9/26/2012
Disclaimers/Confessions
Best Practices for Eye Care Staff Related to Medical Records
Presented by.
Charles B. Brownlow, O.D., F.A.A.O.
Medical Records Consultant
PMI, LLC
DrBrownlow@PMI‐EYES.com
Disclaimers/Confessions, con.
5. Of course the ultimate responsibility for the correct submission of claims and compliance with provider contracts lies with the provider of services, and…
6. The AOA and its presenters, agents, and staff make no representation, warranty, or ff
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guarantee that this presentation and/or its contents are error‐free and will bear no responsibility or liability for the results or consequences of the information contained herein
Role of Doctor and Staff in Records
• Doctor is responsible for every record, even if some material is recorded by staff
– Signature and legible identity of the doctor at the end of each chart signifies the doctor has reviewed all the content and is accepting responsibility for the content
• Staff is responsible for recording based on doctor’s instructions
– Doctor may require staff to initial all entries they make to aid in any review of the content later; internally or externally
This presentation was…
1. Current at the time it was prepared
2. Drawn from national policies related to medical record keeping
3. Prepared as a tool to assist doctors and staff and is not intended to grant rights or impose obligations
4. Prepared and presented carefully to ensure the information is accurate, current and relevant Keys to Good Health Care and Good Medical Records
Doctors and staff must…
• Carefully interview each patient to learn why they’ve come in
• Provide the care each patient needs; no more no less
• Accurately record all elements of the history, examination, diagnoses, management options
• Choose codes to represent what is done, based on the content of the record
• Submit a bill to the patient and/or to the patient’s insurance company for payment
National Guidelines for Records
• Codes for all procedures and all diagnoses are chosen based on three national documents:
– Current Procedural Terminology (CPT, © American Medical Association) – International Classification of Diseases, 9th Edition
– The Documentation Guidelines for the Evaluation and Management Services, 1997
• Health Information, Privacy and Portability Act (HIPPA) requires all payers and insurers to use and respect those documents in preparing and considering claims for health care services
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9/26/2012
“Reason for Visit” Runs the Show!
• A record without a clear reason for the visit will be rejected and the doctor will be paid nothing
• The reason for visit determines who pays the bill…the patient, the medical insurer or the vision plan
• “The chief complaint is a concise statement describing the symptoms, problems, conditions, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s words.”
• Think of the CC as the “Reason for Visit”
•
Eg. Day 1: Patient report of symptoms
– CC: “Red, irritated, right eye, past 2 days.” Day 3: Doctor recommended return
– CC: “Patient returned at doctor’s request for recheck of OD keratitis ”
1997 Documentation Guidelines (DGs)
Written 1997…15 yrs AGO!
• Created to standardize and “simplify” medical record documentation
• DGs put more detail into CPT definitions to j
make the choices of codes more objective
– Objective means fewer arguments with auditors
– Fewer arguments with auditors is a good thing!
• Most ODs and key staff have never read them!
– Find them at aoa.org/coding, or email…
– [email protected]
CPT Rules Come First, Then the Documentation Guidelines
• CPT describes key components in general terms: – History and physical examination are graded…
•
•
•
•
problem focused
problem focused, expanded problem focused, detailed, or comprehensive
– Medical decision making is graded… straightforward, low, moderate or high complexity
Current Procedural Terminology, CPT
• CPT Includes…
– Five digit code for every health care procedure in common use in the US, and
– Definition for each of those procedures • Doctors/staff choose codes by comparing the content of the patient’s record to the CPT definition
– Note: Copyright prohibits the use of any CPT code unless the medical record shows the service matches the CPT definition
CPT Rules Come First, Then the Documentation Guidelines
• For new patients, CPT requires that record qualifies on all three key components
– History, physical examination, medical decision making
• For established patients, CPT requires that record qualifies on two of three components
– History and/or physical examination, and/or medical decision making
CPT Rules Come First, Then the Documentation Guidelines
• Documentation Guidelines describe CPT’s key components in more specific terms: – “Detailed” case history includes at least:
• Extended history of present illness
• Extended review of systems
• Problem pertinent past/family/social history
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p /
y/
y
– “Detailed” physical examination includes:
• At least nine elements, ophthalmic or psychiatric
– “Low complexity” medical decision making includes:
• *Limited number of diagnoses and management options, and
• Limited amount and complexity of data, or
• *Low risk
(Note: ‘Grade’ for decision making is based the highest two of the three, *Dx/management options, amount and complexity of data, and *risk. Those with * are best for use in choosing eye care codes)
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9/26/2012
Contents of Records Are Subject to Several Sets of Rules:
Procedure Coding Example (CPT)
99203
• Standard use, established by providers
– SOAP format (Subjective, Objective, Assessment and Plan)
– Aligns information in the order that it is gathered
– History, Examination, Medical Decision Making
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,
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• Standard of care, established by the courts
– If it is not recorded, it was not done!
• Payers’ requirements, by contract
– Signature requirements, interpretations and reports, doctors’ orders for any special testing
Chief Complaint Runs the Show!
• “The CC is a concise statement describing the symptoms, problems, conditions, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patients words.
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• Think of the CC as the “Reason for Visit”
• Eg. Day 1: Patient complaint
– CC: “Red, irritated, right eye for 2 days.” Day 3: Doctor recommended return
– CC: “OD Keratitis Recheck”
Review of Systems (ROS)
• “A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.”
• 14 Systems:
Constitutional Symptoms (fever, weight loss)
Musculoskeletal
Eyes
Integument
Ears, Nose, Mouth, Throat
Neurological
Cardiovascular
Psychiatric
Respiratory
Endocrine
GI
Hematological/Lymphatic
GU
Allergic/Immunologic
History
Detailed
HPI: Extended 4+
ROS: Extended 2‐9
PFSH: Pertinent 1
Exam
Detailed
TBA
MDM
Low
TBA
New Patient E/M requires 3 of 3 Criteria
History of Present Illness
History of Present Illness (HPI)
• “ The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptoms or from the previous encounter to the present.”
• It includes:
Location
Timing
Quality
Context
Severity
Modifying Factors
Duration
Associated Signs & Symptoms
• Brief HPI: 1‐3 elements
• Extended HPI: 4+ or the status of 3+ chronic conditions
Review of Systems
• Problem Pertinent: inquires about the system directly related to the problem from the HPI.
• Extended: inquires about the system directly related to the problem from the HPI and a limited
related to the problem from the HPI and a limited
number (2‐9 systems) of additional system.
• Complete: inquires about the system directly related to the problem from the HPI plus many
additional systems (10‐14 systems)
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9/26/2012
Past, Family, and/or Social History
• Past Hx: the patient’s past experiences with illness, operations, injuries, and treatments; general and eye related
• Family Hx: a review of medical events in the patient’s family, including disease which may be hereditary or place the patient at risk
• Social Hx: an age appropriate review of the past & current activities
• Pertinent: review directly related to HPI (1 item)
• Complete: review of 2 or all 3 items
Procedure Coding Example, 99203, new patient, level 3
Note: New Patient codes require 3 of 3 Components…
Grade to the lowest of the three
Component
CPT Requirement
Documentation Guidelines
History
Detailed
HPI: Extended 4+
ROS: Extended 2‐9
PFSH: Pertinent 1
PFSH: Pertinent 1
Exam
Detailed
9 or more elements, ophthalmic and/or psychiatric
Medical Decision
Making
Low Complexity
Limited Dx/management options, Low risk, and/or
Limited amount/complexity of data
Grading the Physical Examination
History of Present Illness (HPI)
• The grade for the examination is determined by simply totaling the number of gradable elements included in the medical record for the day.
Level of Physical Examination
# of elements
Problem Focused
Problem Focused
1‐5
1
5 ophthalmic
ophthalmic
Expanded Problem Focused
6‐8 ophthalmic
Detailed (Required for 99203)
=> 9 ophthalmic and/or psychiatric
Comprehensive
How Do You Grade The History?
Level of Hx
HPI
ROS
PFSH
Problem Focused
Brief (1‐3)
None
None
Expanded Problem
Focused
Brief (1‐3)
Problem Pertinent
(1 system)
None
Detailed
Extended (4+)
Extended (2‐9 systems) Pertinent (1)
Comprehensive
Extended (4+)
Complete (10+)
History Required for Visit Codes
New Patient Codes •99201: PF
•99202: EPF
•99203: Detailed
•99204: Comprehensive
•99205: Comprehensive
Complete (2‐3)
Established Patient Codes •99211: Supervised Visit
•99212: PF
•99213: EPF
•99214: Detailed
•99215: Comprehensive
Elements for Grading Physical Examinations for Eye Care Ophthalmic • Visual acuity
• Gross visual fields
• Ocular adnexae
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• Pupils and irises
• Motilities/versions
• Corneas
• Anterior chambers
• Crystalline Lenses
• Bulbar and palpebral conjunctiva
• Intraocular pressures
• Dilated ophthalmoscopy, discs
• Dilated ophthalmoscopy, posterior segments
Brief assessment of mental status
• Orientation to time/place person and
• Mood and affect
• Note: Each exam includes what the patient needs, no more no less…Grading is done after the record is completed!
Grading Medical Decision Making
History of Present Illness (HPI)
• Complexity of decision making is based on the lower grade of “number of diagnoses and management options” and the “level of risk”
Complexity of Medical Decision Making
Number of Dx and Man. Options / Risk
Straightforward
Minimal/Minimal
Low (required for 99203)
Limited/Low
Moderate
Multiple/Moderate
High
Extensive/High
All ophthalmic, both psychiatric
• Note: The requirements for the comprehensive physical examinations for eye visits graded as 99000 codes are totally different than the CPT requirements for the comprehensive ophthalmological services (92004/92014)! Note: “Amount and complexity of data” is not used in this formula because determination of the level is very subjective, varying widely among providers and insurers’ auditors. Keeping the process simple ensures repeatability and accuracy in choosing codes.
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9/26/2012
Grading Medical Decision Making
History of Present Illness (HPI)
• Decision making is graded by first determining the number of diagnoses and management options and the level of risk
Grading Medical Decision Making
History of Present Illness (HPI)
• Level of risk is based on a chart provided in the Documentation Guidelines
Level of Risk Involved in Examples of Each Level of Risk
Diagnosing/Treating/Managing this Case
Diagnoses/management
options
Total number of Dx and options pertinent to visit *
options pertinent to visit Minimal
One self limited/minor problem
Minimal
1
Low Limited
2‐3
Two or more self limiting, one stable or chronic illness, one acute illness/injury, or uncomplicated injury/illness
One chronic illness with mild complications, two stable chronic illnesses, and undiagnosed new problem, acute illness with systemic symptoms, acute complicated injury
Multiple
4‐6
Moderate
Extensive
> = 7
Note: The
Note: The DGs are not specific as to how many diagnoses and management options equate to each level, minimal through extensive. The numbers provided here are a reflection of the presenter’s opinion.
Procedure Coding Example, 99203, new patient, level 3
One or more chronic illness with severe complications, acute or chronic illnesses or injuries posing a threat to life, an abrupt change in neurological status
High
ePrescribing
Note: New Patient codes require 3 of 3 Components…
Grade to the lowest of the three
Component
CPT Requirement
Documentation Guidelines
History…
Detailed
HPI: Extended 4+
ROS: Extended 2‐9
PFSH: Pertinent 1
PFSH: Pertinent 1
Exam
Detailed
9 or more elements, ophthalmic and/or psychiatric
Medical Decision
Making
Low Complexity
Limited Dx/management options, Low risk, and/or
Limited amount/complexity of data
Refer to July 2011 webinar for coding details for case history
Medicare Incentives for eRx
• 2% bonus* paid for 2010 and 2011
– Penalty imposed if not using eRx in the future
• Possibly 2013?
• AOA lobbied to exclude ODs from 2012 penalty
– Based on all Medicare payments for the year
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y
– Paid in addition to your PQRS bonus
– Earned by reporting use of eRx at least 25 times/year
• G8553 entered on CMS 1500 form below the office visit code
• Electronic, computer based (not fax) transfer of pharmaceutical Rxes to suppliers
• Most EHR programs do include or will include ePrescribing or integration with standalone eRx
• Stand alone programs available at low or no cost
• Government believes it will reduce errors in prescribing
– Poor handwriting blamed for many bad Rxes
– Permits compilation and maintenance of complete medication list for each patient
More Information on ERx
 Currently using eRx?
 Verify current qualified eRx systems at: surescripts.com/certification‐status.html
 Considering eRx?
 Check out free eRx
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 www.nationalerx.com/
 Find more info at: http://www.getrxconnected.com/OPTOMETRIC/site.aspx
and, aoa.org/EHR.xml
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9/26/2012
Closing Thoughts
HIPPA
• It is the doctors responsibility to offer a Privacy Policy to every patient starting April 13th, 2003 the first time the patient come to the clinic and every time there is a CHANGE in the wording of the Policy
the wording of the Policy
• Needs available to the patients to take home
• Needs to be posted somewhere in the office
• Needs to be on your website
• Approx. 75% of ODs’ offices are still using paper medical records
• All EHR will eventually automatically choose CPT codes for billing
• Getting skilled at accurate coding will assist you in G tti
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di
ill i t
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buying EHR software that codes accurately
• Pull ten charts per doctor and use PMI Grading Sheets to determine correct code for each
• Compare to codes originally used for billing each of those visits
AOA Coding Resources
Codes for Optometry
– Two volumes $135
– AOA Order Department, 1‐800‐262‐2210
• AMA Current Procedural Terminology, and • AOA Codes for Optometry
– ICD‐9 abridged for the eye
– Documentation Guidelines
– Correct Coding Initiatives from Medicare
– HealthCare Common Procedure Coding System (HCPCS) for Coding Materials in Medicare
– Companion readable CD, $25
AOA Coding Resources
AOA.ReimbursementPlus.com
– Subscription based resource, including coding information for procedures and diagnoses, accepted combinations of codes, compliance guidelines and reimbursement information specific to the insurers with which your office is contracted
– Popular program offered to AOA members at significant discount AOA Coding Resources
AOACodingToday.com
• Online Coding and Reimbursement Tool
– Includes info from key national references
• Medicare ‐Coverage determinations, RVUs, Correct Coding Initiatives
• CPT ‐ Current Procedural Terminology
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• ICD9 ‐ International Classification of Diseases • Special information about codes common to eye care (audit cautions, etc.)
• Improves Accuracy and Efficiency of Your Medical Billing, Making It Easier to Submit “Clean Claims”
AOA Coding Resources
PMI, LLC.
• Consulting, Fee Analysis, Friendly Audits, and VisitCoder
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Assists in choosing 99000 and 92000 office visit codes. Minimal training required. Staff or doctors can choose codes with accuracy, objectivity, and repeatability. Increases revenue and self esteem while reducing stress over threat of payer audits.
www.PMI‐Eyes.com
www.visitcoder.com
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9/26/2012
AOA Resources
AOA Resources
AOA Website Sections Provide Information Regarding
Private Insurers and Governmental Health Programs
– Third Party Center http://www.aoa.org/TPC
– Clinical & Practice Advancement Group http://www.aoa.org/CPAG
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Clinical Practice Guidelines
Frequently Asked Questions
Webinars and other online education for doctors and staff
Webinars
and other online education for doctors and staff
Articles in AOA NEWS and the Journal of the AOA
[email protected]
– Email your questions direct to the experts
– Include AOA member’s name and state
• http://www.aoa.org/coding
– Paraoptometric Membership [email protected]
No Office is an Island
• Many resources available, but it’s up to you to seek the answers
• Send emails to:
• [email protected] or
• drames@pmi‐eyes.com
• Don’t be shy about emailing your questions to Questions? Thank You!
Thank You! [email protected] . This is a free service to AOA members and their staff
• Be sure to register for future medical records webinars in the AOA CPAG series
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