welcome to pmi’s - pmimd.com
TRANSCRIPT
![Page 1: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/1.jpg)
Welcome to Practice Management Institute’s Webinar and Audio
Conference Training. We hope that the information contained herein will
give you valuable tips that you can use to improve your skills and
performance on the job. Each year, more than 40,000 physicians and office
staff are trained by Practice Management Institute. For 30 years, physicians
have relied on PMI to provide up-to-date coding, reimbursement,
compliance and office management training. Instructor-led classes are
presented in 400 of the nation’s leading hospitals, healthcare systems,
colleges and medical societies.
PMI provides a number of other training resources for your practice,
including national conferences for medical office professionals, self-paced
certification preparatory courses, online training, educational audio
downloads, and practice reference materials. For more information, visit
PMI’s web site at www.pmiMD.com
Please be advised that all information in this program is provided for
informational purposes only. While PMI makes all reasonable efforts to
verify the credentials of instructors and the information provided, it is not
intended to serve as legal advice. The opinions expressed are those of the
individual presenter and do not necessarily reflect the viewpoint of Practice
Management Institute. The information provided is general in nature.
Depending on the particular facts at issue, it may or may not apply to your
situation. Participants requiring specific guidance should contact their legal
counsel.
CPT® is a registered trademark of the American Medical Association.
Practice Management Institute®
8242 Vicar | San Antonio, Texas 78218-1566
tel: 1-800-259-5562 | fax: (210) 691-8972
![Page 2: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/2.jpg)
Welcome to PMI’sWebinar Presentation
Brought to you by:Practice Management Institute®
pmiMD.com
On the topic:
Clinical Documentation Requirements for Primary Care
Meet the Presenter…
Doug ArringtonCMC, CHC, CHRC, CPC, COC,
CPMAFaculty
Practice Management Institute
![Page 3: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/3.jpg)
Clinical Documentation –Primary Care
Doug Arrington, DNP(c), MSN, FNP, CMC, CPC, COC, CPMA,
CHC, CHRC
Faculty – PMI
References • AHIMA – Clinical Documentation for ICD-10 CM and PCS -
http://www.ahima.org/education/onlineed/Programs/cdi• ICD-10 CM Coding for IM, Primary Care, Peds and OB/GYN -
http://betterhealth.mckesson.com/wp-content/uploads/MED3000-ICD-10-slide-deck-3-14-13.pdf• ICD-10 Clinical Concepts for Family Practice -
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsFamilyPractice1.pdf
• ICD-10 CM Official Guidelines for Coding and Reporting FY 2016 -https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf
• ICD-10 Clinical Concepts for Pediatrics -https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsPediatrics1.pdf
• ICD-10 Clinical Concepts for Internal Medicine -https://www.acponline.org/running_practice/payment_coding/coding/icd10-clinical-concepts-nternal-medicine.pdf
• ICD-10 CM Crosswalks in the primary care setting: assessing reliability of the GEMs and reimbursement mapping -http://jamia.oxfordjournals.org/content/jaminfo/early/2015/02/07/jamia.ocu028.full.pdf
• Thompson, T. (n.d.). The good, the bad, and the Ugly ICD-10 CM -http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Management/finances-coding/The-Good-the-Bad-coding-webinar-April-16.pdf
• Note: None have copyright or TM – okay to copy and use in your practice
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
1
![Page 4: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/4.jpg)
Objectives
• Documentation of acuity and severity of illness• Meaningful Use• Enough information for the coder to apply the
correct code• Identify the anatomical specificity required clinical
documentation for certain primary care diagnoses, and procedures
• Outline the chronic diagnosis for primary care providers, and outline the detailed in documenting chronic disease illness, manifestation, complications, cause, and effect
Guiding Principles of I-10 Clinical Documentation
• “Documentation for ICD-10 is an unnecessary burden.” – The number and type of new concepts required
for ICD-10 are not foreign to clinicians
– The focus of documentation is good patient care
– Patients deserve to have accurate and complete documentation of their conditions
– If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we?
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
2
![Page 5: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/5.jpg)
Basic Clinical Documentation Includes:
• Reason for encounter or chief compliant• • Relevant history of the illness (timeline since
last visit for all follow ups)• Physical examination findings • Diagnostic test results – since last visit• Assessment – for visit – not entire problem
list – only items addressed in the HPI• Clinical impression or diagnosis – only items
in HPI• Medical Plan of Care – items in HPI
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
3
![Page 6: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/6.jpg)
Documentation for Severity and Risk (MDM)
• Comorbidities• Manifestations• Etiology/Causation• Complications (cause
and effect)• Anatomical location –
detailed• Sequelae• Functional state• Trimesters/Weeks
gestations
• Phase/stage of illness or disease
• Complication Codes• Lymph involvement• Lateralization &
localization• Procedure – detailed• Implants, devices,
biologics and medications
• Clinical Scales – Coma Score
Good Documentation Includes
• Rationale for ordering diagnostics and ancillary services
• Health risk factors identified
• Patient’s progress
• Patient’s response to treatment/non compliance identified
• Revisions of diagnosis documented based on clinical results
• All codes reported on the claim form must be supported in the medical record – if it has not been documented – it has not been done.
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
4
![Page 7: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/7.jpg)
What I learned In______
• Type of condition
• Onset – when did it first start
• Etiology/Cause– Infectious agent
– Physical agent
– Internal failure
– Congenital
What I learned In______
• Anatomical location– Structure of problem
• Proximal, distal, medial, lateral, central peripheral, superior, inferior, anterior, posterior
– Laterality• Right or left, bilateral or unilateral
– Severity• Mild, moderate, or severe
– Other factors• Smoking, geographic location, occupation, high risk
behaviors,
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
5
![Page 8: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/8.jpg)
What I learned In______
• Time parameters– Intermittent, recurring, acute/chronic
• Complications or Comorbidities– Diabetes with neuropathic joint
– Intracranial Injury
• Manifestations– Paralysis, Loss of consciousness
What I learned In______
• Healing levels– Routine, delayed, malunion, non-union
• Findings or symptoms– Fever, hypoglycemia/hyperglycemia– Wheezing, murmur, hyperactive bowel sounds
• External cause– MVA, injury, assault, work related, self harm
• Encounter Type– Initial, subsequent, sequela, routine exam,
administrative,
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
6
![Page 9: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/9.jpg)
Poorly Coded or Poorly Documented – definition
• Coding (Documentation) that does not fully define important parameters of the patient condition, [or not documented] that could otherwise be defined given information available to the clinician and/or the coder.
• However, if it has not been documented – it cannot be coded
• Coders are not clinicians – they do not/can not interpret lab reports, diagnostic studies, nor are they magicians – reading between the lines
Documentation is Always Consistent
• One time mention of diagnosis/problem is not enough for coding
• Treated diagnosis are always:– Inpatient
• Assessed through the patient stay – DAILY
– Outpatient• Assessed every visit until it is resolved or stabilized
(chronic disease) – then on a regular basis to ensure that it remains stable
– Never coded from the problem list!!!
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
7
![Page 10: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/10.jpg)
Body Site Examples
• Musculoskeletal/Orthopedic– Laterality, specific bone and bone portion
• Pulmonary– Lobe specific, laterality
• Digestive– Solid organ and digestive tract specific to the
body part, laterality, portions• For patients with resection, ligation, repairs,
insertions, place of devices and stents– Location, laterality, number, chamber, vessels,
valves(s), nerve or nerve plexus
Episode of Care – 7th extender placement
• Initial encounter
• Subsequent encounter
• Sequela
• Please note that a “X” place is used for all codes less than 6 characters
• Fracture– Initial, subsequent,
sequela
– Closed
– Open
– Delayed healing
– Nonunion
– Malunion
– Displaced
– Nondisplaced
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
8
![Page 11: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/11.jpg)
Complications of CareDocumentation Requires an
CAUSE & EFFECT Relationship• Type 2 DM with Diabetic nephropathy
• Anemia due to chemotherapy
• Anemia due to acute/chronic blood loss
Documentation
Before, During and After I-10
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
9
![Page 12: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/12.jpg)
Documentation Before – 1889
Documentation – still on paper chart
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
10
![Page 13: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/13.jpg)
EMR – Happily Ever After
Primary Care – Documentation
• Type
• Site(s)
• Exam Findings
• How bad is it?
• What other disease/condition is making it better or worse?
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
11
![Page 14: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/14.jpg)
Primary Care Documentation
• Hypertension– Benign or malignant is no longer an issue
– Must document• Type – essential or secondary
• Relationship with CKD, DM, CVD or pulmonary
• Comorbidities' – CHF
Primary Care Documentation
• Congestive Heart Failure– Acuity – acute, chronic, acute on chronic– Type – systolic, diastolic
• Atherosclerotic heart disease w/wo angina– Cause – assumed to be atherosclerosis – unless
noted otherwise– Stability or unstable– Vessel(s) if known– Bypass graft involvement – autologous or
biological
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
12
![Page 15: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/15.jpg)
Primary Care Documentation
• Arrhythmias– Location – atrial, ventricle, sub ventricular,
etc.
– Flutter, fib, av block (type), long QT, SSS
– Acuity – acute or chronic
– Cause – HTN, ETOH, dig, other medication
Primary Care Documentation
• Arthritis– Type
• Localized, general, primary, secondary, osteoid, subtype
• Location, affected bones, joints, laterality
• Other conditions – describe all related underlying diseases or conditions
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
13
![Page 16: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/16.jpg)
Primary Care Documentation
• Injuries– Episode of care – initial, subsequent, sequelae
– Site – specific location including laterality
– Etiology – how did it happen? Would you believe?
– Place of occurrence – where did it happen?
– Intent – accidental, assault, self-harm, unknown
– Status – work, civilian, military, school related, other (church)
Primary Care Documentation
• Asthma– Cause – exercise, cough variant, r/t smoking,
chemical exposure, environment
– Severity – mild, moderate, severe
– Other factors – acute, chronic, intermittent, persistent, status asmaticus, acute exacerbation, acute on chronic, ozone days
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
14
![Page 17: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/17.jpg)
Primary Care Documentation
• Diabetes– Type – I, II, drug/chemical induced,
gestational, due to other condition – CF
– Complication – what other body organ/systems are affect by – i.e., foot ulcer
– Treatment – D/E, oral medications, insulin, combination
Primary Care Documentation
• Hypoglycemia or hyperglycemia– Possible to code wo using DM– Document H/H glycaemia and specify if due
to a procedure or other known cause –transient in nature or watchful waiting
• Abdominal pain and tenderness– Location – quadrant, periumbilical, epigastric,
etc.– Pain or tenderness type – colic, rebound,
generalized, localized
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
15
![Page 18: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/18.jpg)
Primary Care Documentation
• Acute respiratory failure– Type – acute, chronic, acute and chronic
– W/wo hypoxia, hypercapnia
• Anemia– Type – Iron def, hereditary hemolytic,
acquired, aplastic, etc.
– Causation – blood loss, due to – and state the condition
Primary Care Documentation
• Hyperlipidemia– Type – pure, mixed, hyperchylomicronemia, etc.
• Hypothyroidism– Type – congenital, acquired
– Causation – post surgical, iodine, etc.
• UTI– Site – cystitis, urethritis, etc.
– W/wo hematuria
– Identify causative agent, if known
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
16
![Page 19: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/19.jpg)
Primary Care Documentation
• Pneumonia– Type – bacterial, fungal, parasitic, mycoses,
aspiration – etc.– Viral pneumonias and influenza, simple to
complex– Location – lobe(s)– Causing agent– Complications – sepsis, shock, respirator
failure, complication of care – hospital acquired
Primary Care Documentation
• Herpes Simplex– Type
– Location
– Severity
– Disseminated
– Associated diagnoses/conditions
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
17
![Page 20: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/20.jpg)
Primary Care Documentation
• Purpura– Type
– Thrombocytopenic
– R/t other conditions i.e., immune, congenital
– Capillary fragility
– Pseudo hemophilia
– Comorbidities
Primary Care Documentation
• Obesity– Type
– Excess caloric intake
– W alveolar hypoventilation
– Drug induced – document drug
– Syndrome – PCOS – document
– BMI
– Other related comorbidities
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
18
![Page 21: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/21.jpg)
Depression
• Episode– Single or recurrent
– Severity – mild, moderate, severe – w/wo psychotic features
– Remission – partial or full
Otitis Media
• Incidence – acute, chronic, recurrent• Laterality• Type – serous, allergic, mucoid, etc.• Rupture w/wo• Infectious agent, if known• Exposure to tobacco smoke• Comorbidity(ies)• Tubes – w/wo
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
19
![Page 22: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/22.jpg)
Primary Care Documentation
• Cellulitis– Site – anatomic
– Laterality
– Cellulitis of limb – right, left, upper, lower,
– Measurement
– Internal/external – mouth, other orifices'
– Associated conditions/disorders
Gout
• Type – drug induce, idiopathic, primary, secondary, w renal impairment – identify
• Acuity – acute, chronic – w/wo tophus, attack, flare
• Other contributing factors
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
20
![Page 23: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/23.jpg)
Primary Care Documentation
• Newborn– Delivery type
– Maternal Hx
– Gestational age, weight, length
– Acquired conditions –
– Congenital
– Physical exam – document presence of everything – this for some may be the first baseline exam
Burns
• Type – corrosion, thermal
• Site – body & laterality
• Degree – first, second, third degree
• Percentage – TBSA rule of nine’s
• 3rd. Degree specify
• cause
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
21
![Page 24: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/24.jpg)
Primary Care Documentation
• Under dosing– Medication – taken less frequently than
prescribed or not using the medication at all.
– If reduction in the dosage results in relapse/exacerbation the medical condition must also be documented
External Cause
• How – fall, mva, accident
• Where – home, work, school
• Activity – skiing, ironing, gardening
• Status – civilian, military, volunteer,
• No national requirement for reporting external cause (provider 1500)
• Worker’s comp may require
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
22
![Page 25: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/25.jpg)
Primary Care Documentation
• History – personal and family of– Malignant neoplasm – specify type– Congenital malformation/deformation – specify
type– Allergies – type– Chemotherapy– Radiation therapy– Surgical history– Medical history – chronic problems– Mental health problems
Primary Care Documentation
• Risk Factors– Genetic carrier – CF, hemophilia, Scell
– Susceptibility to – Ca – type, endocrine disease
– Environmental exposures
– Work exposures
– Comorbidity – what added risk factor’s are their (DM and depression)
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
23
![Page 26: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/26.jpg)
Primary Care Documentation
• Retained Foreign Body– Glass, metal, radioactive, tooth, tampon, gun shot
pellet, road rash – gravel
• Contact with/exposure to– HIV– Anthrax– Varicella– Mold (type)– Second hand smoke– Other
Primary Care Documentation
• Reproductive Services– Contraceptive type(s) history of
– Procreative management
– Pregnancy test
– Pregnancy state (incidental)
– Supervision of pregnancy
– Antenatal screening
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
24
![Page 27: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/27.jpg)
Primary Care Documentation
• BME– 19 or less– 20.0 – 20.9– …..– 60.0 – 69.9– 70+– Associated conditions– Pediatric BMI (2 – 20)
• Less than 5th percentile for age• Fifth percentile to less than 85th percentile for age• 85th percentile to less than 95th percentile for age• Greater than or equal to 95th percentile for age
Primary Care Documentation
• Mechanical device complication– Body system
– Device type
– Complication – breakdown, displacement, leakage, infection, hemorrhage, pain, embolism, fibrosis, anything else?
– Episode – initial, subsequent, sequela
– Document primary medical condition and or comorbidities
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
25
![Page 28: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/28.jpg)
Primary Care Documentation
• Complications of care– Affected body system – specific
– Condition – specific
– Condition is a/an complication or expected outcome
– Complication occurred – intraoperative or postoperative
– Associated medical condition(s)
Primary Care Documentation
• Socioeconomic/psychosocial – Education/literacy– Employment– Occupation exposure – type– Housing– Social environment– Upbringing– Support system– Family circumstances– Anything else?
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
26
![Page 29: Welcome to PMI’s - pmiMD.com](https://reader031.vdocuments.us/reader031/viewer/2022022103/6211871aa4254a4c63769a36/html5/thumbnails/29.jpg)
Questions?
Thank you for your attendance!
Get your questions answered on PMI’s Discussion Forum: http://www.pmimd.com/pmiForums/rules.asp
Contact information: Doug Arrington [email protected]
Practice Management Institute www.pmiMD.com
Webinar/Audio Conference September 15, 2015
27