Disclaimer

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Disclaimer

• This presentation is intended only for use by
  Tulane University faculty, staff, and students.
  No copy or use of this presentation should occur
  without the permission of Tulane University.
  Tulane University retains all intellectual
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  presentation. Tulane University makes no claim,
  promise, or guarantee of any kind about the
  accuracy, completeness, or adequacy of the
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  such content.

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Documenting an Outpatient Visit
Overview of Basic Principles
Before viewing, print the file Documenting an
Outpatient Visit which contains a handout and a
quiz
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Read Before Proceeding
Physicians and Staff may earn one compliance
credit by viewing this presentation, completing
the assessment, and faxing the assessment to the
HIPAA Compliance Office 504-988-7777 This
presentation may be viewed for compliance credit
only once in a fiscal year (July 1 - June 30).
To check to see how many compliance credits you
have and to see which training sessions you have
completed, contact the University Privacy and
Contracting Office at 504-988-7721
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It is the policy of TUMG to provide healthcare
services that are in compliance with all state
and federal laws governing its operations and
consistent with the highest standards of business
and professional ethics. Education for all TUMG
physicians is an essential step in ensuring the
ongoing success of compliance efforts.
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This is the first of a 6-part series focused on
documenting outpatient services.

• Part 4 Documenting Medical Decision Making
• Part 5 Time-Based Codes
• Part 6 Linking to Resident Notes

• Part 1 Overview of Basic Principles
• Part 2 Documenting a History
• Part 3 Documenting an Exam

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TUMG Physicians are responsible for documenting
their outpatient visits and selecting the level
of service to be billed to the carrier.
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Purpose of Presentation

• To provide information regarding documenting and
  selecting a level of service for outpatient
  visits
• To provide links to source documents that will
  assist physicians in the understanding and
  application of documentation guidelines.

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The WYSI-WYG Principle(WYSI-WYG)
The WYSIWYG principle defines the relationship
between documentation and level of service What
You See Is What You Get
Corollary If it isnt written, it didnt
happen, and it cant be billed
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An understanding of Evaluation and Management
Guidelines, paired with the WYSI-WYG Principle,
greatly reduces the potential for Level of
Service Documentation Mismatches
Physician I know the service is a 99204
Reviewer/Coder I see a 99202
Physician Note Chief Complaint Expanded
History Detailed Exam Moderate Decision Making
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Outpatient Visit Essentials

• 1) Documentation that supports the level of
  service billed
• Does the note contain all the elements required
  for the level of service selected?
• 2) Clearly established Medical Necessity
• Does the note provide a clear reason for the
  visit, and are the assessment and plan clearly
  related to the reason for the visit?

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Its a matter of writing and/or dictating
History
Physician Note Chief Complaint History Exam Medica
l Decision Making
Exam
Decision Making
To avoid underdocumenting, the physicians note
must reflect all the elements of History, Exam
and Medical Decision Making performed for each
outpatient encounter.
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To insure that documentation supports the level
of service

• Understand and apply General Principles of
  Medical Record documentation
• Understand and apply Evaluation and Management
  documentation guidelines click here (jump to
  slide 18)
• Link to other supporting documentation (resident
  notes, staff notes, patient questionnaires)

Links to Documentation Resources (click on the
link to open) 1995 General Principles of Medical
Record Documentation 1997 General Principles of
Medical Record Documentation Linking to resident
notes and teaching physician guidelines
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To insure that Medical Necessity is established a
note should contain

• A clearly stated chief complaint click here
• A clearly stated diagnosis(es) or, in absence of
  a diagnosis, signs and symptoms
• A clearly stated or easily inferred rationale for
  ordering diagnostic or other ancillary services

WORD OF CAUTION The only instance where
information can be inferred is for ordering
diagnostic or other ancillary services. The chief
complaint and the diagnosis cannot be inferred
they must be clearly documented
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Auditors are not psychics
I sense a complete review of systemsbut the
crystal ball is cloudy regarding a chief
complaint and the exam
Medical Record Reviewers or Coders do not fill in
gaps in a note. Each outpatient visit must stand
alone. Reviewers will not look back at prior
notes to support a level of service.
Note
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Need More Information?

• The TUMG Compliance Educator / Audit Specialist
  is available to any physician/section/department
  that would like further information on outpatient
  documentation guidelines or other compliance
  topics.
• Contact
• Sue Straumanis, CPC, CHC
• sstrauma_at_tulane.edu
• Phone [phone]

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End of Presentation
To Earn Compliance Credit
Complete and Sign the Documenting an Outpatient
Visit Quiz Fax to 504-988-7777
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Chief Complaint

• The Chief Complaint is a concise statement
  describing the symptom, problem, condition,
  diagnosis, physician-recommended return, or other
  factor that is reason for the encounter This is
  usually stated in the patients own words.
• Source Medicare Physician Guide A Resource for
  Residents, Practicing Physicians, and Other
  Healthcare Professionals. 11th Edition Oct.
  2009, pg. 102.

• Corollary The Chief complaint cannot be
  inferred.

• Click here to return to main presentation

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Basics of E/M Coding 6 slidesThe Meet or
Exceed Principle

• Established Patients OR Follow-Up Consults, the
  Physician must MEET or EXCEED documentation
  requirements for two of three E/M Components.
• History/Medical Decision Making
• Exam/Medical Decision Making

• New Patients OR Initial Consults, the Physician
  must MEET or EXCEED documentation requirements
  for three of three E/M Components
• History
• Exam
• Medical Decision Making

There are six slides in this section of the
presentation at slide 6 there is a link to
return to the main presentation
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A word about Established Patient documentation

• Although Established Patient/Follow-Up Consult
  E/M level of service is based on two of three E/M
  components, that does not mean that the physician
  should not document elements of all three E/M
  components if the information is germane to the
  treatment of the patient.
• Medical Decision Making must always be one of the
  two components when determining level of service
  to ensure medical necessity is being met.

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New Patients Selecting A Level of Service
A physician note documents a detailed History,
expanded Exam and Moderate Medical Decision
Making. What New Patient code or Consult code is
supported by the documentation?
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New Patients Selecting A Level of Service
With new patients or consults, the LOWEST of the
three E/M key components documents determines the
level of service. In this case, a 99202 or 99242.
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Established Patients Selecting A Level of
Service
A physician note documents a detailed History,
expanded Exam and Moderate Medical Decision
Making. What established patient code is
supported by the documentation?
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Established Patients Selecting A Level of
Service
With established patients, the LOWEST of the two
highest E/M key components documented determines
the level of service. In this case,
documentation supports a level 99214.
Click here to return to main presentation