Documentation for Coding This chapter provides an overview of documentation requirements. It begins with a primer covering basic principles of documentation, proceeds to a basic review of documentation guidelines relevant to evaluation and management (E/M) services, and ends with a brief consideration of documentation concepts specific to critical care services. BASIC PRINCIPLES OF DOCUMENTATION Because both payors and the government profile clinicians, documentation and subsequent coding must reflect accurately the service provided. Accurate coding provides an appropriate picture of the work that clinicians perform. One of today’s controversies is whether professional coders or physicians should perform coding. It is ultimately up to each individual physician to decide this issue. However, the physician should keep in mind that even if a professional coder selects the codes, it is the physician who will be held responsible because the claim is submitted in the name of the physician. The coding for E/M services should follow the documentation guidelines discussed in this chapter. Therefore, these services could be coded by either the physician or a professional coder if the codes are selected based on these guidelines. For more complex areas, such as surgery, which uses many modifiers, it might be advisable for professional coders to do the coding if they are coding based on the physician’s documentation in the operative note. However, the physician should review the coding for any service, E/M or surgery, to verify what has been assigned. Coding should be a team effort between the physician and the office staff. There are several basic principles of documentation (Table 5). One of the most important is legibility, which has become very important for hospitals because validation surveys, that usually go hand in hand with Joint Commission on Accreditation of Healthcare Organization (JCAHO) surveys, are focusing on legibility. Legibility becomes crucial during audits, which may occur years after the note was written. It is difficult to defend a claim if the physician cannot convincingly read the note on the witness stand. It also is vital to double-check that documentation accurately reflects and supports the service provided. LEVELS OF E/M CODES The level of E/M codes (not including critical care codes) is determined by 3 key components: •
History (including chief complaint, history of the present illness, review of systems, and past, family, and social history)
•
Physical examination of specific body areas and organ systems
•
Medical decision making (including diagnosis and management options, amount and complexity of data being reviewed, and risks of complications and/or morbidity or mortality)
Contributory elements include counseling, coordination of care, and the nature of the problem. Other than in critical care codes, time is not a key element. Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.
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Table 5. Basic Principles of Documentation •
Medical record should be complete, legible, dated, and signed with credentials
•
Each patient encounter should include S.O.A.P. (Subjective, Objective, Assessment, Plan)
•
The rationale for all tests ordered should be documented or easily inferred
•
Past and present diagnoses should be readily available
•
Appropriate health risk factors should be identified
•
Patient progress, response to treatment, and revision in plan should be documented
•
ICD-9 codes should justify the provided services by verifying the problem that required them
•
You cannot bill for what you perform, only for what you document
HISTORY Chief Complaint. The chief complaint is characterized as a concise statement that describes the symptom, problem, or condition. Often, it is described in the record in the patient’s own words. The chief complaint must be documented for all inpatient and outpatient visits and all levels of service. In office settings, the ancillary staff frequently documents the chief complaint, but the physician always should double-check the information. The chief complaint may be listed as “follow-up.” However, if the body of the note documents that most of the systems are stable and that the patient is doing well, an auditor may question why the patient needed the service. If the follow-up is for a chronic condition, the condition should be stated such as “follow- up for hypertension” or “followup for congestive heart failure.” Levels of History. There are 4 possible levels to the history: problem-focused, expanded problem-focused, detailed, and comprehensive (Table 6). Other elements of the history are the history of the present illness, review of systems, and past, family, and social history. The history of the present illness is a chronologic description of why the patient is being examined and contains 8 elements (Table 7). A “brief history” is comprised of 1 to 3 elements, and an “extended history” has 4 or more elements. One element that causes confusion is “context,” which means the context in which the symptom(s) present(s). For example, did the symptom develop when the patient was vacuuming?
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Table 6. Levels of the History of Present Illness Problem-focused — 1 to 3 elements Expanded problem-focused — 4 or more elements Detailed — 2 to 9 elements Comprehensive — 10+ elements
Table 7. Elements of the History of Present Illness Location — where is symptom or pain Quality — character of the symptom or pain Severity — rank of the symptom or pain Duration — description of how long the symptom or pain has been present or how long it lasts when the patient has it Timing — description of when the pain or symptom occurs Context — the situation associated with the symptom Modifying factors — things done to make the symptom or pain better or worse Associated signs/symptoms — description of other symptoms or pains that occur in conjunction with the present condition or illness Review of Systems. The review of systems is the inventory of body systems, which is a subjective assessment. It involves findings associated with the primary complaint. The use of templates may help to prompt the physician or the patient in such a review. There are 3 levels to the review of systems. Review of 1 system is considered “problem pertinent,” review of 2 to 9 systems is considered “extended,” and review of 10 or more systems is considered “complete.” Past, Family, and Social History. The past, family, and social history covers both the patient and his or her family. Past history encompasses illnesses, operations, and current medications for the patient. Family history includes heredity and risk factors. Social history is comprised of use of tobacco and alcohol, living arrangements, marital status, occupation, and education. There are 3 levels of past, family, and social history. A “pertinent history” discusses patient history, family history, or social history. A “complete history” can encompass 1 to 2 of these aspects for established patient visits or all 3 for new patients, observation status, initial hospitalization, or consultation.
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Portions of the history may be documented by ancillary staff and the patient, and standardized history forms and patient questionnaires are acceptable. The physician should refer to such documentation in the note saying, for example, “reviewed and agree.” For subsequent visits of inpatients, the physician can refer to the initial history and physical examination note if that is appropriate. PHYSICAL EXAMINATION Most physicians document the physical examination with the 1995 guidelines, which recognize 10 body areas and 12 organ systems (Table 8), and have 4 levels of examination (Table 9). (See “1995 and 1997 Documentation Guidelines” for a full explanation of current guidelines.) The documentation “all normal” is not sufficient for an all-system examination. Neither is “condition unchanged from yesterday” or “abnormal” for an entire body area. More acceptable than “cardiovascular normal” would be “heart sounds are normal.” Drawing a line through all of the boxes on a list on a template is not acceptable; each box should be checked separately with any abnormal findings described. Symbols, such as the null sign with arrows going up and down, should be used carefully because they can be misinterpreted and result in an item being discounted.
Table 8. 1995 Physical Examination Guidelines 12 Organ Systems
10 Body Areas
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•
Head, including the face
•
Eyes
•
Neck
•
Ears, nose, mouth, throat
•
Chest, including breast and axilla
•
Cardiovascular
•
Abdomen
•
Respiratory
•
Genitalia, groin, buttocks
•
Gastrointestinal
•
Back, including the spine
•
Genitourinary
•
Each extremity
•
Musculoskeletal
•
Skin
•
Neurologic
•
Psychiatric
•
Hematologic/lymphatic/immunology
•
Constitutional (eg, vital signs, general appearance)
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Documentation for Coding
Table 9. Levels of Physical Examination Problem-focused — 1 body area or organ system Expanded problem-focused — 2 to 7 body areas or organ systems Detailed — 2 to 7 body areas or organ systems with 1 system described in detail Comprehensive — 8 or more body areas or organ systems or complete single specialty examination
MEDICAL DECISION MAKING Medical decision making has 3 parts: the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications and/or morbidity or mortality. For the number of diagnoses or management options, it is important to document the specific problem, whether it is stable or worsening, if it is a new problem to the examiner, and if additional evaluations are planned. Overall, diagnoses are rated as minimal, limited, multiple, and extensive, based on the number of points (Table 10). The point system is rated as: •
Self-limited or minor problems — 1 point each (2 maximum)
•
Each established problem that is stable — 1 point
•
Each established problem that is worsening — 2 points
•
Each new problem for which no additional evaluation is planned — 3 points (maximum)
•
Each new problem for which additional evaluation is planned — 4 points
The complexity of data part of medical decision making employs a similar rating system of straightforward, low complexity, moderate complexity, and high complexity. Also, specific actions with tests have differing weights. For example, greater weight is given to the physician who reviews an image personally (2 points) rather than relying on a radiologist for interpretation (1 point). However, the physician must make that notation and describe the findings. Reviewing and summarizing old records requires a notation of what was found in that review. For the risk of complication, morbidity, and mortality aspect, the physician must attempt to determine the overall risk associated with the presenting problem, the diagnostic procedures, and the management options. Whichever area is associated with the highest risk drives the decision. For example, if the presenting problem is associated with moderate risk, but the management options are associated with high risk, the overall risk is rated as high. It is important to document whether the problem is a chronic illness as well as all aspects of proposed treatment plans.
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Table 10. Number of Diagnoses or Treatment Options* •Minimal — 1 point •Limited — 2 points •Multiple — 3 points •Extensive — 4+ points *See text for point system assignment. The same categories apply to complexity of data.
1995 AND 1997 DOCUMENTATION GUIDELINES The first attempt at creating documentation guidelines was a 1992 general consensus document agreed to by physician, hospital, and governmental representatives. The 10 principles provided a broad statement of documentation principles but lacked practical detail, so the CPT Editorial Panel and the Health Care Financing Administration (HCFA, now the Centers for Medicare and Medicaid Services [CMS]) developed detailed proscriptive guidelines for E/M codes in 1995. These were based upon CPT guidelines, and were refined in 1997 to introduce the “counting elements.” There have been various efforts to further refine these documentation guidelines. Refinements were needed to answer a myriad of questions unaddressed in 1995 and 1997, to help reduce the coding errors by providers, and to guide Contractor Medical Directors (CMDs) responsible for implementing Medicare. However, neither an effort by CMS in 2000 nor a 2002 E/M Workgroup of the CPT Editorial Panel was able to create an acceptable alternative. A later attempt to create clinical examples for E/M codes also failed to result in any refinement. In November 2005, CMS issued a resource guide to common E/M questions for office or other outpatient visits, compiling into a central document various bits of information released at various times. This resource is available in Transmittal 731 to the Medicare Claims Processing Manual (Change Request 4032), accessible from the CMS Web page. While CMS issued Transmittal 731 as a “one-stop” resource guide to common E/M questions, none of the information is new to this transmittal, and the transmittal did not pertain specifically to critical care services. Both the 1995 and 1997 documentation guidelines remain current. Some practitioners prefer the 1997 guidelines and the specificity they provide when devising clinical practices intended to both avoid audits and justify claims under review. In some regions of the country (as of October 2005), carriers began modifying the documentation guidelines. For example, offering methods for quantifying the levels of care using a point system. Information provided to SCCM by a CMD indicated these
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policies may be useful for guiding decisions by payors or providers, but do not in any way modify the 1995 or 1997 documentation guidelines. As always, be sure to keep current with local policies by checking with your local carrier. DOCUMENTATION FOR CRITICAL CARE Adult critical care is unique among E/M services in making time a primary criterion for proper billing. For other E/M services, the time spent by the provider is a secondary consideration and is not explicit. Rather, “average times” are implicit for each service, as determined primarily by the Relative Value Update (RUC) Committee. In the outpatient setting, these times are based upon “face-to-face” time with the patient. While in the inpatient setting, time is based upon unit or floor time spent actively involved with necessary elements of the specific patient’s care. It is a different matter for critical care. Adult critical care has special time requirements in that the time must be documented explicitly; the patient must be “immediately available” to the provider in order for that provider’s time to count toward critical care; and time spent on separately reportable procedures for that patient must be deducted explicitly in the note (eg, “spent 32 minutes providing critical care, excluding time spent inserting the catheter”). When documenting for adult critical care services (99291 – 99292), the most important item is explicit documentation of time spent by the provider. This cannot be emphasized enough, since so many denials are linked to confusion about the provider’s time. While the clinical (or medical) conditions and the treatment criteria are important, it is the provider’s time that must be absolutely clear. (See Chapter 2 for a full discussion of adult critical care.) While pediatric/neonatal codes (99468-99469, 99477-99478, 99479-99480) also involve time in a manner different than other E/M services, the fact they are all-day codes somewhat reduces the confusion. It is still vitally important to understand which services count toward the codes and to document those services, but not as crucial to document the time actually spent except to note when the first day ends and care continues into subsequent days. (See Chapter 5 for a full discussion of pediatric/neonatal critical care.) Next in importance to documentation of time spent is clarity about where (relative to the patient) the services are provided. While critical care is not limited to the intensive care unit (ICU), it is crucial that the patient be immediately available to the provider. So while it is true that “available” does not limit providers to the bedside, any services provided on a different floor or building than the patient do not count toward the critical care time. A key service provided by critical care physicians and the expert team is prevention. The providers understand this and the patient and family appreciate it. Yet prevention often is difficult for administrators to “see” in the documentation, and only documented
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services can be coded, submitted, and ultimately paid. This creates a dilemma for many critical care providers and their coding staff. In such situations, it can help to keep in mind that critical care comprises not only interventions, but also decision making. If decision making is involved, even if treatments are not changed or tweaked for an extremely tenable patient, that activity is a billable service. So while merely reviewing or itemizing what someone else did previously (noting the drip setting, writing that the previous treatment continues, and noting that you concur with it) is not billable as critical care. Reviewing the situation, weighing alternatives, and making an informed decision about the best care certainly is billable, even if your decision is to make no changes to the treatment and no intervention. One CMD recommends: “Use the personal pronoun!” Note that observations leading to decisions are services, but observations merely iterating other treatments are not decisions. Use of the personal pronoun in progress notes can clarify for claims processors what the provider did that qualifies as critical care, even as treatment and settings remain constant. (See Chapter 2 for a full discussion of time, location of service, and other criteria for coding critical care.) SUMMARY Of the many guidelines for documentation of coding, perhaps the most important is legibility because there is always the possibility that an audit will require a physician to decipher notes that were written many years earlier. The necessary elements of the history include the chief complaint, history of the present illness, review of systems, and past, family, and social history (Table 11). These components are used to determine whether the history is problem-focused, expanded problem-focused, detailed, or comprehensive. Guidelines for the physical examination suggest review of 10 body areas and 12 organ systems to establish a problem-focused, expanded problem-focused, detailed, or comprehensive examination. Documentation of medical decision making encompasses the diagnosis and management options, the amount and complexity of data being reviewed, and risks of complications and/or morbidity or mortality. Documentation in all of these areas is required to support coding and billing choices.
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Table 11. Case History Matrix* The level of history cannot be higher than the lowest level met by any of the components. A chief complaint must be stated with each visit. History of Present Illness
Brief (1-3 elements)
Brief
Extended (4 or more elements)
Extended
Review of Symptoms
None
Problempertinent (1 system)
Extended (2 to 9 systems)
Complete (10+ systems)
Past, Family, Social History
None
None
Pertinent† (1 to 3 areas)
Complete‡
Problemfocused
Expanded Problemfocused
Detailed
Comprehensive
History
*Requires 3/3 key components for initial hospital care and initial inpatient consultation. Requires 2/3 key components for subsequent hospital visit and subsequent inpatient consultation. †1 to 2 areas for emergency department visits, subsequent hospital visits. ‡All 3 areas for initial patient visits and initial hospital consultations.
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Clinical Scenario #3 A 23-year-old female presents with SOB, wheezing, and lightheadedness. Patient with h/o asthma and was admitted 5 months ago. Symptoms began 4 days ago. No fever, positive cough with green sputum. No N/V/D, no CP. Vital Signs: B/P - 131/87 mm Hg, Pulse - 120, RR - 30, Temp - 36.90C Meds: Albuterol, Flovent
PMH- Asthma, NKDA
FH - Father - Hx of COPD
SH - denies alcohol, smoking, or drugs
PE: A&O, seems SOB, pulse 123, RR-34. Respiratory- Breath sounds decreased w/prolonged exp. bilaterally, wheezing on exp., no cyanosis, sl use of accessory neck muscles, resonance bilaterally w/percussion, pulse ox on RA 90%. Cardio- RRR, Ø murmurs, rubs, or gallops. Abdo- soft, + BS, Ø guarding. Eyes- clear. ENT- TMs non-red, mobile, throat non-red, no swelling. Neck- no masses, thyroid nl, no adenopathy. Orders: O2 at 2 L via mask, continuous pulse ox, CBC, SMA7, CXR, ML. Resp peak flow, albuterol nebs x2, prednisone 80 mg, 15 mg proventil, cont neb. Dr. Tom Attending. Admit to Dr. Jones. Diagnosis: Acute Exacerbation of Asthma History. The chief complaint in this case is documented as shortness of breath. There are 3 elements to the history of the present illness based on the physician’s note: location, duration, and associated signs and symptoms. Accordingly, the documentation offers a brief history rather than a complete history of the present illness. The clinician documented review of 4 systems: constitutional (lack of fever), respiratory (cough), gastrointestinal (no nausea or vomiting), and cardiovascular (no chest pain). Accordingly, it is considered an extended review of systems. For a patient in whom the clinician makes a more comprehensive review of systems, but only 4 of the systems have pertinent findings, documentation of the pertinent abnormal or normal findings, followed by a notation that findings for all other systems were negative would constitute a complete review of systems. Documentation of the patient having a history of asthma (patient history), the father having a history of chronic obstructive pulmonary disease (family history), and the patient not smoking (social history) constitute a complete past, family, and social history. Overall, the brief history of the present illness, extended review of the systems, and complete past, family, and social history in the case study characterizes an expanded problem-focused history (Table 11). Taking it to a higher level might involve delving into more detail about the history of the present illness, such as any special use of inhalers or nebulizer treatment and the patient’s response. Physical Examination. The physical examination includes a detailed respiratory examination (decreased breath sounds, expiratory wheezing, patient seemed short of breath, no cyanosis).
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Some auditors even might consider it a comprehensive single specialty examination, but that probably would require more information. Medical Decision Making. The medical decision making is considered to have high complexity because the patient presents with a new problem that requires additional evaluation. The complexity of the data is multiple, involving laboratory tests, radiology, and medical procedures, and the risk of the presenting problem is high because the problem is a severe exacerbation of a chronic illness. The number of diagnoses or management options is extensive, the amount and complexity of data to be reviewed is moderate, and the risk of complications and morbidity or mortality is high. Unlike the history, in which 3 of 3 items are needed, only 2 of 3 items are required to determine the level of medical decision-making complexity. Assigning a Level of Service. Because the patient is receiving an emergency department service, history (expanded problem-focused), physical examination (detailed), and medical decision making (high) are required to determine the level of care. Because the level of service can be no higher than the lowest level of any element achieved, which is the expanded problem-focused history, this case is coded as 99283 for the emergency department visit.
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