demystifying medical documentation
DESCRIPTION
This is a concise review of the medical documentation requirements for evaluation and management services. This medical documentation summary targets all health care providers who must document inpatient or outpatient health care encounter information for billing and coding for third party payers. Outlined in this summary is the 1997 Guidelines for Evaluation & Management Services published by Medicare. The individual documentation requirements for the history, examination and medical decision making components of medical documentation are illustrated through the use of Medicare's auditing tool, CMS' Medicare Part B HGSAdministrators Documentation Worksheet.TRANSCRIPT
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MedicalMedicalTemplatesTemplates
Demystifying Medical Documentation
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A Quick Review of A Quick Review of Medical DocumentationMedical Documentation
RequirementsRequirements
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Patient EncountersPatient Encounters
The Centers for Medicare and Medicaid Services (CMS) has published definitions and documentation guidelines for the key components of a medical encounter note, using CPT codes.
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Key Components of DocumentationKey Components of Documentation
HistoryExamMedical Decision MakingCounselingCoordination of CareNature of Presenting ProblemTime
Key components in selecting the level of E/M services
1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
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The HistoryThe History
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History Components and Levels History Components and Levels
HPI ROS PFSH Type of HistoryBrief N/A N/A Problem Focused
Brief Problem pertinent
N/A Expanded Problem Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
New patient evaluations MUST have at least a Detailed History
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History of Present IllnessHistory of Present IllnessEVERY encounter MUST contain a Chief Complaint!
Preferentially stated in patients’ words
Elements of HPILocationQualitySeverityDurationTimingContextModifying factorsAssociated Signs and Symptoms
BriefContains 1-3 elements listed
ExtendedContains ≥ 4 elements
OR discusses 3 chronic or inactive conditions
BriefContains 1-3 elements listed
ExtendedContains ≥ 4 elements
OR discusses 3 chronic or inactive conditions
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Review of SystemsReview of SystemsConstitutional SymptomsEyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary (Skin, Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/Immunologic
Problem PertinentDocuments responses to the system directly related to the presenting problem
ExtendedDocuments positive and negative responses to 2-9 systems related to the problem
CompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)
Problem PertinentDocuments responses to the system directly related to the presenting problem
ExtendedDocuments positive and negative responses to 2-9 systems related to the problem
CompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)
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Past, Family and Social HistoryPast, Family and Social History
Past Medical HistoryIllnesses, Operations, Injuries and Treatments
Family Medical HistoryInclude heritable diseases and those that place the patient at increased risk
Social HistoryAn age appropriate review of past and current activities
PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI
PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI
CompleteAll initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areas
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The ExamThe Exam
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Recognized Single Organ SystemsRecognized Single Organ SystemsCardiovascularEars, Nose, Mouth, ThroatEyesGenitourinary (Female)Genitourinary (Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkin
DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area
DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area
ComprehensiveA general multi-system examA complete exam of an organ system and
other related body areas or organ systems
Most levels require a minimum of a Detailed ExamMost levels require a minimum of a Detailed Exam
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MultiMulti--organ System Examorgan System ExamDetailed
≥3 vital signsBP, sitting or standingBP, supinePulse, rate and regularityRespirationsTemperatureHeightWeight
≥2 elements* of at least 6 organ systems or body areas examinedOR ≥1 element of at least 12 organ systems
Comprehensive≥2 elements* in at least 9 organ systems or body areas
*Refer to 1997 Guidelines for Evaluation & Management Services*Refer to 1997 Guidelines for Evaluation & Management Services
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Single Organ System ExamSingle Organ System Exam
DetailedDocument ≥12 elements* (NOT Eye and Psychiatric exams)
Eye and Psych exams document ≥9 elements
ComprehensiveDocument ALL elements*
*Refer to 1997 Guidelines for Evaluation & Management Services*Refer to 1997 Guidelines for Evaluation & Management Services
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Elements of Individual Organ SystemsElements of Individual Organ SystemsConstitutional
Vital signsGeneral appearance of patient
Nutrition, Body habitus, Development, Deformities, Grooming
EyesInspection of conjunctivae and lidsExam of pupils and irisesOphthalmoscopic exam of optic discs
Ears, Nose, Mouth and ThroatExternal inspection of ears and noseOtoscopic examAssessment of hearingInspection of nasal mucosa, septum, and turbinatesInspection of lips, teeth and gumsExam of oropharynx
NeckExam of neckThyroid
RespiratoryAssessment of effortPercussion of chestAuscultationPalpation of chest
CardiovascularPalpation of heartAuscultationCarotid artery examAbdominal aorta examFemoral arteries examPedal pulses examExtremities for edema or varicosities
Chest (Breasts)InspectionPalpation
GastrointestinalAbdominal examLiver and spleen examHernia presence or absenceAnus, perineum, rectum examStool for occult blood
1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services
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Exam elements, continuedExam elements, continuedLymphatic
NeckAxillaGroinOther
MusculoskeletalGait and stationInspection, palpation digits and nailsExam of bones, joints, muscles AND 1 or more
Inspection or palpationRange of motion and presence/absence of painStabilityMuscle strength and tone
SkinInspectionPalpation
NeurologicCranial nervesDeep tendon reflexesSensation
PsychiatricJudgment and insightOrientation to person, time, placeMemory, recent and remoteMood and affect
Genitourinary
MaleScrotal contentsPenisDigital rectal exam of prostate gland
FemaleExternal genitaliaUrethraBladder examCervixUterusAdnexa/parametria
1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services
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Medical Decision Medical Decision MakingMaking
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Elements of Medical Decision MakingElements of Medical Decision Making
• Number of diagnoses or Management Options• Amount or Complexity of data to be reviewed• Risk of Complications, Morbidity or Mortality
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Complexity of Medical Decision MakingComplexity of Medical Decision Making
Number of DiagnosesOr Management Options
Amount or Complexity of Data to be Reviewed
Risk of Complications Morbidity or Mortality
Complexity of Decision Making
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate
Extensive Extensive High High
2 out of 3 elements must be met2 out of 3 elements must be met 1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services
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WorksheetsWorksheetsCalculating Documentation LevelsCalculating Documentation Levels
Adapted fromHGSAdministrators Documentation Worksheet
CMS Medicare Part B
Adapted fromHGSAdministrators Documentation Worksheet
CMS Medicare Part B
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HistoryHistoryHPI: Status of chronic conditions□1 condition □2 conditions □3 conditions
□1-2
□3
HPI elements□Location □Severity □Timing □Modifying factors
□Quality □Duration □Context □Associated signs & symptoms
□Brief1-3
□Extended4 or more
Review of Systems□Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes
□CV □MS □Neuro □Aller/Immun □Resp □Psych
□All others negative
□None
□Pertinent to
Problem1 system
□Extended
2-9 Systems
□Complete
10 or more Systems
PFSH□Past History □Family History □Social History
□None
□Pertinent
1
□Complete
2 or 3
Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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ExaminationExaminationBody Areas□Head, Face □Chest, Breasts, Axilla
□Abdomen □Neck □Back, Spine
□Genitalia, Groin, Buttocks □Each Extremity
Organ Systems□Constitutional □ENT □Resp □MS □GI □Skin
□GU □Psych □CV □Eyes □Heme/Lymph □Neuro
□1
Body Areaor
System
□Up to 7
Body Areas or
Systems
□Up to 7Body Areas
orSystems
□8 or more
Body Areasor
Systems
Problem Focused
ExpandedProblem Focused
Detailed Comprehensive
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Medical Decision MakingMedical Decision Making
Reminder:There are 3 components used to determine the complexity of medical decision making
• Number of diagnoses or Management Options• Amount or Complexity of data to be reviewed• Risk of Complications, Morbidity or Mortality
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Number of Diagnoses or Treatment OptionsNumber of Diagnoses or Treatment OptionsComplexity of Medical Decision MakingComplexity of Medical Decision Making
A B x C = DProblem status Number Points Result
Self-limited or minor Max = 2 1Established problem (to examiner)
Stable or improved1
Established problem (to examiner)Worsening
2
New problem (to examiner)No additional workup planned
Max = 1 3
New problem (to examiner)Additional workup planned
4
Total
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Amount and/or Complexity of Data ReviewedAmount and/or Complexity of Data ReviewedComplexity of Medical Decision MakingComplexity of Medical Decision Making
Reviewed Data Points ResultClinical lab tests reviewed and/or ordered 1
1
1
1
1
2
2
Review and/or order of tests from radiology section of CPT
Review and/or order of tests from medicine section of CPT
Discussion of test results with performing physician
Decision to obtain history from source other than patient
Review and summarization of history obtained from source other than patient
Independent visualization of image, tracing or specimen (NOT reviewing report)
TOTAL
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Guide to Determining Guide to Determining Risk of ComplicationsRisk of ComplicationsComplexity of Medical Decision MakingComplexity of Medical Decision Making
Risk Presenting Problem Dx Procedure Ordered Management Options SelectedMinimal -1 self-limited or minor problem -Venipuncture
-X-rays-EKG-EEG-Urinalysis-ECHO
-Rest-Gargles-Elastic bandages
Low -2 or more self-limited or minor problems-1 stable, well- controlled chronic illness-Acute uncomplicated illness or injury
-Physiologic tests NOT under stress i.e., PFTs-Noncardiovascular imaging studies + contrast
Barium enema-Superficial needle biopsies-Clinical lab tests requiring arterial puncture-Skin biopsies
-OTC drugs-Minor surgery without identified risk factors-Physical therapy-Occupational therapy-IV fluids without additives
Moderate -Mild exacerbation of 1 or more chronic illnesses-2 or more stable, chronic illnesses-Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump)-Acute illness with systemic symptoms-Acute complicated injury
-Physiologic tests under stressCardiac stress testCardiopulmonary exercise test
-Diagnostic endoscopies with NO risk factors-Deep needle or incisional biopsy-Cardiovascular imaging studies with contrast
NO identifiable risk factorsCardiac catheterization
-Obtaining body cavity fluidThoracentesis
-Minor surgery WITH identified risk factors-Elective major surgery with NO identified risk factors-Prescription drug management-Therapeutic nuclear medicine-IV fluids with additives-Closed treatment of fracture
High -Severe exacerbation or progression of 1 or more chronic illnesses
-Acute or chronic illness or injury that threatens life or limb
-Abrupt change in neurologic status
-Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests-Diagnostic endoscopies + Risk factors -Discography
-Elective surgery + Risk factors-Emergency Major surgery-Parenteral controlled substances-Drug therapy requiring intensive monitoring-Decision to not resuscitate or to de-escalate care due to poor prognosis
The highest level in ANY category determines the overall riskThe highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services
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Final Determination Final Determination Complexity of Medical Decision MakingComplexity of Medical Decision Making
A Number of diagnoses or treatment options
≤ 1Minimal
2Limited
3Multiple
≥4Extensive
B Highest risk Minimal Low Moderate High
≥4Extensive
High Complexity
C Amount and complexity of data reviewed
≤ 1Minimal or Low
2Limited
3Multiple
Type of decision making Straightforward Low Complexity
Moderate Complexity
Circle the appropriate descriptions for Rows A, B, CThe Column with 2 or 3 circles determines the final Complexity of Medical Decision Making
Circle the appropriate descriptions for Rows A, B, CThe Column with 2 or 3 circles determines the final Complexity of Medical Decision Making
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Determining Overall Service LevelsDetermining Overall Service Levels
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Inpatient EncountersInpatient EncountersInitial Hospital EncounterOr ObservationRequires 3 components within shaded area
Subsequent Inpatient Or Follow upRequires 2 components
History D or C
D or C
SF/L
I9922199218
C C PF EPF D
C
M
EPF
II9922299219
DC
H H
III9922399220
III9923399263
M
II9923299262
PF
SF/L
Examination
Complexity of medical decision
LEVELInit Hosp Care Observation
I9923199261
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/LowC = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Outpatient, Outpatient, Consults Consults (Outpatient, Inpatient)(Outpatient, Inpatient) and ERand ER
New Office / Consult / ERRequires 3 components within shaded area
Established OfficeRequires 2 components
PF ER: PF
PF EPF D C
PF
Minimal problem that may
not require
presence of
physician
I99211
SF
D
II-212
CEPF
L
III-213
H
V-215
M
IV-214
PF ER: PF
SFER: SF
I99-20199-24199-25199-281
History EPFER: EPF
DER: EPF
CER: D
CER: C
EPFER: EPF
SFER: L
CER: D
II-202-242-252--282
CER: C
DER: EPF
LER: M
HER: H
III-203-243-253-283
V-205-245-255-285
MER: M
IV-204-244-254-284
Examination
Complexity of medical decisionLEVELNew PtOutpt ConsultInpt ConsultER
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Documenting Time Documenting Time As a Determinant of Level of ServiceAs a Determinant of Level of Service
“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time?Time: Face to face in outpatient setting
Unit/floor in inpatient setting
□Yes □No
Does documentation describe the content of counseling or coordinating care □Yes □No
Does documentation reveal that more than half the time was counseling or coordinating care? □Yes □No
Documentation of Time requires that ALL of the answers to the above questions are YES
Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet
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Summary Examples Summary Examples Documentation RequirementsDocumentation Requirements
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Initial Hospital CareInitial Hospital CareMust meet ALL criteria
99223Comprehensive History and ExamHigh complexity Medical decision making
99222Comprehensive History and ExamModerate complexity Medical decision making
99221Detailed OR Comprehensive History and ExamStraightforward or Low Complexity Medical decision making
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Initial Inpatient ConsultationInitial Inpatient ConsultationMust meet ALL criteria
99255Comprehensive History AND ExamHigh complexity medical decision making
99254Comprehensive History AND ExamModerate complexity medical decision making
99253Detailed History AND ExamLow complexity medical decision making
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New Outpatient EncounterNew Outpatient EncounterNot a ConsultNot a Consult
Must meet ALL criteria
99205Comprehensive History and ExamHigh complexity medical decision making
99204Comprehensive History and ExamModerate complexity medical decision making
99203Detailed History and ExamLow complexity medical decision making
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New Outpatient ConsultNew Outpatient ConsultMust meet all criteria
99245Comprehensive HistoryComprehensive ExamHigh complexity medical decision making
99244Comprehensive HistoryComprehensive ExamModerate complexity medical decision making
99243Detailed HistoryDetailed ExamLow complexity medical decision making
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Established Outpatient EncounterEstablished Outpatient EncounterMust meet 2 out of 3 criteria
99215 Comprehensive HistoryComprehensive ExamHigh complexity medical decision making
99214Detailed HistoryDetailed ExamModerate complexity medical decision making
99213Expanded Problem Focused HistoryExpanded Problem Focused ExamLow complexity medical decision making
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