Overview of Coding and Documentation


Evaluate and monitor the patient

Treat the patient

Document the service

Code 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 services

Teaching Physician guidelines – government payors have strict guidelines regulating when a physician bills with a Resident’s involvement
Florence is rewriting


Level I – Current Procedural Terminology (CPT)
Codes

Developed and maintained by the AMA

Consist of five-digit codes and two-digit modifiers
 Level II – HCPCS National Codes

Developed by CMS and maintained by a national panel

Consist of one alpha character followed by four-digits

Also 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!!!!!


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)

 Patient’s progress, including response to treatment, change in diagnosis, and patient noncompliance;
 Relevant health risk factors;

Written plan of care should include (when appropriate):

Treatments and medications, specifying frequency and dosage;

Any referrals and consultations; and

Patient/family education


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.


E&M Services – (Evaluation and Management Services)

Levels of Care

E&M Documentation

CMS/AMA Guidelines


Key Components

History

Exam

Decision Making

Contributory Factors

Counseling

Coordination of care

Presenting problem

Time


History

Exam
 Decision Making


Chief Complaint (CC)

History of Present Illness (HPI)
 Review of Systems (ROS)

Past, Family & Social History (PFSH)


Organ Systems

For a General Multi-System Exam

Body Areas


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.

 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.

 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 .

 Capturing 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.

 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

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

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