BC ADVANTAGE 2014 AUDIO EVENT: E&M AUDITING. Presented by: Darlene Boschert, RHIA, CPC, CPC-H, CPC-I

Transcription

1 BC ADVANTAGE 2014 AUDIO EVENT: E&M AUDITING Presented by: Darlene Boschert, RHIA, CPC, CPC-H, CPC-I

2 MATERIALS NEEDED SOAP note: Abdominal Pain 4 copies: audit sheets including- History 97 General Multisystem Examination 95 Examination Medical Decision Making 2

3 CMS GUIDELINES Presentation based on CMS guidelines Your MAC provider guidelines may vary Basics only 3

4 4

5 COMPONENTS E/M services are scored based on the documentation of necessary components History - 1 st component Examination - 2 nd component Medical Decision Making (MDM) 3 rd component Contributing factors Counseling, coordination of care, nature of presenting problem, and time 5

6 HISTORY History of the medical record documentation should include four areas: Chief Complaint History of Present Illness Review of Systems Past, Family and Social History 6

7 CHIEF COMPLAINT Per CMS Guidelines the medical record should clearly reflect the chief complaint Concise statement that describes the problem/condition for the patient encounter Identifies the medical necessity of the service 7

8 HISTORY - HPI History of Present Illness - HPI Location Severity Timing Modifying Factors Quality Duration Context Associated Signs and Symptoms 8

9 HISTORY - HPI Brief History 1-3 Elements Extended History 4 or more elements for 95/97 guidelines 3 or more chronic/inactive for 97 guidelines Location Severity Timing Modifying Factors Quality Context Duration Associated Signs & Symptom Brief Extended 1-3 Elements 4 > elements or status of 3> chronic or inactive cond. 3> chronic or inactive cond. 9

10 SOAP ABDOMINAL PAIN Patient is a 52-yr-old established female patient who comes in complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends. 10

11 HISTORY - HPI We have 6 elements of the HPI Timing - intermittent Location right lower quadrant pain Associated signs and symptoms diarrhea Duration x one week Modifying Factors tried Imodium Context or Severity wakes her at night Extended HPI Location Severity Timing Modifying Factors Quality Context Duration Associated Signs & Symptom Brief 1-3 Elements Extended 4> elements or status of 3> chronic or inactive cond. 11

12 HISTORY - ROS Review of Systems ROS Constitutional ENT Eyes Cardiovascular GI GU Respiratory Musculoskeletal Psychiatric Integumentary Endocrine Hem/Lymph Allergy/Immunology Neurologic 12

13 HISTORY - ROS Unremarkable and/or non-contributory are not acceptable forms of review of systems documentation Specifics of positive findings need to be documented, not necessary for negative findings Systems reviewed must meet medical necessity All others negative "remainder of the 10 review of systems were reviewed and are all negative". No double dipping 13

14 HISTORY - ROS None Pertinent to 1 system Extended 2-9 systems Complete 10 systems or all others negative Constitutional ENT Eyes Pertinent Cardiovascular To 1 system Respiratory GI GU Neurology Musculoskeletal Psychiatric Integumentary Endocrine Hem/Lymph Allergy/Immunology All Others Negative None Extended 2-9 Systems Complete 10 systems or all neg 14

15 SOAP: ABDOMINAL PAIN Patient is a 52-yr-old established female patient comes in complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends. 15

16 HISTORY ROS We have 5 Review of Systems Constitutional: positive fatigue, neg. -chills, sweats GI: positive vomiting, neg. - blood in stool Respiratory: neg. shortness of breath Cardiovascular: neg. chest pain GU: neg. urinary problems Extended ROS Constitutional ENT Eyes Cardiovascular Respiratory GI GU Neurology Musculoskeletal Psychiatric Integumentary neg. Endocrine Hem/Lymph Allergy/Immunology All Others Negative None Pertinent: 1 systems Extended: 2-9 systems Complete: 10 Systems or all 16

17 HISTORY - PFSH Past Medical, Family, Social History PFSH Past History Current medications, past surgeries, past illnesses Family History Family; i.e., parents, siblings, children, aunts, uncles, grandparents Social History Smoking, alcohol intake, marital status, sexual history, employment status, educational information 17

18 HISTORY - PFSH Established or New Patient How many histories are documented? Past Medical History Family History Social History Past Medical History Family History Social History Established 1 2 or 3 Patient None None History History Area Area New Patient None None 1 or 2 3 History History Areas Areas 18

19 SOAP: ABDOMINAL PAIN Patient is a 52-yr-old established female patient who comes in complaining of intermittent episodes of right lower quadrant pain and diarrhea x one week. She has had a couple of episodes of vomiting. She has tried Imodium, but has found no relief. The pain does wake her occasionally at night and complains of fatigue. She denies blood in the stool, chills, or sweats. She has no shortness of breath, chest pain or urinary problems. She has a history of diverticulitis and is due for a colonoscopy. The patient is a non-smoker and consumes approximately 2 beers on the weekends. 19

20 HISTORY - PFSH Established patient We have two histories Past Medical History - history of diverticulitis Social History alcohol and non-smoker 20

21 UNOBTAINABLE HISTORY 21

22 LET S PUT HISTORY TOGETHER HPI History of Present Illness 1 Chronic Conditions 2 Chronic cond 3 Chronic Cond Brief Extended Location Severity Timing Modifying Factors Elements Quality Duration Context Associated Signs & Symp Elements or 3 chronic conditions. ROS Review of Systems Constitutional ENT Eyes Cardiovascular GI None Pert Extended Complete GU Respiratory Neurology Musculoskeletal to Systems 10 Systems or Psychiatric Integumentary Endocrine Hem/Lymph System all negative Allergy/Immunology All Others Negative PFSH - PAST, FAMILY, SOCIAL HISTORY EST PT. Past Medical History Family History Social History None None 1 History 2-3 History NEW PT Past Medical History Family History Social History None None 1-2 History 3 History Level of history is determined by the column that is Prob Exp Prob Detailed Comp 22 marked farthest to the left Focused Focused

23 SECOND COMPONENT: EXAMINATION An examination based on either the 1995 or 1997 documentation guidelines examinations are based on the organ systems and body areas examinations are based on bullets outlined through specific system examinations 23

24 EXAMINATION Examination is the hands on examination performed by the provider Negative or normal meet documentation guidelines If abnormal reason it is abnormal must be documented 24

25 97 EXAMINATION GENERAL MULTISYSTEM Constitutional Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff) General appearance of patient e.g. development, nutrition, body, habitus, deformities, attention to grooming EYES Inspection of conjunctivae and lids Examination of pupils and irises e.g. reaction to light and accommodation, size, symmetry Ophthalmoscopic examination of optic discs e.g. size, C/D ratio, appearance and posterior segments e.g. vessel changes, exudates, hemorrhages 25

26 97 EXAMINATION GENERAL MULTISYSTEM Ears, Nose, Mouth, &Throat External inspection of ears and nose Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing e.g. whispered voice, finger rub, tuning fork Inspection of nasal mucosa, septum and turbinates' Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck Examination of neck e.g. masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid e.g. enlargement, tenderness, mass 26

27 97 EXAMINATION GENERAL MULTISYSTEM Respiratory Assessment of respiratory effect e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement Percussion of chest e.g. dullness, flatness, hyper resonance Palpation of chest e.g. tactile fremitus Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs Cardiovascular Palpation of heart e.g. location, size, thrills Auscultation of heart with notation of abnormal sounds and murmurs Examination of: Carotid arteries e.g. pulse, amplitude, bruits Abdominal aorta e.g. size bruits Femoral arteries e.g. pulse, amplitude, bruits Pedal pulses e.g. pulse amplitude Extremities for edema and/or varicosities 27

28 97 EXAMINATION GENERAL MULTISYSTEM Chest (Breasts) Inspection of breasts e.g. symmetry, nipple discharge Palpation of breasts and axillae e.g. masses or lumps, tenderness Gastrointestinal Examination of abdomen with notation of (abdomen presence of masses or tenderness) Examination of liver and spleen Examination for presence or absence of hernia Examination when indicated of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated 28

29 97 EXAMINATION GENERAL MULTISYSTEM Genitourinary (Male) Examination of the Scrotal Contents, e.g. Hydrocele, spermatocele, tenderness of cord, testicular, mass Examination of the penis Digital rectal examination of prostate gland e.g. size symmetry, nodularity, tenderness Genitourinary (Female) Pelvic examination (with or without specimen collection for smears and cultures) including: Examination of external genitalia e.g. general appearance, hair distribution, lesions and vagina e.g. general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, rectocele Examination of the urethra e.g. masses, tenderness, scarring Examination of the bladder e.g. fullness, masses tenderness Cervix e.g. general appearance, lesions, discharge Uterus e.g. size, contour, position, mobility, tenderness, consistency, 29 descent or support Adnexa/parametria e.g. masses, tenderness, organomegaly, nodularity

30 97 EXAMINATION GENERAL MULTISYSTEM Lymphatics Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other Musculoskeletal Examination of gait and station Inspection and/or palpations of digits and nails e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck, 2) spine, ribs and pelvis, 3) right upper extremity 4) left upper extremity, 5) right lower extremity 6) left lower extremity. The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone e.g. flaccid cog wheel, spastic with 30 notation of any atrophy or abnormal movements

31 97 EXAMINATION GENERAL MULTISYSTEM Skin Inspection of skin and subcutaneous tissue e.g. rash, lesions, ulcers Palpation of skin and subcutaneous tissue e.g. induration, subcutaneous nodules, tightening Neurologic Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes e.g. Babinski Examination of sensation e.g. touch, pin, vibration, proprioception Psychiatric Description of patient's judgment and insight Brief assessment of mental status including: Orientation to time, place, and person Recent and remote memory Mood and affect e.g. depression, anxiety, agitation 31

32 SOAP ABDOMINAL PAIN 97 EXAM Vital signs: 120/85, WT 134, Temp The patient is comfortable appearing and in no apparent distress. Neck: Supple. Thyroid: Normal. Heart: regular rate and rhythm. No edema. Lungs: clear to auscultation. Abdomen is soft and non-tender with normal bowel sounds and no masses. No guarding or rebound. Skin clear, no rashes or ulcers. Urine dip is negative aside from trace of glucose. 32

33 97 EXAMINATION We have 9 bullets identified Constitutional Vitals, General Appearance Neck Thyroid Heart auscultation, edema Respiratory - auscultation GI abdomen Skin skin clear Problem Focused - One to five elements identified by a bullet Exp. Prob. Focused - At least six elements identified by a bullet Detailed - At least two elements identified by a bullet from each six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems Comprehensive - Performed all elements identified by a bullet and document at least two elements by a bullet from each of nine area/system 33

34 95 EXAMINATION Body Areas = BA BA BA BA BA BA BA BA BA BA BA Head, including the face Neck: neck (masses, symmetry, etc.), thyroid Chest (Breasts): inspection breast, palpation breast/axillae Abdomen Genitalia, groin, buttocks Back, including spine Left upper extremity Right upper extremity Left lower extremity Right lower extremity 34

35 95 EXAMINATION Organ Systems=OS OS OS OS OS OS OS Constitutional: 3 of the following: sit/stand BP, sup BP, temp, pulse rate, respiratory, height, weight or general appearance Eyes: Conjunctivae/lids, pupils/irises, optic discs Ears, Nose, Mouth/Throat : External exam ears/ nose, external auditory canal/tympanic membrane, hearing assessment, nasal mucosa/septum/turbinates', lips/teeth/gums, oropharynx Respiratory: Respiratory effort, chest percussion, chest palpation, auscultation of lungs Cardiovascular :Palpation heart, auscultation, exam of: carotid, femoral arteries, abdominal aorta, pedal pulses, extremities Gastrointestinal: Abdominal, lever/spleen, hernia, stool sample taken, anus, perineum, rectum 35

36 95 EXAMINATION (CONTINUED) OS OS OS OS OS OS Genitourinary: Male: scrotum, penis, DRE/prostate Female: pelvic, ext. genitalia, urethra, bladder, uterus, adnexa/parametria cervix, Musculoskeletal: Gait/station, digits/nails, examination of joints, bone, muscles, inspect & palpate, stability, ROM, strength & tone Skin: Inspection skin/ subcutaneous tissue, palpation skin/ subcutaneous tissue Neurologic: Cranial nerves, deep tendon reflexes, sensation Psychiatric: Judgment/ insight, MSE: orientation, remote & recent memory, mood & affect Hematological/lymphatic: Neck, axillae, groin, other/immunologic 36

37 SOAP ABDOMINAL PAIN 95 EXAM Vital signs 120/85, WT 134, Temp The patient is comfortable appearing and in no apparent distress. Neck: Supple. Thyroid: Normal. Heart: regular rate and rhythm. No edema. Lungs: clear to auscultation. Abdomen is soft and non-tender with normal bowel sounds and no masses. No guarding or rebound. Skin clear, no rashes or ulcers. Urine dip is negative aside from trace of glucose. 37

38 97 EXAMINATION We have 9 bullets identified Constitutional Vitals, General Appearance Neck Thyroid Heart auscultation, edema Respiratory - auscultation GI abdomen Skin skin clear Problem Focused Exp Prob Focused Detailed Comprehensive One to five elements identified by a bullet At least six elements identified by a bullet At least two elements identified by a bullet from each six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems Performed all elements identified by a bullet and document at least two elements by a bullet from each of nine area/systems 38

39 95 EXAMINATION BA BA BA BA BA BA BA BA BA BA Body Areas = BA Head, including the face Neck: neck (masses, symmetry, etc), thyroid Chest (Breasts): inspection breast, palpation breast/axillae Abdomen Genitalia, groin, buttocks Back, including spine Left upper extremity Right upper extremity Left lower extremity Right lower extremity 39

40 95 EXAMINATION OS Constitutional OS Eyes OS Ears, Nose, Mouth/Throat Organ Systems = OS 3 of the following: sit/stand BP, sup BP, temp, pulse rate, respiratory, height, weight or general appearance Conjunctivae/lids, pupils/irises, optic discs External exam ears/ nose, external auditory canal/tympanic membrane, hearing assessment, nasal mucosa/septum/turbinates', lips/teeth/gums, oropharynx OS Respiratory Respiratory effort, chest percussion, chest palpation, auscultation of lungs OS Cardiovascular Palpation heart, auscultation, exam of: carotid, femoral arteries, abdominal aorta, pedal pulses, extremities OS Gastrointestinal Abdominal, lever/spleen, hernia, stool sample taken, anus, perineum, rectum OS Genitourinary Male: scrotum, penis, DRE/prostate Female: pelvic, ext genitalia, urethra, bladder, cervix, uterus, adnexa/parametria OS Musculoskeletal Gait/station, digits/nails, examination of joints, bone, muscles, inspect & palpate, OS Skin OS Neurologic OS Psychiatric OS Hematological/ lymphatic stability, ROM, strength & tone Inspection skin/ subcutaneous tissue, palpation skin/ subcutaneous tissue Cranial nerves, deep tendon reflexes, sensation Judgment/ insight, MSE: orientation, remote & recent memory, mood & affect Neck, axillae, groin, other/immunologic 40

41 SOAP: ABDOMINAL PAIN 95 EXAM Vital signs 120/85, WT 134, Temp The patient is comfortable appearing and in no apparent distress. Neck: Supple. Thyroid: Normal. Heart: regular rate and rhythm. No edema. Lungs: clear to auscultation. Abdomen is soft and non-tender with normal bowel sounds and no masses. No guarding or rebound. Skin clear, no rashes or ulcers. Urine dip is negative aside from trace of glucose. 41

42 95 EXAMINATION We have 5 organ systems and 1 body area Organ Systems Constitutional, Cardiovascular, Respiratory, GI, Skin Body Area Neck, Thyroid Problem Focused Exp Problem Focused Detailed Comprehensive 1 organ system or 1 body area 2-7 organ systems or body areas, no detail of system required 2-7 organ systems or body areas, with affected system in detail 8 or more organ system OR Problem Focused Exp Problem Focused Detailed Comprehensive 1 organ system or 1 body area 2-4 organ systems or body areas 5-7 organ systems or body areas 8 or more organ system 42

43 THIRD COMPONENT: MEDICAL DECISION MAKING The medical decision making portion of the documentation includes information that tells the diagnosis of the patient and how the diagnosis or diagnoses will be treated. Three areas of documentation: Diagnosis Complexity Risk 43

44 MDM DIAGNOSIS Cannot get credit for mentioning a diagnosis that may not be applicable to the day s visit Minimum of one diagnosis treated with a developed plan of care. Diagnosis should have relevance to the treatment. Mentioning diagnosis may be a secondary issue 44

45 MDM - DIAGNOSIS Self Limited/Minor? Improved? Worsening? New Problem, no work-up? New Problem, additional work-up? Self Limited or minor (stable, improved, or worsening) (Max 2) 1 x Established problem, stable, improved 1 x Established problem, worsening 2 x New problem; no additional work-up planned (Max 1) 3 x New problem; additional work-up planned i.e.; referred, testing 4 x Total 45

46 MDM COMPLEXITY OF DATA Review and/or order clinical lab tests 1 Review and/or tests in radiology section 1 Review and/or tests in medicine section 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or discussion of case with another health provider 2 Independent visualization of image, tracing or specimen itself (not simple review of report) 2 TOTAL 46

47 SOAP: ABDOMINAL PAIN Right lower quadrant pain, etiology unclear We will schedule her today for a abdominal ultra sound and CBC. Depending on ultra sound results, we may proceed with the colonoscopy. I will also let the patient know of the CBC results. Patient was informed to go directly to the emergency room if pain worsens. 47

48 MDM COMPLEXITY OF DATA 2 Points: 1 point Order CBC 1 points Order Ultra Sound Urine Dip????? Review and/or order clinical lab tests 1 1 Review and/or tests in radiology section 1 1 Review and/or tests in medicine section 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health provider 2 Independent visualization of image, tracing or specimen itself (not simple review of report) 2? TOTAL 2 48

49 RISK- MDM There are three components to the table of risks: Presenting problem Diagnostic procedures Management options 49

50 LEVEL OF RISK -MDM Presenting Problem Diagnostic/Procedure Management Minimal One self-limited minor problem Lab testing, ECG, X-ray Rest, gargles, dressing Low 2 or more self-limited problems PFT, nonvascular image OTC drugs, PT, minor surgery 1 stable chronic, acute illness or injury uncomplicated Moderate 1 or more chronic illness w/mild Cardiac stress test, Minor surgery with risk, elective exacerbation, 2 or more chronic endoscopy major surgery, prescriptions, illness, acute illness with acute fracture treatment, dislocation uncertain progress or complicated injury High 1 or more chronic illness w/severe Cardiac imaging w/contrast Elective major surgery exacerbation, acute or chronic electrophysiological tests emergency major surgery, DNR illness that may pose a threat to endoscopy, discography decision, drug therapy that life, abrupt neurological change require intensive monitoring 50

51 SOAP: ABDOMINAL PAIN Right lower quadrant pain, etiology unknown We will schedule her today for an abdominal ultrasound and CBC. Depending on the ultrasound results, we may proceed with the colonoscopy. I will also let the patient know of the CBC results. Patient was informed to go directly to the emergency room if pain worsens. 51

52 LEVEL OF RISK - MDM Let s decide the scoring on this scenario!! Go back to the slide that has your descriptions of the Level of Risk MDM. See if you can pick out the correct level. 52

53 SCORING THE MDM So, let s see if you came up with the same thing that I have!!! Moderate MDM Diagnosis 4 points Complexity 2 points Risk Moderate Diagnosis 1 or less or more Complexity 1 or less or more Risk Minimal Low Moderate High Level Straight forward Low Moderate High 53

54 LEVEL OF SERVICE Three of Three Components The lowest components of all three Two of Three Components Middle or level with 2 components 54

55 LEVEL OF SERVICE Place of Service? Office New or Established? Established Codes? Require 2 out of 3 or 3 out of 3 components? 2 out of 3 components 55

56 LEVEL OF SERVICE Detailed History Expanded Problem Focused Exam 97 Moderate MDM Level? Detailed History Detailed Exam 95 Moderate MDM Level?

57 THANK YOU FOR LISTENING Darlene Boschert, RHIA, CPC, CPC-H, CPC-I 57