Clinical Documentation Tips
Reflection of Acuity &
Medical Necessity
“I Bill for It”
Objectives
 Understand the elements of synergies in clinical
documentation impacting physicians and hospitals
 Understand relationship between specificity in
documentation and patient acuity
 Learn how patient acuity and comorbid conditions
drives medical necessity and E & M assignment
 Appreciate the “pitfalls” and “traps” of documentation
that contribute to denials and downcoding of E & M
History of Present Illness
 HPI is chronological description of the development of
the patient’s present illness from the first sign and/or
symptom or from the previous encounter to the
present.
 Focus upon present illness!
HPI
 HPI → 8 elements
 Location
 Quality
 Severity
 Duration
 Timing
 Context
 Modifying factors
 Associated signs and symptoms
HPI that are really “HPI’s”
 Mrs. Jones, a 75 year old patient presented to the
Emergency Room with abdominal pain lower
left quadrant of three days duration, suddenly
worse last night, with associated shortness of
breath, took Maalox, didn’t help. Pain described
as at 10 on a pains scale of 10. Pain now 7 out of
10 after receiving Morphine in the ER.
Right to the Point
Right to the Point
 HPI- The patient presented from the Personal Care
Home with a two day history of worsening shortness of
breath and nonproductive cough. She started using
oxygen at home but this got progressively worse ,
particularly when ambulating, and she came to the
Emergency Room this morning and was found to be in
acute respiratory distress.
Right to the Point
 She was evaluated and found to have acute hypoxemic
respiratory failure, congestive heart failure with
possible pneumonia. She was stabilized somewhat in
the Emergency Room but is still short of breath, more
so that at her usual baseline. She is being admitted for
further evaluation and treatment.
Assessment & Plan
 This is a 75 year old-female with 1) Acute congestive
heart failure, acute left ventricular systolic dysfunction
with probable chronic left ventricular systolic
dysfunction. We are going to admit her, give her fluid
restrictions, intravenous Lasix for diuresis and
pulmonary toilet. Will monitor closely.
Assessment & Plan
 1) Chronic obstructive pulmonary disease
exacerbation with acute on chronic respiratory
failure and hypoxia and hypercapnia and acute
respiratory acidosis. We are going to give her oxygen
and pulmonary toilet with Duoneb treatment. Will
diurese her as noted above. Will cover empirically
for infection with Avelox, 400 mg, IV daily. Monitor
closely and call in pulmonology service and
cardiology service if clinical conditions worsen.
Assessment & Plan Continued
 3) Diabetes mellitus, Type II controlled, and will
continue her on Lantus and start her regular insulin
sliding scale and monitor
 4) Hypertension, will continue current medications
and monitor
 History of breast cancer. Status post lumpectomy,
apparently stable.
 5) History of long QT syndrome. She does have an
implantable defibrillator. Will rule out MI per
protocol and monitor closely
 (Total time for H & P examination one hour)
The Driver
Role of HPI
 HPI drivers:
 Extent of PFSH, ROS and physical exam
performed
 Medical necessity for amount work performed
and documented
 Medical necessity for E & M assignment
 Medical necessity of an Evaluation and Management
(E/M) encounter is often visualized only when viewed
through the prism of its characteristics captured in
specific History of Present Illness (HPI) elements.
Speaking of Medical Necessity
 Federal law requires that all expenses paid by
Medicare, including expenses for Evaluation and
Management services, are medically reasonable and
necessary.
 1862(a)(1)(a) of the Social Security Act, Title XVIII
 No payment can be made for items and services that
are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member.
 Applies to physician and hospital
Synergy of Clinical Documentation
 Physician Responsible for patient designation
assignment
 Inpatient versus Outpatient Service
 The decision to admit a patient is a complex medical
judgment which can be made only after the physician
has considered a number of factors, including the
patient's medical history and current medical needs,
the types of facilities available to inpatients and to
outpatients, the hospital's by-laws and admissions
policies, and the relative appropriateness of treatment
in each setting.
Documentation of Acuity
 Factors to be considered when making the decision to
admit include such things as:
 The severity of the signs and symptoms exhibited by the
patient;
 The medical predictability of something adverse happening
to the patient;
 The need for diagnostic studies that appropriately are
outpatient services (i.e., their performance does not
ordinarily require the patient to remain at the hospital for 24
hours or more) to assist in assessing whether the patient
should be admitted; and
 The availability of diagnostic procedures at the time when
and at the location where the patient presents.
Business Synergy
HPI
Assessment
Plan
Medical Necessity
Hospital & Physician
Medical Necessity
 Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a 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.
 Less Complex diagnoses potentially warrant a
lower level of E & M
Medical Complexity
Signs, Symptoms &
Nonspecific Diagnoses
 Chest Pain/Acute Coronary




Syndrome
Hypoxemia/Acute
Respiratory Distress
Nausea and Vomiting
CHF
Postobstructive Pneumonia
with right lower lobe cancer
inoperable
Specific Diagnoses
 Non ST MI with unstable angina
 Acute hypoxemic respiratory
failure
 Food poisoning with severe
dehydration
 Acute on chronic systolic left
sided heart failure
 Suspected gram-negative
pneumonia in a patient with
known inoperable RLL cancer
Medical Necessity
 Medical necessity of E/M services is generally
expressed in two ways: frequency of services and
intensity of service (CPT level).
 Medicare’s determination of medical necessity is
separate from its determination that the E/M service
was rendered as billed.
Medical Necessity
 Medicare determines medical necessity largely through the
experience and judgment of clinician coders along with the
limited tools provided in CPT and by CMS.
 At audit, Medicare will deny or downcode E/M services
that, in its judgment, exceed the patient’s documented
needs
Elements of Medical Necessity
 Medical necessity of E/M services is based on the
following attributes of the service that affected the
physician’s documented work:
 Number, acuity and severity/duration of
diagnoses/ problems addressed through history,
physical and medical decision-making.
Common Documentation
Deficiency
 Progress Note
 9/13 10:10 AM- Patient had no new complaints, stable
overnight. VS stable, Labs WNL.
 Assessment and Plan: Continue Present Management
 Deficiency
 Not Clear Face-to-Face Encounter
 Absence of Diagnoses
 No Billable E & M service
Elements of Medical Necessity
 The context of the encounter among all other
services previously rendered for the same problem
 Complexity of documented comorbidities that clearly
influenced physician work.
 Physical scope encompassed by the problems (number
of physical systems affected by the problems).
Complexity Does Matter
Less Complex
More Complex
 Acute respiratory distress
 Acute respiratory failure
 CHF
 Acute systolic CHF
 CHF worsening
 Acute on chronic systolic
 COPD exacerbation
 COPD exacerbation with
hypoxemia
CHF
 Acute respiratory failure with
COPD exac
 COPD exacerbation with
chronic respiratory failure
Complexity Does Matter
Less Complex
More Complex
 Acute renal insufficiency
 Acute renal failure
 Chronic hypoxemia
 Chronic respiratory failure
 Cardiac arrhythmia
 Atrial fibrillation
 Acute renal failure
 Acute tubular necrosis/acute
 Chronic renal failure
interstitial nephritis
 Chronic renal failure stage IV
 Hypoalbuminemia
 Protein calorie malnutrition
Medical Decision Making
27
Decision Point
Medical Decision Making
 Medical decision making refers to the complexity of establishing
a diagnosis and/or selecting a management option as measured
by:
 The number of possible diagnoses and/or the number of
management options that must be considered;
 The amount and/or complexity of medical records, diagnostic tests,
and/or other information that must be obtained, reviewed, and
analyzed; and
 The risk of significant complications, morbidity, and/or mortality,
as well as comorbidities associated with the patient's presenting
problem(s), the diagnostic procedure(s) and/or the possible
management options.
29
Medical Decision Making
 MDM consists of 4 levels
 Straight Forward Complexity
 Low Complexity
 Moderate Complexity
 High Complexity
 General Rule of Thumb is inpatient encounter should
equate to Moderate or High Complexity
30
Amount & Complexity of Data
 The amount and complexity of data to be reviewed is
based on the types of diagnostic testing ordered or
reviewed.
 A decision to obtain and review old medical records
and/or obtain history from sources other than the
patient increases the amount and complexity of data to
be reviewed
31
Number of Diagnoses &
Management Options
 The number of possible diagnoses and/or the number
of management options that must be considered is
based on the number and types of problems addressed
during the encounter, the complexity of establishing a
diagnosis and the management decisions that are
made by the physician.
32
Documentation Tips
 DG: For each encounter, an assessment, clinical
impression, or diagnosis should (must)be
documented. It may be explicitly stated or implied in
documented decisions regarding management plans
and/or further evaluation.
 For a presenting problem with an established diagnosis the
record should reflect whether the problem is: a) improved,
well controlled, resolving or resolved; or, b) inadequately
controlled, worsening, or failing to change as expected.
33
Documentation Tips
 For a presenting problem without an established
diagnosis, the assessment or clinical impression
may be stated in the form of a differential
diagnoses or as "possible,” "probable,” or "rule
out” (R/O) diagnoses.
34
Best Strategy Documentation
 Chief Complaint: Chest Pain
 HPI- Eighty-five year old female patient unassigned
presented to the ER with abdominal pain 8 out 10
radiating to the chest, associated shortness of breath,
worse at night and after eating a large meal. Patient
states pain was waxing and waning for last few days,
became intolerable this morning, not relieved by
Maalox, prompted her to seek medical attention in the
Emergency Room.
Best Strategy Documentation
 Assessment & Plan
1. Chest pain- possible MI but less likely given the fact the
patient does not have any risk factors for MI other than age.
Will still initiate the ROMI protocol to ensure we don’t get
caught in situation of blind obedience
2. Abdominal pain- likely mesenteric ischemia in light of the
fact patient’s abdominal pain is worse after eating a large
meal. Will order mesenteric duplex ultrasound and CT scan
with contrast to evaluate status of vasculature. Will consult
surgery for their recommendations of further work-up. IV
pain meds as needed and NPO for now.
Practical Documentation Tips
 When documenting MDM, a list of established
diagnoses or potential diagnoses is insufficient for coding
purposes without additional indications in the record of
meaningful and necessary evaluation for each problem.
 Practitioners should record relevant impressions,
tentative diagnoses, confirmed diagnoses and all
therapeutic options chosen related to every problem for
which evaluation and management is clearly
demonstrated
 Tip- stability of chronic conditions should be
documented as well as discussion of relationship to
abnormal diagnostic results to established or provisional
diagnoses.
Documentation Approach
Tell Documentation
 Assessment:
 Dizziness and headache


Show Documentation
 Assessment:
 Dizziness and headache

TIAAcute sinusitis
 Hypertension
 Hyperlipidemia
 Gout
 History of breast cancer

TIA- with patient describing an
episode of slurred speech and
difficulty finding words and
weakness of left arm, this may
be a TIA, will order a follow-up
CT as initial in ER was
indeterminate.
Hypertension- BP reading in
the ER indicated hypertensive
urgency, 205/120, perhaps BP
elevation contributing to
patient’s dizziness and
headache. Will monitor and
step up her anti-hypertension
meds
Clinical Case Study
 HPI: Mrs. Cold Weather presented to the
Emergency Room with shortness of breath of
three days duration, complains of chest pain at
the same time of shortness of breath, waxing
and waning, stabbing at some time, 8 out of 10,
not relieved by her usual nitro.
 PFH: Ischemic cardiomyopathy, hypertension,
EF 10-15%
Clinical Case Study Continued….
 PSH: quite smoking 20 years ago, lives with her
husband who is in good health for his age
 Past Surgical History; Non-contributory
 Labs: BNP 2276, cardiac enzymes and Troponin mildly
elevated
 Chest X-ray shows cardiomegaly with pulmonary
vascular congestion
Clinical Case Study Continued….
 Clinical Impression:
 Chest pain and shortness of breath rule out MI, rule out
MI protocol
 Elevated BNP- will start IV Lasix IV 80 mg, monitor
output, chest X-ray PM,
 Reduced EF- left ventricular systolic dysfunction
 Chronic renal insufficiency
Take Two
Clinical Case Study Continued….
 Clinical Impression: Mrs. Cold Weather with history
of ischemic cardiomyopathy and end stage renal
disease presents with chest pain and shortness of
breath
 Possible MI, will follow MI protocol
 Possible Acute systolic CHF, likely chronic in
nature also, continue to diurese. Will contact
patient’s regular cardiologist
 End stage renal disease- will need monitor renal
function closely and diurese carefully
Table of Risk
 The risk of significant complications, morbidity,
and/or mortality is based on the risks associated with
the presenting problem(s), the diagnostic
procedure(s), and the possible management options.

DG: Comorbidities/underlying diseases or other factors that
increase the complexity of medical decision making by
increasing the risk of complications, morbidity, and/or
mortality should be documented.
44
Severity Risk Ramifications
 PDX: Hypotension
 PDX: Acute Systolic
 Secondary DX
 Congestive Heart
Failure
 Chronic Renal Failure
 Hyperkalemia
 Hyperlipidemia
 Hypercholesteremia
CHF
 Secondary DX
 Chronic Renal Failure
End Stage with fluid
overload
 Hyperkalemia
 Hyperlipidemia
 Hypercholesteremia
Financial Ramifications
 PDX Hypotension
 PDX Acute Systolic CHF
 MS-DRG 316
 MS-DRG 291
 Other Circulatory System
 Heart Failure and Shock
Diagnoses without
CC/MCC
 Relative Weight .6147
 Approximate
Reimbursement =$4302.90
(Blended rate= $7,000)
with MCC
 Relative Weight 1.4943
 Approximate
Reimbursement = $10,4601
(Blended rate = $7,000)
APR-DRG Ramifications
 PDX Hypotension
 PDX Acute Systolic CHF
 APR-DRG 207
 Other Circulatory
System DX
 SOI 1/ROM 1
 Relative weight .4850
 Reimbursement $3,395
(blended rate $7,000)
 APR-DRG 194
 Heart Failure
 SOI 3/ROM 1
 Relative weight 1.1222
 Reimbursement
$7,855.40 (blended rate
$7,000)
Now a Word from our Sponsor
 Progress note Day #2
 No events overnight, patient has no complaints,
appears comfortable
 Pneumonia-will start IV antibiotic, order WBC
 COPD exacerbation-will start Duonebs, IV steroids,
pulmonary toilet, will encourage smoke cessation
 Hypertension –will monitor
New & Improved
 Progress Note Day # 3
 No events overnight, patient has no complaints,
appears comfortable
 Pneumonia-will start IV antibiotic, order WBC
 COPD exacerbation-will start Duonebs, IV steroids,
pulmonary toilet, will encourage smoke cessation
 Hypertension, will monitor
Principles of Documentation
 The documentation should support the
intensity of the patient evaluation and/or the
treatment, including thought processes and the
complexity of medical decision-making as it
relates to the patient's chief complaint for the
encounter.
Principles of Documentation
 The patient's progress, including response to
treatment, change in treatment, change in diagnosis,
and patient non-compliance should be documented
Importance of Proper and
Accurate Documentation
 Services billed to the Medicare program are the sole
responsibility of the Medicare provider.
 Your documentation needs to be unique, specific,
and should accurately reflect the services you are
billing.
Importance of Proper and
Accurate Documentation
 Documentation not only must reflect necessity and
the services provided but also must be consistent
among the providers involved in an episode of care.
 Medicare payment for services may be denied if the
supporting documentation is not thorough.
Clinical Thought Processes
 Progress note Day #2
 CC- shortness of breath
 HPI- patient still complaining of shortness of breath but only when
he first gets up in morning
 Pneumonia-improving, WBC trending down to 16 from 24, bands
8, still has fever and x-ray slow clearing, will continue IV
antibiotics, follow labs,
 COPD exacerbation-slowly improving, lungs still junky, easily
short of breath with minimal exertion, will continue Duonebs,
IV steroids, pulmonary toilet, will encourage smoke cessation
Clinical Thought Processes
 Progress note Day #3
 CC- shortness of breath
 HPI- patient still complaining of shortness of breath but no
episodes in last 12 hours


Pneumonia-improving, WBC almost back to within upper limits of normal,
morning labs show WBC 12 from initial 24, bands 2, fever has just about
cleared, x-ray slow clearing, will step down to PO antbx, anticipate discharge
tomorrow.
COPD exacerbation-resolving, responded well to hospital course of therapy.
Patient agrees to smoking cessation counseling outpatient.
Nature of Presenting Problem
 Ensure the nature of the patient’s presentation
corresponds to CPT’s contributory factors of the
nature of the presenting problem and/or patient’s
status descriptions for the code reported.
Nature of Presenting Problem
 For instance:
 99231 – “Usually the patient is stable, recovering or
improving.”
 99232 – “Usually the patient is responding inadequately
to therapy or has developed a minor complication.”
 99233 – “Usually the patient is unstable or has developed
a significant complication or a significant new problem.”
Evidence Based Medicine
There Must Be a Better
Way!
The Five Step Process
 Determine that the service is medically necessary
 Provide the service needed in order to properly meet the
patient’s needs.
 Document the service provided.
 Select the most appropriate CPT/HCPCS code for the
medically necessary service that was provided and properly
documented.
 Submit the service to Medicare that was medically
necessary and documented.
Medical
Necessity
Clinical
Impression
E&M
MDM
CC
Physical
Exam
History
Questions
Questions about this presentation? Contact
Glenn Krauss at glennkrauss@earthlink.net