Briefing: Enhancing Clinical Documentation

1. Briefing:Enhancing Clinical Documentation Date: 25 March 2010 Time:0900–0950

2. Documentation • Review pertinent documentation components in order for our providers to receive credit for work performed • Tools to accomplish complete documentation • Accurate coding • Elements of coding

3. Accurate Coding • Appropriate HealthCare + Good Documentation = Accurate Coding • 1. Appropriate Healthcare: Providing medically necessary services relevant to the patients needs and condition • 2. Good Documentation: Appropriately recording all services provided • More documentation, doesn’t always mean it’s good • Properly performing 1 & 2 drives accurate coding

4. Accurate Coding Pre-requisites • A history & physical relevant to the visit type, diagnosis and procedures done • Appropriate: • Ear exam for URI diagnosis • Neb treatment for asthmatic • Inappropriate: • Knee exam for epistaxis diagnosis • Everything that the team does needs to be documented • All history, exam, tests, procedures • Labs, rads, meds, procedures must be associated with the proper diagnosis

5. Accurate Coding Pre-requisites Cont’d • A working knowledge of coding • E&M, CPT, ICD-9 • If you do not know the rules you cannot accurately document your workload • DoD Coding Guidelines – these are essential! • A working knowledge of AHLTA • Efficient documentation methods • Available tools • How AHLTA supports (and doesn’t support) accurate coding

6. Accurate Coding Pre-requisites Cont’d • Document smarter • Not necessarily more • <50% counseling & coordination • Specific elements for each service you provide • Specific diagnoses • Key components for E&M • Concise procedure notes (just clicking procedure is insufficient • EKGs • PFTs • Injections

7. Elements of Coding • Evaluation and Management (E&M) • A summary of the work performed • New vs. Established patients • Office vs. Preventive vs. Consultation • Prolonged services codes • Diagnosis codes: ICD-9-CM • Provides reason why services provided • aka: Medical Necessity • Procedure codes: CPT/HCPCS

8. Document Conditions That Impactthe Encounter • Hypertension • Diabetes Mellitus • Asthma • Congestive Heart Failure • Parkinson’s Disease • COPD • Emphysema

9. Is This Gaming the System? • No, provided all information documented is medically relevant to the encounter • Follow MHS Coding Guidance • Based upon but not identical to Center for Medicaid and Medicare (CMS) and American Medical Association (AMA) guidelines

10. Preventive Medicine Codes • Used for physical exams and other visits performed specifically for Preventive Medicine • Not based on number of element (bullets) • Dependent on age and gender appropriate preventive H&P • If it’s a preventive medicine visit, use the preventive medicine codes • Face-to-face PHAs typically qualify • Code the additional E&M when documentation supports a separately identifiable problem seen at the same time as preventive service

11. Documentation of the Well woman exam using the AIM Form produces this note Patient data fabricated for training purposes

12. Key Points to Capturing Workload • Accurate and complete documentation • Always document procedures • Preventive Medicine Visits • Know when to use them • Cannot be used in conjunction with other E&M* • Providers should never accept a 99211 * Unless a separately identifiable E&M was performed and documented

13. Tools to Improve Coding • 1997 E&M Documentation Guidelines • DoD Coding Guidelines • AHLTA • S/O Templates, AIM Forms, COMPASS • Encounter Templates • Favorites List • Workflow

14. Workload Recognition • Know E&M types and levels (who can use them and who can’t) • Document all the Procedures (CPT Codes) that the provider and the team do • Document ALL of Subjective and Objective findings • Incorporate team documentation with AHLTA • Use numerous AHLTA Tools • Know how and when to change the code that AHLTA gave

18. Coding Scenario HX: 46-y.o. black female, squadron commander, hypertensive; current meds atenolol 50 mg and HCTZ 25 mg daily. Complains of fatigue for the last few weeks, stating that she is tired and sleepy by the end of the day with trouble staying awake while watching TV. Fatigue is 7 on scale of 10 compared to normal. No orthopnea, GU symptoms or palpitations. No other complaints.

19. Coding Scenario - Better Documentation HX: 46-y.o. black female, squadron commander, hypertensive; new pt to FM presenting for follow-up from previous base; non-smoker, father died of CVD at age 67, mother history of diabetes; current meds atenolol 50 mg and HCTZ 25 mg daily. Complains of fatigue for the last few weeks, stating that she is tired and sleepy by the end of the day with trouble staying awake while watching TV. Fatigue is 7 on scale of 10 compared to normal. No orthopnea, no shortness of breath, no extremity edema, no hx of autoimmune diseases, no rashes, no hx of nausea, no hx of dizziness, no muscle tenderness, no hx of diabetes, denies depression.

20. Coding Scenario PX: BP 145/85, pulse 62, respirations 20, weight 168 lbs. HEENT: PERRLA; sclerae/conjunctiva clear. ENT normal; neck, no bruits, no JVD, or masses; lungs clear except for rare scattered high-pitched expiratory wheezes posteriorly; heart regular rhythm, no murmurs; gallops or rubs; abdomen is soft and non tender, no masses. No hepatosplenomegaly. Extremities, no edema.

21. Coding Scenario - Better Documentation O: BP 145/85, pulse 62, respirations 20, weight 168 lbs. 46y.o WDWN mildly anxious in NAD, alert, orientated X3; HEENT: PERRLA, sclerae/conjunctiva clear. Ears: TM good landmarks, ext canal without erythema. Nose: nl; Throat: non-erythematous; Neck: no bruits, no JVD, or masses, thyroid normal without masses, no post/ant cervical and axillary lymphadenopathy; Lungs: clear except for rare scattered high-pitched expiratory wheezes posteriorly, normal respiratory effort; Heart: regular rhythm, no murmurs, gallops or rubs; Abdomen is soft and non-tender, no masses. No hepatosplenomegaly. Extremities, no edema.

22. Coding Scenario • Labs: Hgb 12.4; potassium 3.2 • Assessment: • Hypertension controlled by present meds • Mild hypokalemia due to diuretic • Mild fatigue secondary to atenolol • Mild bronchial constriction secondary to atenolol • Plan: • Continue atenolol and HCTZ as before • Start potassium chloride tabs 8 mg TID with meals • Explained cause of fatigue and assured patient this is a common side effect of the medication which should improve with the potassium chloride • Recheck in two weeks and check potassium

23. Coding Scenario The E&M code is 99214 (RVUs: 1.42) But………… With Better Documentation: 99204 (RVUs: 2.3)

24. Patient data fabricated for training purposes

25. Patient data fabricated for training purposes

26. Summary • Accurate, complete documentation = accurate coding • Minimize changes Provider/Coder Comparison • Document smarter, not harder • Familiarize yourself with coding tools and use them • Receive credit for work performed • Provide accurate information for business planning

27. Questions