Documentation Challenges

Transcription

1 Agenda History Taking Eye Codes Diagnostic testing guidelines Kirk A. Mack, COMT, COE, CPC, CPMA Senior Consultant Corcoran Consulting Group 2 2 Coding is a Team Sport Involves everyone in the office Requires good communication Relies on quality charting Based on medical necessity Teamwork enhances compliance Cooperation improves morale Problems Introduced by EHRs Data always looks real even if it isn t Charting by default can hide medical problems Copy forward can copy legacy data not relevant to today Quantity of information increases and can produce information overload 4 4 EHR Documentation Issues Garbage in... Garbage out Documentation and Correct Coding General Principles The medical record should be complete and legible Each patient encounter should include: Reason for encounter and relevant history Physical examination findings Prior diagnostic test results Assessment, clinical impression or diagnosis Date and legible identity of the observer Source: Evaluation and Management Services Documentation Guidelines AMA and CMS

2 Chief Complaint In the patient s own words Identifies the reason for visit Along with primary Dx, CC helps determine who is responsible for payment Medicare Coverage Policy... coverage is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient s condition. When a beneficiary goes to an ophthalmologist with a complaint or symptom of an eye disease or injury, the ophthalmologist s services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to ophthalmologist for an eye examination with no specific complaint, the expenses are not covered even if the exam discovered a pathologic condition. Source: MCM 2320 Medicare Coverage Policy What does that mean? No complaint no reimbursement Problematic Chief Complaint Chief complaint reads: Blank no notations Here for complete eye exam Routine eye exam Annual check-up Want to check the health of my eyes I had cataract surgery and I ve never seen better You sent me a recall card My wife made the appointment for me Problematic Chief Complaints EHR Examples Decreased vision in both ears Patient complains, no complaints Diabetes in both eyes 4 years Borderline diabetes, it affects vision, not affected IOL eval in both eyes for one year Chief Complaint The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words. Documentation guidance: The medical record should clearly reflect the chief complaint. Source: 1997 E/M Documentation Guidelines (DG)

3 Chart Documentation Chief Complaint Illustrative Chart Note In the patient s own words Justifies your charge Identifies the reason for visit Blurred vision Difficulty seeing signs while driving Uncontrolled DM R/O DR 3 month POAG check as directed Symptom Symptom / ADL Systemic disease Chronic disease CC: Patient states He said to come back today. No changes in vision Code: Dx: H53.8 (Blurry Vision) Illustrative Chart Note Illustrative Chart Note CC: Patient states He said to come back today to check my cataract. No changes in vision Provide chronic Condition as CC CC: Doing wonderful HPI: Cataracts Code: Dx: H25.13 (NSC) Code: Dx: H25.13 (Nuclear cataracts) Illustrative Chart Note Better Chart Note CC: Doing Wonderful CC is not helpful CC: 6 mo cataract check per Dr. A HPI: Cataracts HPI is too abbreviated. HPI: Cataracts OU 1 x 2 yrs 2, VA fluctuates 3 for last 6 mos, current glasses no help, night 4, difficulty with reading 5 Code: Dx: H25.13 (Nuclear cataracts) Code: Dx: H25.13 (Nuclear cataracts)

4 CC: Pt here for cornea check Dx: Early K-cone, no progression Tx: Continue current CL, RTO 6 mo or sooner if VA Office Visit Cornea Check Hx: No changes Exam: CE, DFE Poor CC does not support visit Claim = Not a covered service Office Visit Cornea Check CC: 6mo K-cone check. vision fluctuating OU; gradually worse x 2 mo; glasses no help Dx: Early K-cone, no progression Tx: Continue current CL, RTO 6 mo or sooner if VA Claim = Covered visit Hx: Good health, NKDA Exam: CE, DFE Patient Pay Office Visit Diabetic Retinopathy Office Visit Diabetic Retinopathy CC: Pt here for annual retinal exam Hx: No changes CC: Pt here for annual retinal exam Hx: No changes Dx: BDR OU Exam: CE, DFE Dx: BDR OU Exam: CE, DFE Tx: Return as needed to PCP to check diabetes; RTO 12 mo or sooner if VA Tx: Return as needed to PCP to check diabetes; RTO 12 mo or sooner if VA Covered or Not covered? Not covered - Patient Pay Office Visit Diabetic Retinopathy CC: 12 mo recheck DM, vision fluctuating OU; worse AM x 2wks; glasses no help, BS not controlled Dx: BDR OU Tx: Return to PCP to check BS; RTO 6-9 mo or sooner if VA Covered visit Hx: IDDM x 6yrs; Insulin, NKDA Exam: CE, DFE E/M Key Components History HPI ROS Review of Systems PFSH Personal, Family, Social History Examination Decision Making Diagnoses diagnoses and management options Data tests, additional information Risk gravity of the disease(s)

5 History The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. History (HPI) Location Quality Severity Modifying factors Timing Context Duration Associated signs and symptoms Source: 1997 E/M Documentation Guidelines (DG) History Cat eval OU; c/o RT eye decreased VA, blurred vision OD, trouble with street signs. How many HPI elements are there? History Cat eval OU; c/o RT eye decreased VA, blurred vision OD, trouble with street signs. How many HPI elements are there? Location RT/OU Quality decrease, blurred VA Context trouble with street signs History Cat eval OU; c/o RT eye decreased VA, blurred vision OD, trouble with street signs. How many HPI elements are there? Location RT/OU Quality decrease, blurred VA Context trouble with street signs What other HPI elements could be documented? History Cat eval OU; c/o RT eye decreased VA, blurred vision OD, trouble with street signs. How many HPI elements are there? Location RT/OU Quality decrease, blurred VA Context trouble with street signs What other HPI elements could be documented? Duration How long? Severity How blurry is the VA? Very

6 What s correct? Your chart note for the HPI reads: Itchy, scratchy, burning, stinging eyes How many elements are there? What s correct? Your chart note for the HPI reads: Itchy, scratchy, burning, stinging eyes 2 (itchy, scratchy, burning, stinging are in 1 category) Location = eyes Quality = itchy, scratchy, etc. THE FINAL PRODUCT: HPI EMR hic-ups 58 year old male presented for evaluation of Diabetes for 3 months. It affects vision not affected. The problem is constant. It occurs primarily when driving at night. Quality is fixed. Patient described the following signs and symptoms: none currently to report. (HPI) Challenges Expands on the CC Develops the CC Provides value Some EMR create a narrative or paragraph Read the final product it must make sense Not our best effort. Who did it? The HPI must be performed by the physician in order to be counted for E/M coding (992xx) Chart must reflect the physician s work In physician s handwriting Dictated to a scribe but physician appends attestation EMR requires attestation History Challenges Review the history before finalizing Is it accurate? Does it make sense? Does it support medical necessity? Source: CMS

7 Agenda History Taking Eye Codes Diagnostic testing guidelines E/M Value of Eye Exam New Patients Non-facility Rate Eye Code Non-facility Rate Source: 2018 MPFS, National (participating providers) Value of Eye Exam Established Patients E/M vs Eye Codes E/M Non-facility Rate Eye Code Non-facility Rate E/M Codes Complicated 2+ pages needed 5 levels of service Wide range Universal Used 30% Eye Codes Simple definitions Easy documentation 2 levels of service Higher reimbursement Not universal Used 70% Source: 2018 MPFS, National (participating providers) Office Visits Medicare Utilization Patterns Optometry (41) CPT New Patients λ CPT Established Patients λ Level 5 E/M <1% Level 5 E/M <1% Level 4 E/M 11% Level 4 E/M 58%* Comprehensive Eye Level 3 E/M 79%* Level 3 E/M 36%* Comprehensive Eye Intermediate Eye Level 2 E/M 9%* Level 2 E/M 5% Intermediate Eye Level 1 E/M <1% Level 1 E/M <1% Office Visits Medicare Utilization Patterns Optometry (41) CPT New Patients Λ CPT Established λ Patients Level 3 E/M 10% Level 4 E/M 10% Comp Eye Exam 69% Comp Eye Exam 48% Level 2 E/M 2% Level 3 E/M 19% Intermediate Eye 7% Intermediate Eye 17% *Combined utilization of E/M and eye codes Source: CMS data 2016, 41 - Optometry Source: CMS data 2016, 41 - Optometry

8 Eye Exams You sent in a claim using CPT code What entry is NOT required in the medical record? a) Extraocular muscles b) Exam of external adnexa/lids c) Cornea d) Treatment program e) All are required Eye Exams You sent in a claim using CPT code What entry is NOT required in the medical record? c) Cornea Comprehensive Eye Exam 92004, Required Elements History General medical observations Gross visual fields (confrontation) Basic sensorimotor exam External adnexa Ophthalmoscopy Dilation not required (some carriers disagree) Comprehensive Eye Exam 92004, Required Elements Elements not specifically mentioned: Measure visual acuity IOP Biomicroscopy Color vision testing Patient orients to person, place, time Comprehensive Eye Exam 92004, Required Elements Initiate or continue diagnostic and treatment program (not specifically designated elements) Treatment program: Medication Lenses Minor procedure Schedule major surgery Refer for treatment Counsel on risks Diagnostic(s): Refraction Perimetry Imaging Lab work X-ray, MRI, CT Schirmer s tear test Comprehensive Eye Exam 92004, Evaluate complete visual system Not medically necessary on every visit (EMR) Auto-completion is controversial, troublesome Typically, 1-2 times per year (no specific limits)

9 Comprehensive Eye Exam (920x4) Key Points Flexible history taking, appropriate for each case Fewer elements than E/M comprehensive service Independent of medical decision making Requires diagnostic and treatment program Dilation not absolutely required Illustrative Office Visit Diabetic Eye Exam CC: Recent Dx of diabetes, desires eye exam Dx: Diabetes w/out ocular involvement Tx: Monitor BS, weight, diet, see PCP; update glasses RX Hx: DM Exam: VA, IOP, SLE, DFE; Test: Refraction Code: & Dx: E11.9 (Diabetes) Illustrative Office Visit Diabetic Eye Exam Illustrative Office Visit Diabetic Eye Exam CC: Recent Dx of diabetes, desires eye exam Dx: Diabetes w/out ocular involvement Tx: Monitor BS, weight, diet, see PCP; update glasses RX Code: & Dx: E11.9 (Diabetes) Hx: DM Exam: VA, IOP, SLE, DFE; Test: Refraction Exam missing CVF, EOM CC: Recent Dx of diabetes, desires eye exam Dx: Diabetes w/out ocular involvement Tx: Monitor BS, weight, diet, see PCP; update glasses RX Code: & Dx: E11.9 (Diabetes) Hx: DM Exam: CE, DFE Test: Refraction Eye Exams You sent in a claim using CPT code What entry is NOT required in the medical record? a) Examination of the adnexa/lids b) Gross visual fields c) A diagnosis that describes a new condition or a new problem d) General medical observations Eye Exams You sent in a claim using CPT code What entry is NOT required in the medical record? b) Gross visual fields

10 Intermediate Eye Exam 92002, Required Elements History General medical observations External ocular adnexa Intermediate Eye Exam 92002, Initiate or continue diagnostic procedures, as indicated, and treatment program Other exam elements as desired or needed Source: CPT Source: CPT Intermediate Eye Exam 92002, New condition (or) Existing condition with new problem Intermediate Eye Exam 92002, Not suitable for every follow-up visit More frequent than CEE, but no specific limit New condition: Acute disease Injury New Dx New symptoms New problem: Disease progression Added co-morbidity Exacerbation Re-occurrence (episode) Failed tx, substitute tx Source: CPT Source: CPT Illustrative Office Visit Corneal Abrasion Illustrative Office Visit Corneal Abrasion CC: Right eye, red, sore, difficulty keeping it open Dx: Corneal abrasion Tx: Antibiotic gtts OD qid x 1 week; RTO 1 week Hx: Healthy Exam: VA, SLE CC: Right eye, red, sore, difficulty keeping it open Dx: Corneal abrasion Tx: Antibiotic gtts OD qid x 1 week; RTO 1 week Hx: Healthy Exam: VA, SLE New Problem Code: Dx: S05.01XA (corneal abrasion) Code: Dx: S05.01XA (corneal abrasion)

11 Office Visit Established Uncontrolled Glaucoma Office Visit Established Controlled Glaucoma CC: IOP as directed for COAG OU Dx: COAG unstable OU Tx: New anti-glaucoma med Hx: Healthy, compliant with meds Exam: VA, SLE; IOP exceeds target pressure Tests: HRT II OU CC: IOP as directed for COAG OU Dx: COAG stable OU Tx: Continue meds; RTO 4 mos for CE, DFE Hx: Healthy, compliant with meds Exam: VA, SLE; IOP meets target pressure CPT = CPT = Summary Eye codes are not universal; some E/M codes are needed Guidelines for E/M coding are long and involved they are not simple to learn or use Proper documentation to support the selected code is critical The gravity of the disease is the ultimate criteria for the level of service Agenda History Taking Eye Codes Diagnostic testing guidelines Outline 1. Supervision 2. Interpretation and Report 3. Case studies Common Ophthalmic Tests Medicare Utilization Patterns (41 - Optometry) CPT Procedure λ CPT Procedure Λ Fundus Photo 14% Tear Osmolarity 3% 9213x Scanning Laser (50/50) 14% Gonioscopy 2% 9208x Perimetry 9% Pachymetry 2% 9222x Ext Ophthalmoscopy 4% External Photo 1% Frequency is per 100 office visits (%) on Medicare beneficiaries Source: CMS data (2016), 41 Optometry

12 Supervision General supervision Physician reviews notes Direct supervision Physician immediately available Personal supervision Physician in the room General Supervision Perimetry Fundus photography External ocular photography Scanning computerized ophthalmic diagnostic imaging (OCT) Orthoptics Extended color vision testing Dark adaptation exam Visual evoked potential (VEP) done by certified tech A-scan biometry Specular endothelial microscopy and cell count Pachymetry Source: CMS MPFS Direct Supervision Fluorescein angiography ICG angiography A-scans (tumors) Immersion B-scan, high resolution biomicroscopy Contact B-scan Visual evoked potential (VEP) done by non-certified tech Electro-oculography (EOG) Electroretinography (ERG) Source: CMS MPFS Chart Documentation Physician s order (Medical necessity) Date performed Technician s initials Reliability of the test Patient understanding, cooperation Test findings Assessment, diagnosis Impact on treatment, prognosis Physician s signature Medicare Test Policy 42 CFR Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Diagnostic Test Order Tests are ordered by the physician for a medically appropriate reason, generally after the eye exam Technicians cannot order tests Order may be scribed by staff on physician s direction VF for COAG next visit per Dr. Smith Standing orders are not reimbursed

13 Testing During Postop Period Services not included in the global surgery package: Diagnostic tests and procedures, including diagnostic radiological procedures Examples: Testing unrelated to the prior surgery Testing to evaluate an unfortunate outcome Testing to prepare for another surgery Not covered: testing to confirm the expected outcome Two months after a cataract surgery, during the comanagement period, the physician orders a visual field to follow the patient s glaucoma. The tests are not part of the global package and are billable. a) True b) False Testing Following Surgery Source: MCPM, Chapter 12, 40.1B Testing Following Surgery Two months after a cataract surgery, during the comanagement period, the physician orders a visual field to follow the patient s glaucoma. The tests are not part of the global package and are billable. Chart Documentation.with interpretation and report a) True Interpretation & Report Carriers generally distinguish between an interpretation and report of an x-ray or an EKG procedure and a review of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete written report similar to that which would be prepared by a specialist in the field does not meet the conditions for separate payment of the service. This is because the review is already included in the E/M payment. Interpretation & Report For example, a notation in the medical records saying fx tibia or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An interpretation and report should address the findings, relevant clinical issues, and comparative data (when available). Source: CMS MCPM Chapter 13, 100 Source: CMS MCPM Chapter 13, 100

14 Test Interpretation What does it show? Increased blind spot What does it mean? Progression of glaucoma What are you going to do about it? Add a medication Visual Field Interpretation Plan: Threshold perimetry to re-evaluate POAG October 10, 2012 Mary Smith, COA 1 false positive Good patient cooperation Arcuate scotoma, OU POAG, shows progression since last visit Add another anti-glaucoma medication I. C. Better, O.D. Illustrative Test Interpretation TEST: Optic nerve OCT Illustrative Test Interpretation TEST: Optic nerve OCT Interpretation: Normal Dx: POAG What s wrong? Interpretation: Normal Dx: POAG Why was test done? Observations? Data? Illustrative Test Interpretation TEST: Optic nerve OCT Interpretation: OCT for POAG. No retinal nerve fiber layer loss or changes at this time. No treatment indicated. Dx: POAG Improved Interpretation Test Interpretation Create a template/form for diagnostic tests Paper or EMR require the same information Follow same approach for dictation Separate interpretation for each test Separate interpretation for each eye for unilateral tests 92225, 92226

15 Summary CC determines coverage Understand the requirements for the eye codes Test orders and interpretations More help For additional assistance or confidential consultation, please contact us at: Phone: (800) Website: Mobile App: Corcoran 24/7