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4/30/2016
Why Bother to Self-Audit?
A Deep Dive into Evaluation and
Management Coding and Auditing
for Chiropractic Assistants
Perilyn Olson, D.C., MCS-P
For KMC University
• Self-audit can improve standards of
documentation considerably and increase
doctor and team member’s knowledge and
confidence
• Self-auditing is used as a continuous
improvement incentive for all clinical staff
• Self-audit can deliver an improvement in
practice at no extra cost
Today’s Objectives
• Identify the expected standards of a compliant
and complete E/M visit record
• Learn to audit documentation to ensure the most
important details are present
• Analyze and correct the most commonly missed
components of appropriate documentation
• Understand the federal requirements for
Medicare documentation and apply this
knowledge to new and established patient E/M
services
Expected Standards of a Compliant
and Complete Patient Record
The Guideline and Expectation
“The patient must have a significant
health problem in the form of a
neuromusculoskeletal condition
necessitating treatment, and the
manipulative services rendered
must have a direct therapeutic
relationship to the patients
condition and provide
reasonable expectation of
recovery or improvement of ….
FUNCTION!
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4/30/2016
Medicare Documentation Guidelines
Initial Visit
• History
• Description of Present
Illness
• Physical Exam
• Diagnosis
• Treatment Plan
• Date of initial
treatment
Subsequent Visits
• History
• Review of chief
complaint
• Physical Exam
• Document daily
treatment
• Progress related to
treatment goals/plan
Comprehensive Notes Tell the Story
Studies have shown that there
are many ineffective
procedures related to chart
documentation. One of the
most frequently reported
concerns is individual
physician practices. It has been
found that documentation is
used more as a tool to recall
events rather than as a means
to justify treatment decisions,
often leading to a lack of
completeness, accuracy and
timeliness in completing charts
Documentation Reviews
• Are all entries dated,
timed and signed with
names printed after the
signature?
• Are the patient’s details
recorded clearly on each
page?
• Do note entries make
reference to specific care
plans?
• Are non-registered staff
entries countersigned?
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• Are all entries free of
subjective opinion,
jargon, abbreviation and
offensive comments?
• Are any alterations or
deletions initialed and
still legible?
• Are all care plans in place
and dated at the time of
writing?
Know Your License Requirements
• Each state has written
or implied
documentation rules
• Sometimes one is not
aware until it’s too late
• Find out whether your
state has specific rules
• Don’t find out the hard
way
Good Documentation Protects
• Provides an accurate timeline
of treatment
• Confirms compliance
• Ensures consistency of patient
care
• Enhances quality of the care
given
• Clarifies the actual happenings
in the visit
• Is a chronological record of
your experiences with the
patient
• Should include phone calls and
other “orders”
Another Approach: 5-W’s
• Who — Performing, supervising, and referring doctors?
• What (and How Many) — Services and quantities of
services performed? Documented well?
• Where — Place of service?
• When — Date of service?
• Why — Medical necessity and diagnosis in place?
• The fundamental underpinnings for documenting and
reporting services to Medicare are that every item of
information reported on the claim (electronic or paper)
must be true and accurate, and it must be reflected in
the patient’s medical record.
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Signature Requirements
4/30/2016
What Do They Want?
Coding and Documentation Must Match
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4/30/2016
Conduct a Baseline Audit
Episodes of Care
The
Foundational
Visit of the
Episode
Job 1--Dr. Listening
• Patient history, written
and spoken
• Ask thoughtful questions
about paperwork
• Chief and additional
complaints
• HPI, ROS, and PFSH
• Begin to formulate
thoughts about
Examination
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New Patient? New Condition? New
Episode?
• These should be handled
the same
• From a documentation
point of view, they ARE
the same
• Known as the E/M visit
• Treat if you wish, but THIS
material must be covered
Job 2--Dr. Finding
• Must be driven by history
• Include tests and
measurements to
quantify history
• Distinguish between
important nuances
• Record everything in the
patient’s record
• Determine whether
additional diagnostic
testing rationale exists
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4/30/2016
Job 3--Dr. Thinking
• This is initial
assessment (S+O)
• H + E = D => Tx Plan
• Diagnosis for each
region you plan to treat
• Treatment plan is
obvious based on DX
• DX and plan for each
component service
Job 4--Dr. Fixing
• Clarify and execute your
plan
• Goals are associated
with the plan
• Medical necessity is
clear, if necessary
• It’s logical to expect to
see the treatment
coded that you chose
The
Foundational
Visit of the
Episode
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4/30/2016
Evaluation and Management
• Detailed, comprehensive,
and qualitative
documentation of patient
evaluation and
management services
• These encompass the
requirements of an initial,
foundational visit
Evaluation + Management (E/M)
Let’s Be Crystal Clear!
• E/M services can be initial
or established patient
• If a NEW patient, haven’t
been seen EVER or within
THREE years
• Everyone else is an
ESTABLISHED patient
Seven Components of EM
• Key Components:
– History
– Examination
– Clinical Decision
Making
• Contributory
Components:
– Counseling
– Coordination of Care
– Nature of the
Presenting Problem
• Least Important:
– Time
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Our Focus
• The components of history
and the implementation of
the process
• The components of exam
and the implementation of
the process
• The components of clinical
decision making and the
implementation of the
process
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Let’s Start with History!
4/30/2016
The History
Key Components
Chief Complaint (CC)
The Chief Complaint is a
concise statement
describing the symptom,
problem, condition,
diagnosis, or other factor
that is the reason for the
encounter, usually stated
in the patient’s own
words.
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History of Present Illness (HPI)
History of Present Illness
(HPI) is a chronological
description of the
development of the
patient’s present illness
from the first sign or
symptom or from the
previous encounter to the
present. (We know this as
O, P, Q, R, S, T)
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History of the Present Illness
1.
2.
3.
4.
5.
6.
7.
8.
4/30/2016
History of Present Illness
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated
Signs/Symptoms
Psst! Remember, this is for
each and every condition
you’re treating!
CC & HPI Note Example-EHR
CC &HPI Note Example-Intake
New Incident, Burst, or Episode:
Established Patient
The History
• You must think like a NP
• What is the HPI of THIS
episode, burst or incident?
• Might not need full blown
updated intake form
• HPI must be CLEAR about
THIS particular E, B or I
• Create a “lesser” version of
your NP intake form
• Could be within note if
necessary
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4/30/2016
New Episode or Burst of Care
CC & HPI Update Note Example-EHR
History of Present Illness
Review of Systems (ROS)
• Reviews the body systems related
to the (CC) chief complaint, and
identified in the (HPI) history of
present illness (Let’s Discuss!)
• CPT defines ROS as “An inventory
of body systems obtained
through a series of questions
seeking to identify signs and/or
symptoms that the patient may
be experiencing or has
experienced.”
Review of Systems (ROS)
Review of Systems (ROS)
“The review of systems
helps define the problem,
clarify the differential
diagnosis, identify needed
testing, or serves as
baseline data on other
systems that might be
affected by any possible
management systems.”
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•
•
•
•
•
•
Constitutional
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Integumentary
(skin and/or
breast)
•
•
•
•
•
Musculoskeletal
Neurological
Psychiatric
Endocrine
Lymphatic
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4/30/2016
The History
ROS Example--EHR
ROS Example--EHR
ROS Example
Review of Systems (ROS)
New Incident, Burst, or Episode:
Established Patient
•
•
•
•
•
•
•
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You must think like a NP
What is the updated ROS of THIS
episode, burst or incident?
Might not need full blown
updated intake form
Can refer to original ROS by date
Should update MS and N in KMC’s
opinion for this THIS particular E,
B or I
Create a “lesser” version of your
NP intake form
Could be within note if necessary
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Updated ROS Example--EHR
Documentation of Past, Family
and/or Social History (PFSH)
4/30/2016
Past, Family, and Social
History (PFSH)
The History
• The PFSH consists of a review
of three areas:
– past history (the patient’s past
experiences with illnesses,
operations, injuries and
treatments)
– family history (a review of
medical events in the patient’s
family, including diseases which
may be hereditary or place the
patient at risk)
– social history (an age appropriate
review of past and current
activities)
Past Family Social History (PFSH)
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EHR PFSH Sample
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4/30/2016
Past History Sample
Family History
Social History Sample
New Incident, Burst, or Episode:
Established Patient
•
•
•
•
•
•
•
PFSH—Updated Patient History
(855) 832-6562
You must think like a NP
What is the updated PFSH (if any) of
THIS episode, burst or incident?
Might not need full blown updated
intake form
Can refer to original PFSH by date
Relate your update of PFSH for this
THIS particular E, B or I condition
Create a “lesser” version of your NP
intake form
Could be within note if necessary
Now What?
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4/30/2016
The History
Start Your Examination with
Outcomes Assessment Tools
•
•
•
•
•
•
•
•
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Visual Analog Scale
Revised Oswestry
Pain Drawings
Roland-Morris Disability
Neck Pain Disability Index
Headache Disability Index
Bournemouth
Functional Rating Index
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4/30/2016
EHR Examination Samples
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EHR Examination Samples
EHR Examination Samples
EHR Examination Samples
Score The Examination
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4/30/2016
Medical Decision Making Step #1
Medical Decision Making #3
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Medical Decision Making: Final Talley
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EHR DX and Assessment Samples
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4/30/2016
EHR TX Plan Sample
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4/30/2016
We’re Here to Help!
[email protected]
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(855) 832-6562
4/30/2016
Clinical Decision Making: #1
Clinical Decision Making #2
Clinical Decision Making #3
Clinical Decision Making: Final Tally
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