ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 5 of 10 Instructor: Paul Sherman, DC

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1 Online Continuing Education Courses ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 5 of 10 Instructor: Paul Sherman, DC Important Notice: This download is for your personal use only and is protected by applicable copyright laws. Its use is governed by our Terms of Service on our website (click on Policies on our website s side navigation bar). SPECIFIC PHYSICIAN S CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES FOR MEDICARE REIMBURSEMENT: As previously described the only procedure covered by Medicare when performed by a chiropractor is chiropractic manipulative treatment (CMT) specifically spinal manipulation codes 98940, and COMMONLY USED CPT CODES IN CHIROPRACTIC PRACTICE THAT ARE APPROVED FOR REIMBURSEMENT FOR ALL NON-MEDICARE CLAIMS: Attended electrical muscle stimulation (low volt, high volt and interferential therapy) Unattended electrical muscle stimulation Ultrasound Hydrocollator or cold packs Mechanical traction Therapeutic exercise (rehab) Neuromuscular Reeducation (rehab) Group Therapy Procedures (rehab) Massage therapy includes but is not limited to, joint mobilization, manual traction, passive range of motion, soft tissue mobilization, myofascial release/trigger point therapy Spinal manipulation one to two regions Spinal manipulation three to four regions Spinal manipulation five regions Extraspinal manipulation (extremities) Note: Three Medical Nutrition Therapy Codes which should only be used when the D.C. is actually performing a specific nutritional work-up to include the following: Consultation, examination, laboratory testing (when appropriate), nutritional and/or dietary recommendations or follow-up care in relation to nutrition Medical nutrition therapy-initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. 1

2 97803-Medical nutrition therapy-re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy-group (2 or more individuals), each 30 minutes. Note: Three special codes for Surface EMG effective 1/02/02 which all fall under the category of Motion Analysis: Comprehensive computer-based motion analysis by video-taping and 3-D kinematics Dynamic plantar pressure measurements during walking Dynamic surface electromyography during walking or other functional activities (1-12 muscles). Note: Four Acupuncture codes effective 1/1/05 are allowed for use by a chiropractor as per their licensure and scope of practice: Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with patient Acupuncture, one or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with reinsertion of needles (this code is listed separately in addition to the primary procedure code) Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient, with reinsertion of needles (this code is listed separately in addition to the primary procedure code). Note: The doctor should reference the Physician s Current Procedural Terminology CPT code book from the AMA for additional codes. DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (E/M CODES): Note: This is a non-covered service for reimbursement from Medicare when performed by a chiropractic physician, but the non-participating and participating chiropractor can charge the patient for all non-covered services provided the patient was given written advanced notice that the service was a non-covered service. UNDERSTANDING EVALUATION/MANAGEMENT (E/M) CODES: 3 CATEGORIES: 1. Office visits-most important to chiropractic. 2. Hospital visits-more concerned with allopathic physicians M.D., D.O. etc. 3. Consultations- 2 SUBCATEGORIES OF OFFICE VISITS: 1. New Patient-Is a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to 2

3 the same group practice, within the past three years. 2. Established Patient-Is a patient who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. SPECIFIC EVALUATION AND MANAGEMENT CODES FOR BOTH NEW AND ESTABLISHED PATIENTS: NEW PATIENT E/M CODES: New patient E/M limited-presenting problem is self-limited or minor. Requires a problem-focused history, problem focused examination and straightforward medical decision making. Time involved 10 minutes New patient E/M expanded-presenting problem is of low to moderate severity. Requires an expanded problem focused history, an expanded problem focused examination and straightforward medical decision making. Time involved 20 minutes New patient E/M detailed-presenting problem is of moderate severity. Requires a detailed history, a detailed examination and medical decision making of low complexity. Time involved 30 minutes New patient E/M comprehensive-presenting problem is of moderate to high severity. Requires a comprehensive history, a comprehensive examination and medical decision making of moderate complexity. Time involved 45 minutes New patient E/M complex-presenting problem is of moderate to high severity. Requires a comprehensive history, a comprehensive examination and medical decision making of high complexity. Time involved 60 minutes. ESTABLISHED PATIENT E/M CODES: Established patient E/M minimal-presenting problem is minimal. Does not require the presence of a physician. Time involved 5 minutes Established patient E/M limited-presenting problem is self-limited or minor. Requires a problem focused history, a problem focused examination and straightforward decision making. Time involved 10 minutes Established patient E/M expanded-presenting problem is of low to moderate severity. Requires an expanded problem focused history, an expanded problem focused examination and medical decision making of low complexity. Time involved 15 minutes Established patient E/M detailed-presenting problem is of moderate to high severity. Requires a detailed history, detailed examination and medical decision making of moderate complexity. Time involved 25 minutes Established patient E/M comprehensive-presenting problem is of moderate to high severity. Requires a comprehensive history, a comprehensive examination and medical decision making of high complexity. Time involved 40 minutes. 3

4 E/M CODES RECOGNIZE 7 COMPONENTS (DESCRIPTORS) USED TO DETERMINE THE LEVEL OF SERVICE: E/M DESCRIPTORS CONSIST OF THE FOLLOWING: History* Examination* Medical decision-making* Nature of presenting problem Counseling Coordination of care Time Note: Hx, examination and medical decision-making are the 3 (*) key components necessary to determine the level of E/M service. Also, it is selected by the lowest of the 3 key components Note: If counseling or coordination of care predominant time is then considered the key or controlling factor to qualify for the level of E/M services 1. History-consists of a C/C, history of present illness (HPI), review of system (ROS) and Past family and/or social history (PFSH). In addition, there are four different levels of history, which are as follows: Four levels of history: Problem focused Hx-consists only of brief history, ROS and PFSH are not applicable. Expanded Problem focused Hx-consists of a brief history and brief (ROS) PFSH not applicable. Detailed Hx-consists of extended history (HPI), extended (ROS) and pertinent PFSH. Comprehensive Hx-consists of extended history (HPI), complete (ROS) and complete (PFSH). Note: All levels of the history when applicable as noted above comprise the HPI, ROS and PFSH. Below is a breakdown of the documentation requirements for these components. History of present illness (HPI) consists of: Location Quality Severity Duration Timing Context/setting Modifying factors Associated signs and symptoms 4

5 Selecting the type of HPI: A problem focused and expanded problem focused Hx-consists of a brief Hx identified by: 1-3 of the elements listed above A detailed and comprehensive Hx-consists of an extended Hx identified by: At least 4 or more of the elements listed above or the status of at least 3 chronic or inactive conditions Review of system (ROS) consists of: Constitutional symptoms (vital signs) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal/Genitourinary Musculoskeletal Skin and/or breast Neurological/Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Selecting the type of ROS: A problem focused Hx: ROS not applicable An expanded problem focused Hx-consists of a brief ROS identified by: Review of the 1 body system that is directly related to problem A detailed Hx-consists of an extended ROS identified by: Review of 2-9 body systems listed above A comprehensive Hx-consists of a complete ROS identified by: Review of at least 10 body systems listed above Past Family and/or social Hx (PFSH) consists of review of 3 areas: Past Hx-past experiences with illnesses, operations, injuries and Tx Family Hx-review of diseases or risk factors in the patient s family Hx Social Hx-age appropriate review of past and current activities Selecting the type of PFSH: Problem focused & expanded problem focused Hx PFSH not applicable Detailed Hx-consists of a Pertinent PFSH identified by: Review of at least 1 Hx item from any of the 3 PFSH listed above Comprehensive Hx-consists of a Complete PFSH identified by: Review of at least 1 Hx item from 2 of the 3 PFSH listed above or Review of at least 1 Hx item from each of the 3 PFSH listed above 5

6 2. Examination-refers to physical examination. There are 2 major categories: 1. General Multi-System Examination i.e.: constitutional, eyes, ears, nose, mouth, throat, neck, respiratory, cardiovascular, chest (breasts), Gastro- Intestinal (abdomen), genitourinary, lymphatic, musculoskeletal, skin, Neurologic and psychiatric. 2. Single Organ System Examination i.e.: Constitutional, cardiovascular, lymphatic, musculoskeletal, extremities, skin, neurological/psychiatric. There are 4 levels of single organ system examinations: Limited problem focused exam-documentation consists of evaluating 1 or more organ systems or body areas listed under the musculoskeletal single organ system. In addition, 1 to 5 elements (bullets) have to be identified under the specific organ systems or body areas identified. Expanded problem focused exam-documentation consists of evaluating 1 or more organ systems or body areas listed under the musculoskeletal single organ system. In addition, at least 6 elements (bullets) have to be identified under the specific organ systems or body areas identified. Detailed exam-documentation consists of evaluating 1 or more organ systems or body areas listed under the musculoskeletal single organ system. In addition, at least 12 elements (bullets) have to be identified under the specific organ systems or body areas identified. Comprehensive exam-documentation consists of identifying all the elements (bullets) listed under the organ systems or body areas related to the constitutional (vital signs), musculoskeletal, skin, neurological/ psychiatric as well as at least 1 element (bullet) listed under the organ systems or body areas in the cardiovascular, lymphatic and extremities of the musculoskeletal single organ system. Note: For purposes of chiropractic care single organ system examination will be further discussed in section 6 under the heading labeled Content and Documentation Guidelines (bullets) for E/M Services Specifically for the Musculoskeletal Examination (Single Organ System). 3. Medical Decision Making (MDM)-refers to the complexity of establishing a diagnosis and/or selecting a management option. Key items to consider for Medical Decision-Making (MDM): Number of diagnoses and/or number of management options. Amount and/or complexity needed in obtaining, reviewing and analyzing the medical data. Risk involved regarding complications, morbidity (disease) and/or mortality (death) associated with the patient s presenting problem, diagnostic procedure and/or management options. Note: The highest level of risk in any one of these categories (presenting problem, diagnostic procedures or management options) determines the overall risk 6

7 There are 4 types of medical decision making: Straightforward medical decision making-minimal number of diagnoses or management options, minimal or no data to be reviewed, minimal risk of significant complications, morbidity (disease), and/or mortality (death). Low complexity medical decision making-limited number of diagnoses or management options, limited data to be reviewed, low risk of significant complications, morbidity (disease), and/or mortality (death). Moderate complexity medical decision making-multiple number of diagnoses or management options, moderate data to be reviewed, low risk of significant complications, morbidity (disease), and/or mortality (death). High complexity medical decision making-extensive number of diagnoses or management options, extensive data to be reviewed, high risk of significant complications, morbidity (disease), and/or mortality (death). 4. Nature of Presenting Problem-refers to the reason the patient consulted you and it also assists with determining the risks of the medical decision making process specifically the components dealing with complications, morbidity (disease), and/or mortality (death), as previously discussed. There are 5 types of presenting problems: Minimal presenting problem=straightforward MDM-a problem that may not require a physician, but service is provided under the physicians supervision. Self-limited or minor presenting problem=straightforward MDM-a problem that runs a definite or prescribed course, transient in nature and is not likely to permanently alter health status or has a good prognosis with management compliance. Low severity presenting problem=low Complexity MDM-a problem where risk of morbidity (disease) without treatment is low, there is little to no risk of mortality (death) without treatment and full recovery without functional impairment is expected. Moderate severity presenting problem=moderate Complexity MDM-a problem where the risk of morbidity (disease) without treatment moderate, there is moderate risk of mortality (death) without treatment and there is an uncertain prognosis or increased probability of prolonged functional impairment. High severity presenting problem=high Complexity MDM-a problem where the risk of morbidity (disease) without treatment is high, there is moderate to high risk of mortality (death) without treatment or there is a high probability of severe, prolonged functional impairment. 5. Counseling-Discussion with a patient and/or family member concerning one or more of the following six items. Results of diagnostic tests and/or recommended diagnostic studies Prognosis Risks and benefits of management/treatment options Instructions for management/treatment and/or follow-up Importance of management/treatment compliance Patient/family education 7

8 6. Coordination of care-consulting with other healthcare providers. Note: If counseling or coordination of care predominant time is then considered the key or controlling factor to qualify for the level of E/M services. 7. Time-Amount of estimated time the physician spends with the patient (see specific E/M codes previously discussed for both new and established patients, which indicates the time factors required). 8

Practical E/M Audit Form: Initial Outpatient Visit (p.1)

Patient: Name: Chart #: Date of visit: / / Reviewed by: Date of review: / / Practical E/M Audit Form: Initial Outpatient Visit (p.1) Medical History Review Select the level corresponding to lowest of the