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Overview of Coding and Documentation
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Initial Steps
Evaluate and monitor the patientTreat the patientDocument the serviceCode the service
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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
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Documentation Guidelines
Your documentation must support your servicesTeaching Physician guidelines – government
payors have strict guidelines regulating when a physician bills with a Resident’s involvement Florence is rewriting
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The HCPCS coding system consists of two levelsLevel I – Current Procedural Terminology (CPT)
CodesDeveloped and maintained by the AMAConsist of five-digit codes and two-digit modifiers
Level II – HCPCS National CodesDeveloped by CMS and maintained by a national panelConsist of one alpha character followed by four-digitsAlso have modifiers
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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!!!!!
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General Principles of Documenting - Florence 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)
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General Principles of Documenting - FlorencePatient’s progress, including response to
treatment, change in diagnosis, and patient non-compliance;
Relevant health risk factors; Written plan of care should include (when
appropriate):Treatments and medications, specifying frequency and
dosage;Any referrals and consultations; andPatient/family education
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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.
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CPT Coding and Documentation
E&M Services – (Evaluation and Management Services) Levels of Care
E&M Documentation CMS/AMA Guidelines
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E&M Coding
Key Components History Exam Decision Making
Contributory Factors Counseling Coordination of care Presenting problem Time
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Key Components
History
Exam
Decision Making
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History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family & Social History (PFSH)
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Exam
Organ SystemsFor a General Multi-System Exam
Body Areas
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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.
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VCUHS Clinical
Documentation Improvement
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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.
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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.
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Importance of DocumentationCapturing 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.
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Examples of Unable vs Acceptable 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
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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
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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