services identified by CERT 2014:

• Insufficient Documentation

- Lack of documentation for levels billed

- Not all components of codes are being fulfilled, ie. No exam completed

• Incorrect Coding

- Down coding by two levels

• Medical Necessity Not Supported

- Should be able to find a correlation between chief complaint/HPI/exam findings and what isdocumented for medical decision making

- It would not be medically necessary or appropriate to bill a higher level E/M when a lower levelof service is warranted

• Documentation Doesn’t Support Level Billed

- Each encounter must tell a complete story

- Prior encounters cannot be considered unless referenced by date in the encounter beingaudited

- All three components (history, exam and medical decision making) must be present whenbilling initial/new patient visits and three of three not being met

• Time-based Services and Prolonged Services

https://www.noridianmedicare.com/je/partb/docs/materials_common_em_errors_by_cert_and_mr.pdf

Noridian (CMS) Medicare B News

Documentation Guidelines for Medicare Services

By law, Medicare contractors (carriers and MACs) can review any information,including medical records, pertaining to a Medicare claim.

Medical records should be complete, legible, and include the following information:

• Reason for the encounter, relevant history, findings, test results, and date ofservice.

• Assessment and impression of diagnosis.

• Plan of care with date and legible identity of the observer.

• Documentation that supports that the rendering/billing provider indicatedon the claim is the healthcare professional providing the service.

• Records should not only substantiate the service performed,but also the required level of care.

• If the physician uses a scribe, the scribe needs to fully sign the note, with theirown credentials, followed by the physician’s signature and credentials.

Noridian (CMS) Medicare B News

Documentation Guidelines for Medicare Services (cont’d)

Providers billing Medicare for their services must act in accordance with the followingconditions:

• Document in appropriate office records and/or hospital records each time a coveredMedicare service is provided.

• When providing concurrent care for hospital or custodial care facility patients,physicians should identify their specialty in order to help support the necessity.

• Write medical information legibly and sign each entry with a legible signature, orensure that the provider's/author's/observer's identity is present and legible.

• Medical information should be clear, concise, and reflect the patient's condition.

• Sign progress notes for hospital and custodial care facility patients with all entriesdated and signed by the healthcare provider who actually examined the patient.

• Provide sufficient detail to support diagnostic tests that were furnished and the levelof care billed.

• Not use statements such as "same as above" or ditto marks ("). This is not acceptabledocumentation that the service was provided on that date.

https://www.noridianmedicare.com/shared/partb/bulletins/2010/265_oct/Documentation_Guidelines_for_Medicare_Services.htm

Noridian Medical Review

Medical Record Cloning (August 2014):

• Cloned documentation may be handwritten, but generally occurs when usinga preprinted template or an Electronic Health Record (EHR). While thesemethods of documenting are acceptable, it would not be expected the samepatient had the same exact problem, symptoms, and required the exact sametreatment or the same patient had the same problem/situation on everyencounter.

• Cloned documentation does not meet medical necessity requirements forcoverage of services. Identification of this type of documentation will lead todenial of services for lack of medical necessity and recoupment of alloverpayments made.

https://www.noridianmedicare.com/je/partb/docs/materials_common_em_errors_by_cert_and_mr.pdf

Noridian (CMS) Quality Review

Medical Necessity May 2011:

• Per the Internet Only Manual (IOM)Medicare Claims Processing Manual,Publication 100-04, Chapter 12, Section 30.6.1 states:

• "Medical necessity of a service is the overarching criterion for payment inaddition to the individual requirements of a CPT code. It would not bemedically necessary or appropriate to bill a higher level of evaluation andmanagement service when a lower level of service is warranted. The volume ofdocumentation should not be the primary influence upon which a specific levelof service is billed. Documentation should support the level of servicereported."

• Furthermore, all services must be sufficiently documented so the medicalnecessity is clearly evident.


Medical Necessity May 2011:

• Another trend noted by Part B MR is the MDM does not correlate to the chiefcomplaint. One such example would be the HPI supports a follow-up visit forrenal functions tests, hypertension, and reflux. The medical management ofthat patient is then a Physical Therapy referral for low back pain, with nomention of medical management of the issues that brought the patient to theclinic. The documentation did not support complaints of low back pain.

• Part B MR has also noted that the plan of care simply lists the medicaldiagnoses of the patient, with no mention of changes to the plan of care if any,or continuation of current treatment regimens. It is difficult to determine themedical necessity of a visit when the documentation lacks importantinformation, or when the documentation does not support medicalmanagement of the patient's chief complaint.


NAS Templated Documentation:

NAS Part B MR has noted that some Electronic Medical Record (EMR) software programsauto-populate certain aspects of the medical record with information that is not patientspecific. This issue is more profound in the HPI when discussing the context of a certainillness and/or co-morbidity. Documentation to support services rendered needs to bepatient specific and date of service specific. These auto-populated paragraphs provideuseful information such as the etiology, standards of practice, and general goals of aparticular diagnosis. However, they are generalizations and do not support medicallynecessary information that correlates to the management of the particular patient. PartB MR is seeing the same auto-populated paragraphs in the HPIs of different patients.Credit cannot be granted for information that is not patient specific and date of servicespecific.

Universal Healthcare Group

Diagnosis documentation requirements on the Progress Note:

• CMS is looking for an evaluation of each diagnosis on the Progress Note, notjust the listing of chronic conditions, i.e. DM w/Neuropathy—meds adjusted,CHF—compensated, COPD—test ordered, HTN—uncontrolled,Hyperlipidemia—stable on meds. CMS considers diagnoses listed on theProgress Note without an evaluation or assessment as a “problem list”, whichis unacceptable for encounter data submission.

• Each Progress Note must be able to “stand alone”. Do not refer to diagnosesfrom a prior Progress Note, problem list, etc.

Jana Weis, MA, CPCPrincipal

p 208.867.6450f 208.246.5330

[email protected]

www.gillcompliance.com

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