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Revised April 2011
TUMG Compliance
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Documenting an
Outpatient Visit
Overview of Basic Principles
Before viewing, print the file:
Documenting an Outpatient Visit
which contains a handout and a quiz
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Read Before Proceeding
Physicians and Staff may earn one compliance credit by
viewing this presentation, completing the assessment, and
faxing the assessment to the
HIPAA Compliance Office: 504-988-7777
This presentation may be viewed for compliance
credit only once in a fiscal year
(July 1 - June 30).
To check to see how many compliance credits you have
and to see which training sessions you have completed,
contact the University Privacy and Contracting Office at
504-988-7721
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It is the policy of TUMG to provide healthcare
services that are in compliance with all state
and federal laws governing its operations and
consistent with the highest standards of
business and professional ethics. Education for
all TUMG physicians is an essential step in
ensuring the ongoing success of compliance
efforts.
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This is the first of a 6-part series focused on
documenting outpatient services.
Part 1: Overview of
Basic Principles
Part 2: Documenting a
History
Part 3: Documenting an
Exam
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Part 4: Documenting Medical
Decision Making
Part 5: Time-Based Codes
Part 6: Linking to Resident Notes
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TUMG Physicians are responsible
for documenting their outpatient
visits and selecting the level of
service to be billed to the carrier.
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Purpose of Presentation


To provide information regarding documenting and
selecting a level of service for outpatient visits
To provide links to source documents that will
assist physicians in the understanding and
application of documentation guidelines.
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The WYSI-WYG Principle
(WYSI-WYG)
The WYSIWYG principle defines the relationship between
documentation and level of service
What You See Is What You Get
Corollary:
If it isn’t written,
it didn’t happen, and
it can’t be billed
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An understanding of Evaluation and Management Guidelines,
paired with the WYSI-WYG Principle, greatly reduces the
potential for Level of Service – Documentation Mismatches
Physician:
I know the
service is a
99204
Reviewer/Coder:
I see a 99202
Physician Note
Chief Complaint
Expanded History
Detailed Exam
Moderate
Decision Making
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Outpatient Visit Essentials
1) Documentation that supports the level of
service billed
Does the note contain all the elements required for
the level of service selected?
2) Clearly established Medical Necessity
Does the note provide a clear reason for the visit,
and are the assessment and plan clearly related to
the reason for the visit?
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It’s a matter of writing
and/or dictating…
History
Physician Note
Chief Complaint
History
Exam
Medical Decision
Making
To avoid “underdocumenting,” the physician’s
note must reflect all the elements of History,
Exam and Medical Decision Making performed
for each outpatient encounter.
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To insure that documentation supports
the level of service:



Understand and apply General Principles of Medical
Record documentation
Understand and apply Evaluation and Management
documentation guidelines click here: (jump to slide 18)
Link to other supporting documentation (resident
notes, staff notes, patient questionnaires)
Links to Documentation Resources (click on the link to open)
1995 General Principles of Medical Record Documentation
1997 General Principles of Medical Record Documentation
Linking to resident notes and teaching physician guidelines
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To insure that Medical Necessity is
established a note should contain



A clearly stated chief complaint click here
A clearly stated diagnosis(es) or, in absence of a
diagnosis, signs and symptoms
A clearly stated or easily inferred rationale for
ordering diagnostic or other ancillary services
WORD OF CAUTION:
The only instance where information can be
inferred is for ordering diagnostic or other
ancillary services.
The chief complaint and the diagnosis cannot
be inferred; they must be clearly documented
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Auditors are not psychics
I sense a complete
review of systems…but
the crystal ball is
cloudy regarding a
chief complaint and
the exam…
Medical Record Reviewers
or Coders do not fill in gaps
in a note.
Note
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Each outpatient visit must
stand alone. Reviewers will
not look back at prior notes
to support a level of service.
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Need More Information?
The TUMG Compliance Educator / Audit Specialist is
available to any physician/section/department that would
like further information on outpatient documentation
guidelines or other compliance topics.
Contact:
Sue Straumanis, CPC, CHC
sstrauma@tulane.edu
Phone: 504-988-6807
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End of Presentation
To Earn Compliance Credit:
Complete and Sign the
“Documenting an Outpatient Visit”
Quiz
Fax to: 504-988-7777
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Chief Complaint
“The Chief Complaint is
a concise statement
describing the symptom,
problem, condition,
diagnosis, physicianrecommended return, or
other factor that is
reason for the
encounter” This is
usually stated in the
patient’s own words.
Corollary: The Chief
complaint cannot be
inferred.
Click here to return to main presentation
Source: Medicare Physician Guide:
A Resource for Residents, Practicing
Physicians, and Other Healthcare
Professionals. 11th Edition – Oct.
2009, pg. 102.
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Basics of E/M Coding – 6 slides
The Meet or Exceed Principle

New Patients OR Initial
Consults, the Physician
must MEET or EXCEED
documentation requirements
for three of three E/M
Components




History
Exam
Medical Decision
Making
Established Patients OR
Follow-Up Consults, the
Physician must MEET or
EXCEED documentation
requirements for two of
three E/M Components.


History/Medical
Decision Making
Exam/Medical
Decision Making
There are six slides in this section of the presentation– at slide 6
there is a link to return to the main presentation
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A word about Established Patient
documentation
Although Established Patient/Follow-Up Consult E/M level of
service is based on two of three E/M components, that does not
mean that the physician should not document elements of all
three E/M components if the information is germane to the
treatment of the patient.
Medical Decision Making must always be one of the two
components when determining level of service to ensure medical
necessity is being met.
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New Patients – Selecting A Level of Service
E/M Code and
Visit Time (in
minutes)
1- History of
Present Illness
2 – Exam
3 – Medical
Decision
Making
99201-10
99241-15
Problemfocused
Problemfocused
Straight
forward
99202-20
99242-30
Expanded
Expanded
Straightforward
99203-30
99243-40
Detailed
Detailed
Low
99204-45
99244-60
Comprehensive
Comprehensive
Moderate
99205-60
99245-80
Comprehensive
Comprehensive
High
A physician note documents a detailed History, expanded Exam and
Moderate Medical Decision Making. What New Patient code or Consult
code is supported by the documentation?
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New Patients – Selecting A Level of Service
E/M Code and
Visit Time (in
minutes)
1- History of
Present Illness
2 – Exam
3 – Medical
Decision
Making
99201-10
99241-15
Problem-focused
Problem-focused
Straight forward
99202-20
99242-30
Expanded
Expanded
Straight-forward
99203-30
99243-40
Detailed
Detailed
Low
99204-45
99244-60
Comprehensive
Comprehensive
Moderate
99205-60
99245-80
Comprehensive
Comprehensive
High
With new patients or consults, the LOWEST of the three E/M key
components documents determines the level of service. In this
case, a 99202 or 99242.
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Established Patients – Selecting A Level of Service
E/M Code and
Visit Time (in
minutes)
1- History of
Present Illness
2 – Exam
3 – Medical
Decision
Making
99211-10
N/A
N/A
N/A
99212-20
ProblemFocused
ProblemFocused
Straight-forward
99213-15
Exp. ProblemFocused
Exp. ProblemFocused
Low
99214-25
Detailed
Detailed
Moderate
99215-40
Comprehensive
Comprehensive
High
A physician note documents a detailed History, expanded Exam and
Moderate Medical Decision Making. What established patient code
is supported by the documentation?
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Established Patients – Selecting A Level of Service
E/M Code and
Visit Time (in
minutes)
1- History of
Present Illness
2 – Exam
3 – Medical
Decision
Making
99211-10
N/A
N/A
N/A
99212-20
ProblemFocused
ProblemFocused
Straight-forward
99213-15
Exp. ProblemFocused
Exp. ProblemFocused
Low
99214-25
Detailed
Detailed
Moderate
99215-40
Comprehensive
Comprehensive
High
With established patients, the LOWEST of the two highest E/M key
components documented determines the level of service. In this
case, documentation supports a level 99214.
*Click here to return to
main presentation*
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