Overview of Coding and Documentation


Overview of Coding and Documentation

Initial Steps

Evaluate and monitor the patient

Treat the patient

Document the service

Code 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 services

Teaching 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 levels

Level I – Current Procedural Terminology (CPT)


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


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


General Principles of Documenting -


The medical record should be complete and legible

The documentation of EACH patient encounter should include:


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 -


 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

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



Decision Making

Contributory Factors


Coordination of care

Presenting problem


Key Components



 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

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.

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 Documentation

 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.

Examples of Unable vs Acceptable

 Low Hgb, transfuse

 Hypertensive emergency, urgency, crisis

 Urosepsis, change foley

 COPD, home O2


 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