2016 Behavioral Medicine Resident Chart Documentation. Laura Sullivan, MSW, CPC Compliance Auditor

Transcription

1 2016 Behavioral Medicine Resident Chart Documentation Laura Sullivan, MSW, CPC Compliance Auditor 1

2 Legal Stuff The information provided here is being provided by a nonlawyer and should not be construed as legal advice. Each provider is ultimately responsible for bills submitted under their NPI numbers. For specific legal guidance on any billing issue, consult with your Medicare Carrier and/or your health care attorney. The information contained in this presentation should not be copied or distributed without the permission of WVUPC or Laura Sullivan, CPC. 2

3 General Documentation Principles for All Types of Services The medical record should be complete and legible The documentation of each encounter should include: The reason for the encounter and relevant history, physical exam findings and prior diagnostic test results An assessment, clinical impression or diagnosis A plan for care The date and legible signature of the physician If not documented, the rationale for ordering diagnostic or other services should be easily inferred 3

4 Why Good Documentation Matters? Provide specific and descriptive documentation Thorough documentation facilitates the rendition of high quality patient care for payors, the medical record is also used to provide documentation of the site of service, the medical necessity of the service, and that the service documented was the service billed and paid for. An appropriately documented medical record can reduce many of the hassles associated with claims processing and, if necessary, serve as a legal document to verify the care provided Good documentation is the key to correct coding of E/M services 4

5 Chief Complaint Each note must have a Chief Complaint (CC) Ask yourself WHY am I seeing this patient? Unacceptable CC: no problems or complaints Acceptable but not ideal CC: no new complaints or no further complaints 5

6 CC: Examples Office Examples CC: Annual physical CC: Pap & Pelvic CC: follow up for PNA CC: HTN & DM Hospital Examples CC: No changes still SOB CC: Pt has no complaints still following BP. CC: Sugar still elevated. The following was an actual inpatient chief complaint CC: No further episodes of breathing 6

7 History of Present Illness (HPI) Document at least 4 of the following Location Quality Severity Duration Timing Modifying factors Associated signs or symptoms Context 7

8 Past, Family & Social History (PFSH) One element of each should be noted: Example 1: Example 3: Past: No surgeries Past: Gallbladder removed 2008 Family: mother has DMII Family: no known problems Social: Married no children Social: Non Smoker Example 2: Example 4: PFSH: Patient poor historian, no family present to assist PFSH: Patient intubated and unresponsive unable to obtain Non-contributory is unacceptable for any PFSH components 8

9 Review of Systems (ROS) ROS is a review of SYMPTOMS not illnesses or conditions. HTN or DMII are not symptoms Constipation, headaches, sweating, difficulty sleeping, short of breath, arm pain, swelling in toe are just a few examples of an ROS 9

10 Review of Systems Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory GI GU Musculoskeletal Integumentary Neurological Psychological Endocrine Hem/Lymph Allergy/Immuno List at least 2 positives and then you can state all other systems negative 10

11 Unobtainable History If you are unable to obtain a history due to the patient s condition the following must be documented: - Medical reason (not on vent ) - sedated on vent - unable to speak due to.. - That the family wasn t present - If partial history is obtain from family members that should be documented clearly - Previous records - Previous records should be reviewed for history, if not available chart should be noted unable to obtain history, pt is sedated on vent, no family present, no previous records available 11

12 Examination Areas Constitutional (vitals etc) Eyes Ears, nose, throat, mouth CV Resp GI GU Musculoskeletal Skin Neurological Psychological Hem/lymph/Immuno Must document at least 8 areas for a complete exam 12

13 Medications High risk medications should be clearly documented. (IV Insulin, Coumadin, Lithium etc) See Meds list is acceptable (assuming there is a meds listing) Continue home meds is NOT acceptable Long term use of any medication should be in the diagnosis 13

14 Psychiatric Examination 3 of the 7 vitals General appearance of client Assessment of muscle strength and tone Exam of gait and station Description of speech including, rate, volume, articulation, coherence and spontaneity Description of thought processes including, rate of thoughts, content of thoughts( logical vs illogical, tangential) abstract reasoning and computation Description of associations (loose, tangential circumstantial, intact) Description of abnormal or psychotic thoughts including hallucinations, delusions, preoccupation with violence, homicidal or suicidal ideation and obsessions Description of the patient s judgment (concerning everyday activities and social situations) and insight (concerning psychiatric condition) Orientation to time and place Recent and remote memory Attention span and concentration Language (naming objects, repeating phrases) Fund of knowledge (awareness of current events, past history and vocabulary) Mood and affect (depression, anxiety, agitation, hypomania, lability) Problem focused 1-5 bullets Expanded problem focused 6 Detailed 9 Comprehensive all elements (required for all H&P s and Consults) 14

15 Assessment & Plan 1. Documentation should include the condition or symptoms being treated 2. Labs & X-rays reviewed 3. Tests ordered 4. Consulting physicians requested 5. Medications ordered or prescribed 6. Risks and management options 7. Reasons for all of the above 15

16 Specificity of diagnosis Clear and descriptive documentation - Severity: worsening, improving, etc. - Stable (stable on vent is NOT acceptable) - Chronic, Acute, Acute on Chronic - Laterality: right, left, upper right, etc. - Location: lobe of the lung (see diagram 1), quad of the breast (see diagram 2) - Debridement of a wound (diagram 3) documentation is very specific - The medical necessity for all consults, procedures, & lab work must be clearly documented 16

17 Specificity of diagnosis - Dependence vs. Abuse vs. Use - Associated conditions - Controlled (define how) - Uncontrolled (define why) - Outside factors, such as job, family or school stress or other issues - Onset of illness, or symptoms 17

18 Procedures and Surgery - Residents must indicate the teaching physicians presence and participation in the procedure or surgery. Note examples: Dr. X was present during the entire procedure Dr. X was present during the key and critical portion of the surgery **only if the attending was present** 18

19 Signature Sign each note legibly (no initials) Add pager number to signature Date each note clearly (time as necessary) Be proud of your degree and add MD or DO to your signature. You may have a stamp (not a signature stamp) with your printed name and pager number 19

20 Remember!! If it isn t documented it didn t happen 20

21 Compliance: It s Everyone s Concern Compliance with Federal and State health care laws and regulations is the responsibility of all of us! If you have a compliance related question, concern or complaint, we are here to help. Compliance Hotlines: (304) Toll Free (800) You may report compliance concerns anonymously if preferred. You may not be retaliated against for good faith reporting of such concern. WVUPC Compliance Policies on the web: 21

22 Contact Laura Sullivan, MSW, CPC Corporate Compliance Auditor/Educator work cell fax 22

23 Diagram 1 Lung 23

24 Diagram 2 Breast 24

25 Diagram 3 Debridement - Order and medical necessity documented by the physician - Tool used for debridement - Frequency of surgical debridement - Measurement of total devitalized tissue before and after debridement - Area and depth of devitalized tissue removed from wound (not just depth) - Blood loss and description of tissue removed - Evidence of progress of the wound's response to treatment must include - Current wound volume surface dimensions and depth - Presence or absence of signs of infection - Presence or absence of necrotic, devitalized and/or non viable tissue - Other material in the wound that is expected to inhibit healing or promoting tissue breakdown 25