ICD 10 - Improving Clinical Documentation

ICD-10 is finally here and what most of us do not realize is that, it is just not enough that we are able to code in ICD-10 and get the claims billed out, we need to ensure that the documentation is specific and supportive of the ICD-10 diagnoses billed.

We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff  involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.

For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).

Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,

        Clinical Documentation Parameters:

• Onset - when did it start
• Manifestation - Paralysis, Loss of Consciousness
• Comorbidities
• Etiology/Causation - Infectious agent, Physical agent, Internal failure, Congenital
• External Causes - Motor vehicle, Injury, Assault, Accidental, Work related, Intentional Self harm
• Complication
• Detailed Anatomical Location - Proximal, Distal, Medial, Lateral, Central, Peripheral, Superior, Inferior, Anterior, Posterior
• Functional Impairment
• Biological & Chemical Agents
• Phase/Stage
• Lateralization /Localization - Rt side, Lt side, Bilateral or Unilateral
• Severity - Mild, Moderate or Severe
• Time Parameters - Intermittent, Recurring, Postoperative, Postdelivery
• Encounter type - Initial, Subsequent
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:

        Diabetes Mellitus:

• Type of diabetes
• Body system affected
• Complication or manifestation
• Long-term insulin use

        Fractures:

• Site
• Laterality     
• Type - open, closed
• Encounter type - Initial, Subsequent   
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

        Injuries:

• Place of occurrence
• External cause - Cause of injury, how the injury happened
• Activity code - what the patient was doing at the time of the injury ?
• External cause status - Injury related to military, work or others

It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.

New Patient or Established Patient ?

Who is a New Patient ? When do we bill a New Patient ? When does a Patient become an Established Patient ? These are some of the questions that confuse some practices when billing New/Established patients.

There are instances when a patient is seen by a Physician in the Hospital and in the Office and many Practices are not clear as to how to bill the patient visit. 

Determining whether a Patient visit is to be billed as a New Patient visit or an Established Patient visit has significant implications from a Clinical, Financial, Billing and Coding standpoint.

"A New Patient visit is an evaluation and management service provided to a patient who has not received any face-to-face service from any physician of the same specialty who belongs to the same group practice for at least three years".

Conversely an "Established Patient visit is an evaluation and management service provided to a patient who has already received any face-to-face service from any physician of the same specialty who belongs to the same group practice in the last three years".

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years - See more at: http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/New-Vs-Established-Patient.aspx#sthash.O0LGrQSh.dpuf

New Patient visits

1. Patient John Doe comes to see Dr A in his practice after a period of 4 years.

2. Patient John Doe was seen by another physician belonging to a different specialty in the same multispecialty practice, but Patient John comes to see Dr A for the first time.

Established Patient visits

1. Patient John Doe comes to see Dr A in his practice for the first time, Dr A has never seen Patient John before but Dr B another physician in Dr A's practice has seen patient John last year.

2. Patient John Doe was seen by Dr A in the hospital a month ago, he comes to see Dr A in his practice for the first time. Since Dr A has seen patient John within the last 3 years, the office visit becomes an Established visit.

E&M and other Procedures

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213)  is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.
 
But We are definitely allowed to bill a Procedure (20553)  and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :  

20553        Trigger point Inj                                 
99213 - 25  E&M service for  HTN, DM, CAD   
 
Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

E&M Coding & Documentation Guidelines

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently  documented the progress note  to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein,  we have documented more than what is needed, let us assume that we have documented  a Detailed History and a Detailed Exam and have billed  CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals  on Coding and Documentation.   http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Prolonged Services codes CPT 99354 - 99357

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :

CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :

CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.

Total time of Prolonged services	Outpatient	Inpatient
(do not include visit code time)	Prolonged Services Code	Prolonged Services Code
Less than 30 minutes	Not reported	Not reported
30 – 74 minutes	99354	99356
75 – 104 minutes	99354 and 99355	99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of  the medically necessary evaluation and management service and prolonged  services that you bill. 

You must sufficiently document in the medical record that you  personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.   The progress note has to have the start and end times of the visit, along with the date of service.