Specialty Provider Training

1. Specialty Provider Training • July 2019 • Emergency Medicine Documentation and Coding

2. Course Objectives • Review basic principles of coding and documentation of emergency medicine services • Review resident/fellow supervision and documentation requirements for Medicare, Medicaid, and TRICARE • Review data replication and scribe policies

3. Coding and Documenting Emergency Medicine Services

4. Billing Professional Services • Every billed service is assigned codes used for reimbursement, statistics, research, and other purposes. • The complexity of the patient’s condition, as documented in the note, drives the level of evaluation and management service delivered, recorded, and billed.

5. Valuing the Work of Evaluation and Management Services • The Level of Service provided is based on: • Your resource expenditure • Patient’s presenting illness or condition • Documentation should support: • The severity of the patient’s condition/diagnosis • Your effort in managing or treating the diagnosis • Components of the history and exam • Other work, such as reviewing notes or images • Complexity of case

6. Three Key Components of E/M Coding • History • History of Present Illness (HPI) • Review of Systems (ROS) • Past, Family, Social History (PFSH) • Examination • Medical Decision Making NOTE: All three key components are required for emergency medicine coding.

7. Chief Complaint • The chief complaint (CC) is a concise statement describing the symptom(s), problem(s), condition(s), diagnosis, or other factor that is the reason for the patient encounter. • Required for all E/M services • Typically provided by the patient in their own words but can be the observation of the provider if the patient is unable to provide • Must be clearly documented

8. History of Present Illness (HPI) • A chronological description of the development of the patient’s present illness from the first sign/symptom to the present. • Two HPI Levels: • Brief (1-3 elements) 99281-99283 • Extended (4+ elements) 99284-99285 • Elements: • Location • Quality • Severity • Timing • Duration • Context • Modifying Factors • Associated Signs & Symptoms

9. HPIDocumentation Requirements • The HPI may only be documented by the billing provider.* • New changes to the 2019 Medicare Physician Fee Schedule regarding the documentation of the Chief Compliant and History component of E/M services is not applicable to ED services. • The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. • To document that the physician reviewed the information, there must be a notation supplementing or confirming the information. • If the history is unobtainable from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining an history. *As of March 1, 2018, medical students may now document the HPI, Exam, and MDM. However, the Teaching Physician must verify the documentation and perform or re-perform the exam and MDM. Medicare Claims Processing Manual 100-04, Chapter 12, Section 100.1.1 (B)

10. Review of Systems • Document all pertinent positive and negative review of systems. • Recommended statement for a complete review of systems: “All other systems reviewed are negative.” • Please use the term ‘system’ instead of ‘point’ when documenting the review of systems. • If you are using a template/EHR and the ‘all others negative’ box is checked without any positives/negatives otherwise documented, a complete ROS is not counted. Tip: The ROS documentation must show the provider has asked the patient a question. The ROS may be documented in the HPI or in a separate ROS section.

11. ROS Requirements for Emergency Medicine • 99281-99283 • 1 system reviewed • 99284 • 2-9 systems reviewed • 99285 • 10+ systems reviewed

12. Exam Guidelines • There are two versions of the documentation guidelines – the 1995 version and the 1997 version. Either the 1995 or 1997 exam guidelines may be used, but not a combination of the two. • The most substantial differences between the two versions occur in the examination documentation section. • The physical examination is based on the medically necessary examination of organ systems and/or body areas as defined by either: • The 1995 guidelines which recognize 10 body areas and 12 organ systems • The 1997 guidelines which require more detail in the documentation but allow for comprehensive levels for specialty specific exams.

13. Exam Guidelines Reminder: The 1995 examination is based on either body areas or organ systems, not a combination of both. Per Palmetto GBA (North Carolina’s Medicare Administrative Contractor): A ‘general multi-system’ exam refers to 8 or more body areas or organ systems. The 1997 ‘comprehensive’ single organ system exam may be used as guidance when selecting and exam based on the 1995 ‘complete exam of a single organ system.’

14. Exam Component: 1995 Guidelines The body areas recognized are: The organ systems recognized are: • Head, including the face • Neck • Chest, including breasts and axillae • Abdomen • Genitalia, groin, buttocks • Back, including spine • Each extremity: • Right Arm • Left Arm • Right Leg • Left Leg • Constitutional • Eyes • Ears, Nose, Mouth and Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/Lymphatic/ • Immunologic

15. ExamDocumentation Tips • When documenting the examination, the term ‘Abdomen’ refers to a body area, according to Palmetto GBA (NC Medicare Contractor). • Updating your exam template header to “Abdomen/Gastrointestinal” rather than “Abdomen” will help support the intent of the exam as an organ system when documentation reflects both the abdomen and GI system. • Per Palmetto GBA – “More Detail” for a detailed examination using the 1995 Exam Guidelines is defined as: • At least 2 body areas or organ systems with at least 2 findings

16. Exam Component: 1997 Guidelines • There are two types of 1997 examinations: • General Multi-System • Single Organ System exams • Each level is comprised of examination elements identified by bullet points within specific body areas and organ systems. Bullet points must be documented exactly as provided in the CMS exam templates. • The 1997 exam guidelines are typically used more by specialists than primary care. However, most providers tend to document based on the 1995 exam (body areas/organ systems).

17. Example of 1997 Exam “Bullet Points”

18. Medical Decision Making (MDM) • Four Levels: • Straightforward • Low complexity • Moderate complexity • High complexity MDM refers to the work performed by a provider to establish a diagnosis and/or select management or treatment options. The work measures are represented by three tables: • The number of diagnosis and treatment options • Amount and/or complexity of data reviewed • Patient risk for morbidity and mortality

19. E/M: Medical Decision Making Below are the categories and point value assignments for the first table:

20. E/M: Medical Decision Making The below table represents the data review categories and the assigned point values:

22. Medical Decision Making – Documentation Tips • Document the discussion of test results with performing physician (i.e., radiologist). • Document the review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider. • Example: “Patient’s wife states…” ; or “I have reviewed previous records from…” • Document if you independently visualized an image, tracing, or specimen itself (not simply review of the report). • Example: “ I have independently viewed the MRI of the brain from 03/10/16 and….” • Document the patient’s clinical risks if the patient has a high risk for morbidity/mortality.

23. Medical Necessity Payorslook to MDM to support/steer medical necessity. • Per CMS: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. • The patient’s diagnoses or problems and their management/treatment help substantiate the level of service.

24. History Examination Medical Decision Making History Patient CPT & 1995 Exam # of Dx Procedures/tests 1997 Multi System Management Type Code Exam HPI ROS PFSH Organ System/ and/or Risk of ordered and amt Options Exam Elements Type Complications of data Body Area 1 Organ System/ Problem ED 99281 Brief (1-3) N/A N/A 1-5 Elements Minimal Minimal Minimal Focused Body Area Expanded 2-7 Limited Exam Org 99282 Brief (1-3) Pertinent (1) N/A 6-11 Elements Low Low Problem Low Syst/Body Areas Focused Expanded 2-7 Limited Exam Org Moderate 99283 Brief (1-3) Pertinent (1) N/A 6-11 Elements Moderate Moderate Problem Must Syst/Body Areas Focused Address 2-7 Extended Exam All 3 99284 Extended (4) Extended (2-9) Pertinent (1) 12-17 Elements Moderate Moderate Moderate Detailed Org Syst/Body Areas 2 Elements from 9 Compre- 99285 Extended (4) Complete (10+) Complete (2 of 3) 8+ Organ Systems High High High hensive Organ Systems Putting It All Together

25. Teaching Physician Guidelines

26. Medicare Teaching Physician Reimbursement • Medicare pays for Resident Physician services through Medicare Part A to the hospital. Medicare makes the payments based on the proportionate share of Medicare patients seen at the teaching hospital. • Teaching Physicians (TPs) are paid by Medicare Part B on a fee-for-service basis. • Medicare Part B will pay for TP services with the Resident Physician when the teaching physician participates and documents his/her involvement in the service. If the TP does not participate in a given patient service when a resident is involved, and meet specific documentation requirements, the TP may not bill for the service.

27. Medicare Teaching Physician Requirements • For purposes of Medicare payment, E/M services billed by Teaching Physicians (TP) require that the medical record demonstrate: • That the TP performed the service or was physically present during the key or critical portions of the service when performed by the resident; and • The participation of the TP in the management of the patient. • The patient medical record must document the extent of the TP’s participation in the review and direction of the services furnished to each beneficiary. The extent of the TP’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

28. Teaching Physician Guidelines – Unacceptable Attestations Examples: Unacceptable Attestations • “Agree with above.” [followed by legible countersignature] • “Rounded, Reviewed and Agree.” [followed by legible countersignature] • “Discussed with Resident. Agree.” [followed by legible countersignature] • “Seen and Agree.” [followed by legible countersignature] • “Patient seen and evaluated.” [followed by legible countersignature] • A legible countersignature or identity alone • Such documentation is not acceptable, because the attestation does not make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.

29. Only the personal time of the TP is billable for critical care time • A combination of the Teaching Physician’s (TPs) documentation and the Resident's documentation may support the critical care service. The TP must be present the entire time in order to bill. • The medical record documentation of the TP must provide the following information:  • Time the TP spent providing critical care,  • The patient was critically ill during the time the TP saw the patient,  • What made the patient critically ill; and • Nature of the treatment and management provided by the TP. The medical review criteria are the same for the TP as well as for all physicians. Acceptable Attestation: “Patient is in critical condition with ______. I spent ___ minutes providing critical care services of ______. I reviewed the Resident's documentation and I agree with the Resident's assessment and plan of care.”

30. Procedures • Minor procedures of <5 minutes • TP must be present the entire time in order to bill • Endoscopies(other than surgical operations) • TP must be present for entire viewing, including insertion and removal • All time-based services • Must be present the entire amount of time billed https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

31. Medical Students • CMS defines Student as an individual who participates in an accredited educational program (e.g., a medical school) that is not an approved Graduate Medical Education (GME) program. A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student. • Per CMS Policy: • Any contribution and participation of a medical student to the performance of a billable service (outside the collection of the system review and history) must be performed in the physical presence of a TP or a Resident. • The Teaching Physician or Resident must verify in the medical record all student documentation or findings. • The Teaching Physician must personally perform (or re-perform) the physical exam and medical decision making, but may verify any student documentation, rather than re-documenting this work. • Note: If a medical student is serving as a scribe, then all requirements for a scribe must be met. See UNC Health Care System PolicyStat ID 5153539. • See UNC Health Care System PolicyStat ID 6253887 for additional information regarding Medical Student documentation.

32. North Carolina Medicaid Teaching Physician Requirements • The degree of supervision for residents is the responsibility of the TP and should be based on the skill and level of training and experience of the Resident as well as the patient's condition. • E/M Services • TP must be "immediately available" to the Resident and patient by telephone or pager or other telecommunication device • Procedures • TP must utilize "direct supervision" when supervising a resident for procedures. CMS defines direct supervision as: “the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.” https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec410-32.pdf

33. North Carolina Medicaid Teaching Physician Requirements • Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician. Acceptable Attestation for NC Medicaid: “I discussed the patient with the Resident and agree with the assessment and plan as documented.”

34. TRICARE Teaching Physician Requirements • The TP must demonstrate and render sufficient personal and identifiable medical services to the patient to exercise full, personal control over the management of the case. • The TRICARE Manual states the TP must: • Review the patient’s history and the record of examinations and tests in the institution, and make frequent reviews of the patient’s progress; • Personally examine the patient; • Confirm or revise the diagnosis and determine the course of treatment to be followed; and • Either perform the physician’s services required by the patient or supervise the treatment so as to assure that appropriate services are provided by physicians in training and that the care meets proper quality level; and • Be present and ready to perform any service performed by an attending physician in a nonteaching setting when a major surgical procedure or a complex or dangerous medical procedure is performed; and • Be personally responsible for the patient’s care, at least throughout the period of hospitalization.

35. TRICARE Teaching Physician Requirements • The responsibilities of a supervisory attending physician are demonstrated by such actions as: • Reviewing the patient’s history and physical examination; • Personally examining the patient within a reasonable period after admission; and • Confirming or revising the diagnosis; • Assuring that any supervision needed by the physicians in training was furnished; and • Making frequent reviews of the patient’s progress. • Simply reviewing a patient’s progress note and not being available when a resident physician in training renders care is not billable to TRICARE.The TP must document his/her presence as also required by Medicare. • Acceptable Attestation for TRICARE: • “I have seen and evaluated the patient and reviewed the patient’s history, examination and progress note. I agree with the assessment, • diagnosis and plan of care of the Resident as documented. The Teaching Physician must personally document their face-to-face involvement with the patient. Residents cannot attest to the presence of the teaching physician for TRICARE beneficiaries.

36. Documentation Integrity in Electronic Health Records

37. Data Replication in Electronic Documentation • Altering notes improperly may undermine the integrity of the electronic health record (EHR) and jeopardize reimbursement and patient safety. • Medicare does allow documentation changes within limits, including amendments, corrections, addenda, and delayed entries if they are clearly identified and there is no tampering with original content. • The billing provider is responsible for the entire content of the documentation including its accuracy and any copied information. • Clinical documentation must demonstrate clearly distinct variation between notes. • The HPI, ROS, exam, and impression and plan must demonstrate documentation relevant to EACH clinical encounter and be reviewed and edited appropriately. • When possible, the use of copying and pasting of laboratory, pathology or radiology results in its entirety should be minimized in order to reduce “note bloat”. Summarizing findings and medical judgment is encouraged. • See PolicyStat ID: 5153534 Copying and Pasting and Data Replication in Electronic Documentation.

38. Software Features and Capabilities • Templates • Auto-populating tools and drop down menus may multiply the effect of an incorrect piece of data and may also contribute to the inappropriate up coding of an encounter. • Cloning • Cloning occurs when an entry in the EHR is worded the exact same way or is very similar to previous entries. • When entries are copied and pasted without being edited, medical necessity is not established because the documentation isn’t specific to the current patient encounter. • Patient care could be compromised if old treatment plans are copied and pasted.

39. What are auditors looking for? • Inaccurate or outdated information • Redundant information, which makes it difficult to identify the current information • Inability to identify the author or intent of documentation • Inability to identify when the documentation was first created • Propagation of false information • Internally inconsistent progress notes • Unnecessarily lengthy progress notes

40. “Make Me the Author” Function in Epic • Allows a provider to substitute their signature for that of another person who entered notes in the EHR. • This function does not replace the attestation requirement for a Teaching Physician working with a Resident physician as it does not support the documentation by the Teaching Physician of their face-to-face involvement with the patient during the patient encounter.

41. Use of Scribes • Scribes MAY NOT: • Provide any clinical care to patients • Interject their own observations, impressions or recommendations of care for care into the EMR • Scribe Documentation: If the encounter note was written by a scribe, the scribe must sign the note and indicate that they were acting as a scribe. • For example: “Entered by xx, (name of scribe), acting as scribe for Dr./PA/APP. Signature (of scribe)” • Provider Documentation: The provider should include a statement that they reviewed the documentation, and attest to the accuracy of the note. The provider may add to the note if additional information is needed. The provider then co-signs the note. • For example: “The documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me. Signature (of provider)” • See PolicyStat ID: 5153539 Documentation of Care Health Related Data by Scribes.

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