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Essential Components of Physician Documentation and Coding [PODCAST]

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In this episode, Cyndy Kowalski, a manager in our Compliance Services Team at BESLER Consulting, discusses the essential components of physician documentation and coding. Cyndy reviews best practices for documenting medical history, examination, and medical decision making plus how to avoid potential false claims.
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Michael Passanante:   Welcome back! This is Mike Passanante, your host for the Hospital Finance Podcast. And I’m joined today by Cyndy Kowalski, who is a manager at our Compliance Services Team here at Besler Consulting. Welcome, Cyndy!

Cyndy Kowalski: Thank you, Mike. It’s good to be here.

Michael: So today, Cyndy is going to walk us through the essential components of physician documentation and coding. So Cyndy, why don’t we go right to our first question? It appears that talking about documentation is a basic premise. Why is this so important?

Cyndy: The old adage that is frequently heard in every healthcare setting has always been, “If it isn’t documented, it hasn’t been done.” And I think that, that is key to the components that are required. The note in the medical record has to sufficiently describe all of the services that are furnished to a specific patient on a specific date.

When we talk about documentation, I think it’s important to understand that concise documentation is critical in a variety of ways. We are providing patients with quality care, as well as to provide information documentation, to ensure that we receive accurate and timely reimbursement for the services that we are furnishing for the patients.

It needs to chronologically document the care of the patient. It’s required to record all of the pertinent facts, findings and observation about the patient’s history which would include their past and present illnesses, the examination, any testing or treatments that are performed. And certainly, it should include the outcomes.

The medical record and the documentation also assist physicians and other healthcare professionals in evaluating and planning the patient’s immediate treatment and monitoring their healthcare over time, whether it’s an episodic issue or you only see the patient once or if it’s a long-term arrangement where a patient would see their provider.

Michael: So let’s get into the detail here. Can you describe for us some of the essential components?

Cyndy: I think the best place to start with the essentials would be what a payer would require. In order to appropriately bill a claim, and then ultimately adjudicate the claim, the payers are going to require reasonable documentation that the services are consistent with the type of insurance coverage that has been provided.

And what it will validate is the site of service, meaning where that service was actually performed (a hospital setting, an in-patient setting, an outpatient setting, a physician’s office). It will also validate the medical necessity and the appropriateness of the diagnostic and/or the therapeutic services that have been provided.

And in addition, the documentation is going to validate that the services that were in fact provided were accurately reported.

Michael: Legibility, is that a real principle in this age of technology?

Cyndy:  Sadly enough, yes. Certainly over time, with the development of electronic medical records, we certainly are seeing that legibility issue improved. However, legibility as it stands is imperative, that the services that are provided are documented and you’re able to read them clearly. They must be complete and they must be legible. And sadly, that continues to be a challenge.

Michael: Documenting, evaluation and management is a function with some very key elements. Can we discuss those?

Cyndy: Certainly. To determine the appropriate level of service for a patient’s visit, it’s necessary first to determine whether the patient is new or already established.

The physician would then use the presenting illness as a guiding factor for their clinical judgment about the patient’s condition to determine the extent of what services need to be performed. And the key elements include a history, an examination, and medical decision making.

The key elements of service and documentation of an encounter dominated by counseling or any coordination would be an off-shoot of the medical decision making.

Michael: Let’s start with history. Can you describe some of those key elements for us?

Cyndy: Certainly! When we talk about the types of history, there are four areas that we would focus on. The history related to a problem, specifically problem-focused. A patient, that kid comes in and complains of elbow pain, if you will.

The elements that would be required in order to meet those requirements would have to include the chief complaint, what brought the patient to you, and a brief overview of how this event happened, how did you, in fact, injure your elbow.

If it was a more complex complaint or history, it would be referred to as the expanded problem-focused. In which case you would then again, need a chief complaint. You would provide a brief history of the present illness or injury. You would also do a review of systems that was specific to the problem. If I was having asthma concerns, it would require a review just perhaps of the respiratory system, not a complete review of systems.

A more detailed type of history would require information on the chief complaint (why the patient came for evaluation); the history of the present illness (what may have caused it and what makes it linger); a review of systems (which would be more extensive and involve more than one body system); and then, in addition, it would add any past family or social history. It’s a bigger picture if you will. The more complicated the problem, the more information you would need to be able to come up with a diagnosis.

For those that would require a comprehensive history, this would be a patient presented that would be more sick. It would require the chief complaint, the history of the illness, a complete review of systems (top to bottom, if you will), as well as a complete social, family and past medical history. What you’re looking for when you have an ill patient is all of the data points that you possibly can obtain so that you can use that information to develop a comprehensive plan of care.

The extent of the information that you gather is dependent on your clinical judgment and the nature. Again, the more ill the patient, the more data you’re going to look at.

To talk a little bit about the chief complaint is important because the chief complaint is a concise statement. Generally, it is stated in the patient’s own words and it describes what brought them to their provider. It’s going to describe the symptoms, a problem and a condition. And it may be about an upset stomach, fatigue, things like that. It is a statement by the patient as to what brought them here.

When we talk about evaluating for the “what is going on” as far as the history of the present illness, what this will be is a description, generally chronological, of how this developed, how did this happen, when did it happen from the first sign of symptoms up until their visit to you today. And certainly, the elements will include location (“I have pain in my left elbow.”), quality (“It’s a burning pain.”) and the severity on a scale of one to 10.

And if you think about all these questions that are feeding into this history of present illness, you are literally painting a picture of what this looks like. Asking about the duration, “I’ve had this for three months. I’ve had it for three hours. I’ve had it for three days.”

Different descriptors may lead you to a different decision. The timing, (“Does it come or go? Is it constant?”), modifying factors (“My elbow hurts when I use it. It doesn’t bother me when I’m at rest”), and any associated sign (“In addition to a left elbow pain, I also have numbness and tingling down the arm.”)

Now, certainly based on what history you are looking at, there are two ways to get to the present illness. Certainly, if it’s an isolated issue, it could be a brief history or it could be extended. Again, the more complicated, the more ill the patient, the more information you are looking for.

In addition, we are talking a little bit about the review of system. Again, for someone coming in with an elbow pain, it would be limited to the extremities. If someone is coming in with additional signs and symptoms that they’re more ill, you are certainly going to do a more involved review of systems.

So certainly, when someone complains of elbow pain, you do not need to document a head-to-toe assessment review. You are focusing specifically and that would dictate the type of coding selection that you’re going to be doing and the type of reimbursement you are going to receive.

Michael: So, can we next move on to examination? Can you tell us about some key elements related to that?

Cyndy: Certainly! The examination will occur after the provider obtains the chief complaint and the history as to what brings the patient, whether it’s follow up or something else. And the examination will be dictated based on what the patient’s complaint is. So certainly, the exam could involve several organs, several areas or a single organ system.

In the case of our patient with the elbow pain, we would be focusing predominantly on examining the elbow and the arm to determine the extent. This will also feed and enable the provider to base his judgment on what these findings are.  Again, a patient with one specific concern does not necessarily require a complete head-to-toe exam.

A head-to-toe examination is just that, depending on the severity of symptoms that are presented. A comprehensive exam would require a head-to-toe including ears, eyes, nose, abdomen and extremities. All of these exams would have to be performed as well as documented.

And I think it’s important that we understand that performing the actual history-taking or the exact exam itself, the assessment, is only one component.

The second piece of it, in order to develop an accurate claim for billing and reimbursement would be that all of that information that was gathered must then be documented. And that’s how you feed into the “How do I select the code? It’s based on this documentation.” So if the documentation is there, it would support the code that’s been selected.

In a general multi-system exam, which would involve multiple assessments, each body area or organ would contain two or more of the following. So you would need to then include: the head and the neck, the abdomen, the respiratory, things like that. Again, the more ill the patient, the more complex the exam.

Michael: So all of these elements then flow into medical decision making, right?

Cyndy: Correct. Medical decision making refers to the complexity of developing and ascertaining a diagnosis and/or selecting a plan of care or management option for this specific patient.

It is determined by considering a few factors. One would be the number of possible diagnoses or the number of treatment options that might be considered. Going back to our patient with the injured elbow, again, the possible diagnoses would be strains, sprain or fracture, it’s limited because it is one specific area.

Also taken into account are the amount and/or the complexity of additional information – medical records, additional diagnostics, any other type of testing or information that must be obtained then analyzed after it’s reviewed. If you think about a patient that has multiple co-morbidities who sees various specialists for their different issues, it may require gathering all of those records from the specialists, reviewing and analyzing that to develop a comprehensive plan of care for this patient.

To qualify for a specific type of decision making, there are some elements that must be considered and this is what is called the type of the decision making. An example would be a straightforward decision. “You’ve injured your elbow.” It’s very straightforward, “This is what we need to do.” It may be a low complexity. Maybe you have an upper respiratory infection, no other issues going on.

You may also have a moderate complexity element, if you will. It is a more challenging diagnosis. There are multiple systems. There might be multiple co-morbidities.

And then lastly, there’s a high complexity.

I think just by listing them, you can understand the amount of data that is required to reach your diagnosis or your plan of care as well as “how complexities” to review and analyze them. So, these all go into establishing the final diagnosis or final treatment plan.

Michael: Are there any other additional elements that we should be looking out for, Cyndy?

Cyndy: I think the additional elements are probably based on the different types of diagnostics, the different types of testing that would need to be ordered or reviewed, and the indications of the amount or complexity of the data.

An example would be the decision to obtain the old medical records or old history, again, from other specialists, looking at and analyzing perhaps, test results that either contradict or are different than what you originally thought or you originally obtained. Because then, you would have to basically interpret the test a little bit differently.

So, you may have your lab results, but there were past lab results that were a little bit different. It’s going to require some additional thought, if you will, and analysis to come up with a plan of care for this patient.

Another additional amount of complexity is the physician who actually ordered the test and reviews the results and the treatment may be different from the physician who actually interpreted it. You may have a conflict on information. Again, you would require a little bit more data. You’d require some additional analysis in order to reach that conclusion.

I think another area would be the amount of information when you’re documenting. When you think about the complexity, it would be to look at a diagnostic service, “Is order plan scheduled and performed at the time of the evaluation?” These should be all captured as part of your evaluation in management and documented into the medical record.

Any review of these findings should as well be documented. If you’re looking at lab results, a simple notation such as “white count elevated,” or “chest x-ray negative or unremarkable,” is acceptable documentation. The key here is that you’re including it. You don’t want to omit any significant data or factors.

A decision to obtain old records, or any other, is another source that you want to be sure that you obtained the information. But once it’s obtained, you want to make sure that you’re documenting that you did receive it and you did have the opportunity to review it and how that leads you into your diagnosis or your plan of care.

Some risks of complications and morbidity, you want to certainly include those risks into your categories – the presenting problems, how you are incorporating that into your treatment options, assessing the risk related to the disease process and what you anticipate between the present encounter and what may occur for a future encounter.

And again, the risks of complications, morbidity or mortality would be ranked and described as minimal, low, moderate or high.

So certainly, if based on a patient’s co-morbidity and underlying diseases, they have a high risk of developing an infection or additional co-morbid processes. You want to make sure that you analyze that information, but document it, “high risk for return due to…”

All of these things are being performed by the providers. I think where there is often a gap is it is being done and it is being processed mentally by the providers, it is not always captured in their documentation.

It is not that the patients are not sick or that the patients do not require certain treatments. It is a matter of, “Did you paint the picture of exactly what you’re thinking?” And I think that is significant as far as this documentation and how you feed into each of these – the history, the exam, and the decision making.

Michael: So Cyndy, my final question for you today, how do all of these elements correspond to accurate coding and compliance?

Cyndy: I think to relate it back to another podcast that we did, when you think about presenting your claims for processing, for adjudication, you want to make sure that anything that you’re presenting is accurate and it’s timely. You certainly don’t want to be going down the road of a false claim.

And remember, two common areas related to physician coding has to do with presenting or causing to be presented a false claim based on lack of documentation or any other issue. In addition, also, making using or causing to be used a false record because of an omission, because of something you forgot to enter.

Again, you may have performed a very complex assessment and you may have put in a lot of data analysis review to come up with a complex diagnosis and treatment plan. But if you are not documenting as we mentioned in the beginning, if you didn’t document it, then you didn’t do it, therefore you will not be paid for it.

Michael: Cyndy, thanks for all of that great information today and for spending some time with us.

Cyndy: Thank you, Mike.

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