Overview of Coding and Documentation

Initial Steps

Evaluate and monitor the patientTreat the patientDocument the serviceCode the service

Document the Service

Document all services/procedures rendered to a patient in the EMR

Remember: if you did not document it, you did not do it and it cannot be paid

Documentation Guidelines

Your documentation must support your servicesTeaching Physician guidelines – government

payors have strict guidelines regulating when a physician bills with a Resident’s involvement Florence is rewriting

The HCPCS coding system consists of two levelsLevel I – Current Procedural Terminology (CPT)

CodesDeveloped and maintained by the AMAConsist of five-digit codes and two-digit modifiers

Level II – HCPCS National CodesDeveloped by CMS and maintained by a national panelConsist of one alpha character followed by four-digitsAlso have modifiers

ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification ICD-9 coding is a classification system that arranges

diseases and injuries into groups according to established criteria

ICD-9 is based on the World Health Organization’s Ninth Revision, International Classification of Diseases

Code changes are made annually by the government and are effective October 1 – September 30

All CPT codes submitted to payors must have an accompanying ICD-9 code(s)

Effective October 2014 ICD-10 replaces ICD-9 – THE WORLD CHANGES DRAMATICALLY!!!!!

General Principles of Documenting - Florence The medical record should be complete and legible The documentation of EACH patient encounter should

include: Date; Reason for the encounter; Appropriate history and physical exam; Review of lab, x-ray data, and other ancillary services (where

appropriate); Assessment; and Plan of care (including discharge plan, if appropriate)

General Principles of Documenting - FlorencePatient’s progress, including response to

treatment, change in diagnosis, and patient non-compliance;

Relevant health risk factors; Written plan of care should include (when

appropriate):Treatments and medications, specifying frequency and

dosage;Any referrals and consultations; andPatient/family education

General Principles of Documenting

Documentation should support the intensity of the evaluation and/or treatment, including thought processes and complexity of medical decision making;

All entries should be dated and authenticated by physician signature; and

The CPT/ICD-9-CM codes reported on the CMS-1500 should reflect the documentation in the medical record.

CPT Coding and Documentation

E&M Services – (Evaluation and Management Services) Levels of Care

E&M Documentation CMS/AMA Guidelines

E&M Coding

Key Components History Exam Decision Making

Contributory Factors Counseling Coordination of care Presenting problem Time

Key Components

History

Exam

Decision Making

History

Chief Complaint (CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family & Social History (PFSH)

Exam

Organ SystemsFor a General Multi-System Exam

Body Areas

Medical Decision Making

Complexity of establishing a diagnosis

The number of diagnoses or management options;

The amount and complexity of data ordered or reviewed; and

The risk of complications and morbidity/mortality.

VCUHS Clinical

Documentation Improvement

Why Focus on Documentation Physician documentation is the basis for the

hospital coding. Accurate and complete medical record

documentation is critical to reflect the high quality of care provided by the medical staff.

The documentation in the medical record is the key driver of the quality outcome scores for the hospital.

Inadequate documentation can lead to a misrepresentation of the quality of care provided by the facility.

Documentation Basics

All diagnoses and conditions that are monitored, evaluated and/or treated during the hospital stay should be documented

Diagnosis must be stated in codeable terminology ( ICD 9 codes) to be included in the coding process.

Importance of DocumentationCapturing the appropriate diagnosis and

condition is critical for:Accurate severity of illness and risk of mortality reporting.

Compliance with CMS rules and regulations.

Appropriate reimbursement for the care provided.

Supporting length of stay and resources utilized.

Preparation for bundled payments and value based purchasing (VPB).

Support of physician billing.

Examples of Unable vs Acceptable Low Hgb, transfuse Hypertensive emergency,

urgency, crisis Urosepsis, change foley COPD, home O2 CHF Air space disease Thin, low prealbumin Unresponsive Skin breakdown Replete lytes, low Na, K+

Specify type of anemia Malignant or accelerated

hypertension. Sepsis secondary to UTI Chronic respiratory failure Type of pneumonia

(organism), CAP, HCAP Type of malnutrition Coma Pressure ulcer Hyponatremia, Hypokalemia

Specificity of Diagnosis

Anemia – low

Acute blood loss anemia - moderate

Pancytopenia secondary to chemo - high

CHF – low

Chronic systolic or diastolic heart failure - moderate

Acute systolic or diastolic heart failure – high

Respiratory insufficiency – low

Chronic respiratory failure – moderate

Acute respiratory failure - high

Specificity of Diagnosis

Poor nutritional status – low

Mild or moderate malnutrition – moderate

Severe malnutrition – high

Renal insufficiency – low

Acute renal failure or injury – moderate

Acute renal failure secondary to ATN – high

GCS, unresponsive – low

Coma - high