Feature Article
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Understanding Documentation and Coding: Taking Credit When Credit is Due Healthcare providers are currently reimbursed for their services through a system of current procedural terminology (CPT) codes, which were formulated to capture the comprehensiveness and intensity of the services being provided. Three main components are assessed according to the information that the provider collects and documents. Because the final code is dependent upon the information collected, this article will first discuss the importance of documentation and how that information contributes to determining the level of coding for each key component and, second, how the components are used to complete the formulas or rubrics established for each code. The goal of this article is to help the primary care provider increase skills in documentation and coding to ensure appropriate compensation for work performed. An understanding of this information is fundamental to actually determining levels for coding in a variety of healthcare settings.
Documentation for the Components of Coding Why Documentation Is Important The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment and to monitor patient care over time requires thorough documentation. The medical record plays a significant part in communicating among all professionals involved in an individual’s care. Without adequate communication, there is an increased risk that care will be fragmented. Accurate documentation also provides for timely claims review and payment, appropriate utilization review, quality of care evaluations, and data collection that can be useful in the areas of research and education. What Payers Want and Why In reality, the payer asks for very little from the provider of health care services. They need to know the medical necessity, the appropriateness of the diagnostic and/or therapeutic services provided, and that those services provided have been accurately reported. General Principles of Medical Record Documentation The medical record needs to be complete and legible. The documentation of each patient encounter needs to include: (1) chief complaint and/or reason for the encounter, relevant history, physical examination findings, and prior diagnostic test results; (2) assessment, clinical impression, or diagnosis; (3) plan of care; and (4) date and a verifiable legible identity of the healthcare professional who provided the service. If not specifically documented, the rationale for ordering diagnostic and other ancillary services needs to be easily inferred. The identification of health risk factors needs to be recognized and incorporated into the medical record. Records of the individual’s progress, response to and changes in treatment, planned follow-up care and instructions, and diagnosis need to be included. All health insurance claim forms or billing statements must be supported by the documentation in the medical record. Any additions to the medical record must be dated the day the information is added to the medical record, not for the date service was provided. In order to maintain an accurate medical record, all services need to be documented during or as soon as practicable after they are provided. At all times, the confidentiality of the medical record must be fully maintained consistent with the requirements of medical ethics and law. Evaluation and Management Services Evaluation and Management (E/M) Services were created by the American Medical Association in 1966 to standardize the approach to patient assessment and care. There are seven components that define the levels of E/M Services: history, examination, medical decision-making, counseling, coordination of care, nature of presenting problems, and time spent providing the service. For all practical purposes, the determination of E/M Services is dependent only upon the history, physical examination, and medical decision-making categories that represent the key components needed to accurately code for services. This article will investigate how each of these components is evaluated to determine a coding level, which is then applied to the formula for the CPT codes. Documentation of History. As is known, the history is the report by the patient and/or the patient’s caregiver to the provider of conditions that may be influencing the current problem. The history is broken up into three areas: history of present illness (HPI); review of systems (ROS); and past medical, family, and/or social history (PFSH). The HPI serves as a chronological description of the development of the patient’s present illness from the first symptoms and/or signs or from the previous encounter to the present. It needs to provide pertinent details about the reason for the encounter. There are a total of eight items that may be counted when determining the level of coding for the HPI (Table I). The ROS can be described as an inventory of body systems obtained through a series of questions seeking to identify symptoms and/or signs that the patient may be experiencing or has experienced. There are 14 systems that may be evaluated and counted when determining the ROS level for coding (Table II). The PFSH is much simpler than the HPI and ROS from both an identification and counting perspective. However, it also factors into the level for coding that will be assigned within the entire process of history taking during a patient encounter. Discussion about each of the three areas—past medical history, family history, and social history—is used to determine the coding level for this section. There are four coding levels that are determined by the HPI, ROS, and PFSH calculations (Table III). By counting up the items recorded in each area and applying that score to the chart in Table III, the coding level can be determined.
Documentation of Physical Examination. The documentation of the physical examination is divided into body areas and organ systems that are counted and then factored into the level for coding. The provider completes the examination of the areas or systems that need assessment based on the patient’s current complaint, and documents the elements of the exam that were completed for each area or system (Table IV). To clarify terminology, an element is considered to be any discrete portion of a regular physical exam for a specific body area or organ system. The coding level is dependent upon the number of elements carried out during the physical examination (Table V). Medical Decision Making. There are three categories to consider for determining the level of coding for medical decision-making purposes. These include the number of diagnoses or treatment options, the amount and complexity of data to be reviewed, and the overall risk associated with the patient encounter (Table VI). The level for coding is then determined by counting up the respective categories and by assigning accordingly (Table VII).
Formulas or Rubrics for CPT Coding All of the work that providers perform can be summarized into CPT codes, which are used for billing. This includes work done in the office, hospital, nursing facility, domiciliary, or home sites. Reimbursement for the same work done at different sites varies according to the site. This article looks only at the determination of codes for nursing facilities and home visits, but the same principles can be applied to other care sites using their appropriate rubrics. In each of these situations, there are two distinct times at which services are provided: the new patient or admission visit and the established patient or subsequent visit. The CPT coding rubric will vary according to this as well. The information collected, organized, and evaluated during the documentation period (history, physical examination, and medical decision making) can be expressed as coding levels (Tables III, V, VII). The coding level for the three key components can be placed in the CPT coding rubric (Tables VIII, IX) and the final code determined. When it looks like the coding levels straddle two different codes, choice always defaults to the lower code. Nursing Facility Coding A total of six CPT codes are most frequently used by providers within the nursing facility setting. The first three (99301, 99302, 99303) are considered the comprehensive nursing facility assessment codes. 99301. This code is used to bill for the services provided during the evaluation and management of a nursing facility resident in the completion of the required annual assessment by the facility. The three key components are: a detailed interval history; a comprehensive examination; and medical decision making that is straightforward or of low complexity. The provider assessment is performed in conjunction with the annual Minimum Data Set (MDS) reassessment of a resident who is stable with underlying dementia, hypertension, and osteoarthritis. 99302. This code is used to bill for the care provided during the evaluation and management of a nursing facility resident who has experienced a significant change in condition that is believed to be permanent and requiring the nursing facility to perform a comprehensive assessment and develop a new plan of care. The work provided must include the following three components: a detailed interval history; a comprehensive examination; and medical decision making of moderate-to-high complexity. A patient example could be someone with mild-to-moderate dementia who is able to ambulate with use of a single-point cane and eat with set-up only. This patient suffers a stroke and becomes chairbound and requires assistance with meals and placement in a restorative dining program. 99303. This code is used to bill for the care provided during the initial admission or readmission of a new or established patient. The work provided must include the following three components: a comprehensive history, a comprehensive examination, and medical decision making of moderate-to-high complexity. Subsequent nursing facility care requires that two out of the three key components must be present. A patient example would be someone previously residing independently in the community who has suffered a fall resulting with hip fracture requiring surgical repair. During hospitalization there was new onset of confusion regarding identification of a postoperative pneumonia requiring antibiotic therapy, with resultant delay in recovery. The patient required admission to a nursing facility for completion of antibiotic therapy and physical and occupational therapy in order to return to the community. 99311. This code is used to bill for the subsequent evaluation and management of a new or established patient and requires at least two of the following: a problem-focused interval history; a problem-focused examination, and medical decision making that is straightforward or of low complexity. A patient example would be someone being seen on a routine visit who has been stable medically and functionally with no required changes in treatment plan. 99312. This code represents the subsequent evaluation and management of a new or established patient in which at least two of the following exist: an expanded problem-focused interval history; an expanded problem-focused examination; and medical decision making of moderate complexity. A patient example would be someone requiring adjustment in medications for previously controlled blood sugars, hypertension, or a respiratory condition. Another example would be a resident who has fallen and is in need of evaluation to determine whether a fracture has been sustained. 99313. This code represents the highest subsequent care level for the evaluation and management of a new or established patient. In this situation, at least two of the following exist: a detailed interval history; a detailed examination; and medical decision making of moderate-to-high complexity. A patient example would be someone requiring a detailed history and physical, consideration of multiple differential diagnoses along with laboratory testing, and initiation of new medications and plan of care. This would include a resident with significant weight loss, new onset of confusion, and functional impairments.
Home Services Coding New Patient. There are a total of five CPT codes for evaluation and management services provided in the private residence of a new patient. In all cases for a new patient visit, all three key components must be provided during the assessment. 99341. This code is used to bill for the evaluation and management of a patient who requires a problem-focused history, a problem-focused examination, and straightforward decision making. Usually, the problems are of low severity. A patient example would be someone with osteoarthritis and prior joint replacement who has difficulty traveling to a provider’s office or clinic. Otherwise, this patient has no ongoing medical problems. 99342. This code is used to bill for the evaluation and management of a patient who requires an expanded, problem-focused history, an expanded, problem-focused examination, and medical decision making of low complexity. Usually, the presenting problems are of moderate severity. A patient example would be someone with diabetes mellitus and associated neuropathy with gait instability. An evaluation of the patient’s ability to monitor blood sugars, dietary needs, and foot care needs are relevant to the overall plan of care. 99343. This code is used to bill for the evaluation and management of a patient who requires a detailed history, a detailed examination, and medical decision making of moderate complexity. Usually, the presenting problems are of moderate-to-high severity. A patient example would be someone with hypertension, osteoarthritis, diabetes mellitus, and previous coronary artery bypass surgery. In addition to the evaluation for the diabetes management, more thorough assessment of cardiac, respiratory, and functional status are required. 99344. This code is used to bill for the evaluation and management of a patient who requires a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity. Usually, the presenting problems are of high severity. A patient example would be someone with hypertension, diabetes mellitus, coronary artery disease, and osteoarthritis who has been recently discharged from the hospital after treatment of uncomplicated pneumonia. Upon completion of the comprehensive evaluation, the provider contacts a local home health agency to ensure coordination of needed services. 99345. This code is used to bill for the evaluation and management of a patient who requires a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Usually, the patient is considered unstable or has a significant new problem requiring immediate physician attention. A patient example would be someone with coronary artery disease, hypertension, and a history of cardiac arrhythmia. On initial evaluation, the patient is found to be in atrial fibrillation with a heart rate of 130-145 beats per minute and findings of congestive heart failure with low oxygen saturations. The patient requires initiation of diuretic therapy, digoxin, warfarin, and supplemental nasal oxygen. Established Patient. For established patients seen within a private residence, the following four CPT codes are applicable to evaluation and management services. 99347. This code is used to bill for the evaluation and management of a patient who requires at least two of the following: a problem-focused interval history; a problem-focused examination; and straightforward medical decision making. Usually, the presenting problems are self-limited or minor. A patient example would be someone being seen for review of finger stick blood sugar readings and requiring no change in treatment plan. There are no other medical or functional concerns reported by the patient or identified by the provider. 99348. This code is used to bill for the evaluation and management of a patient who requires at least two of the following: an expanded, problem-focused interval history; an expanded, problem-focused examination; and medical decision making of low complexity. Usually, the presenting problems are of low-to-moderate severity. A patient example would be someone being seen for evaluation and management of diabetes mellitus, hypertension, and coronary artery disease with associated anginal symptoms currently controlled on a medication regimen. 99349. This code is used to bill for the evaluation and management of a patient who requires at least two of the following: a detailed interval history; a detailed examination; and medical decision making of moderate complexity. Usually, the presenting problems are of moderate-to-high severity. A patient example is someone being seen for hypertension, osteoarthritis, osteoporosis with prior hip fracture, coronary artery disease, and mild cognitive impairment who is living alone. The evaluation requires attention to multiple historical points, examination of six or more areas/systems, and development of an ongoing plan of care. 99350. This code is used to bill for the evaluation and management of a patient who requires at least two of the following: a comprehensive interval history; a comprehensive examination; and medical decision making of moderate-to-high complexity. Usually, the presenting problems are of moderate-to-high severity. In addition, the patient may be unstable and/or has developed a significant new problem that warrants immediate attention by the provider. A patient example would be someone with diabetes mellitus, hypertension, and mild-to-moderate cognitive impairment who is found to have a sudden change in cognition and functional ability. After completion of the evaluation, appropriate laboratory testing is carried out, and the patient is started on antibiotics for a urinary tract infection with associated subacute delirium.
Conclusion To ensure adequate compensation for work performed, the primary care provider must understand the role of accurate documentation. Without correct and complete documentation of work performed, it is not possible to code properly and thereby receive appropriate reimbursement. This article has covered the key components of documentation and how coding levels and CPT codes are determined. The application of this basic knowledge by the provider travels across the continuum of care. Sources for Information Part B News Special Report, March 19, 2001.
Part B News website. Available at: http://www.partbnews.com. Accessed May 30, 2003.
CPT Products and Services. American Medical Association website. Available at: http://www. ama-assn.org/ama/pub/category/3116.html Accessed July 28, 2003. Annals of Long-Term Care - ISSN: 1524-7929 - Volume 11 - Issue 12 - December 2003 |