What is a physical examination and what determines its extent? According to CMS’ Evaluation and Management Billing Guide, “The examination is the process of collecting diagnostic information through physical applications such as palpation, ausculation, and inspection. The extent of the examination performed depends on clinical judgement and on the nature of the presenting problem(s).”
Body areas recognized for the purpose of Current Procedural Terminology (CPT) definitions are the abdomen, back, chest, extremities, genitalia, groin and buttocks, head and neck. Organ systems recognized for the purposed of CPT definitions are cardiovascular, ears, nose, mouth, and throat, eyes, gastro-intestinal, genitourinary, hematologic/lymphatic/immunologic, musculoskeletal, neurologic, psychiatric, respiratory and skin.
The levels of E/M services are based on four types of examination defines as follows:
- Problem focus: A limited examination of the affected body area or organ system.
- Expanded problem focus:A limited examination of the affected body area or organ system and any other symptomatic or related organ system. This consists of an examination of two to four systems clinically relevant tot he nature of the presenting problem and history of present illness (HPI).
- Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ systems(s). This consists of an examination of five to seven systems clinically relevant to the nature of the presenting problem and HPI.
- Comprehensive: A general multi-system examination of eight or more systems clinically relevant to the nature of the presenting problem and HPI.
The importance of incorporating medical necessity when determining the extent of a physical exam cannot be overemphasized. CMS contractor Trailblazer Health Enterprises states in Documenting Components of an Established Office E/M Service that “when determining the level of examination, consider the clinical circumstances of the encounter. Do not select the type of examination of excessive and unnecessary information recorded solely to meet the requirements of a higher-level service to medically appropriate.”
Editor’s Note: This excerpt is adapted from The Documentation Improvement Guide to Physician E/M by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI.
Q: I am a relatively new CDI specialist in a relatively new CDI program. We learned that we should be examining the health record with an eye toward “what bought the bed.” When we raise this concept to our coders, however, they disagreed with the premise telling us that such a concept was in line with coding regulations. Can you explain how we may have misunderstood this concept or help us to understand where the difference in perception may lay?
A: In 2010 the Recovery Auditors (then called Recover Audit Contractors or RACs) began to challenge both DRG assignment (coding practices) and medical necessity. Recovery Auditors soon found great returns financially with the medical necessity denials, in fact many organizations see this type of denial as their Recovery Auditor’s main focus.
Traditionally coding teams needed to only focus on assuring proper codes were assigned, following the Official Guidelines for Coding and Reporting for sequencing. As long as the “rules” were followed they had no concerns. They were also in the habit of making sequencing choices allowed within the guideline that would lead to the greatest reimbursement.
This practice is not necessarily wrong but with new initiatives related to indirect reimbursement it may lead to take-backs, denials, or other problems. For example, quality measures, readmission monitors, value based purchasing etc., all provide hospitals with potential for indirect reimbursement or financial loss if the hospital does not meet the goals set. These efforts are based on data derived from DRG and code assignments. Severity of illness and risk of mortality measures are based on the same data.
Those who work in the CDI role and come to the profession from a nursing background may be more familiar with the concept of medical necessity related to inpatient status requirements. Particularly, those CDI professional who may have come from a case management or utilization review experience understand and have struggled with medical necessity for years. This focus area now is even more front and center for those who work within the revenue cycle.
I have often discussed sequencing for a lesser paying DRG based on what the patient was actually treated for or what would have “bought the bed,” rather than assigning a code for a diagnosis that was documented and may have reimbursed at a higher level.
Let me give an example of what I mean:
A patient comes to the hospital with a urinary tract infection (UTI) and renal failure/acute tubular necrosis (ATN). Both conditions were present on admission. The UTI taken as principle diagnosis with renal failure/ATN as MCC provides a relative weight of 1.1 with payment of approximately $4,200. If the renal failure with ATN is the principal diagnosis we have a relative weight of .9655 with approximately $3,500 in reimbursement. As a CDI specialist, with medical necessity in mind, our first question is to determine whether the patient required an admission for the treatment of the UTI? Could the UTI have been treated outpatient with antibiotics? Looking at the creatinine level and renal function and the presence of ATN the next question is could the renal failure have been treated/monitored at home? Or did it require an inpatient stay? The choice of principal diagnosis should be a thoughtful decision reflecting the condition that brought the patient to the facility’s door and what treatment was provided, what needed to be done to lead to stability and discharge.
Coders know well the definition of a principal diagnosis as identified by the Uniform Hospital Discharge Data Set as:
“The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
Your program may want to consider conducting monthly coder-CDI team meetings to review difficult cases where the principal and secondary diagnoses may be confusing. Also reach out to those in denial management to request examples of medical necessity denials to re-examine as a team. Review the diagnoses that are frequently denied and discuss how that denial impacts revenue loss. Look at the possibility of other choices for principal diagnosis that might not have triggered a denial for medical necessity. This may be information that the coding staff has not been exposed to and by working together to regularly review items such as these you can strengthen both your CDI and coding efforts.
The more discussion and exposure everyone involved has in regard to how the choice of principal diagnosis affects quality measures, potential denials and payment incentives will assist in that change.
In 2008, only 11% of poll respondents indicated their CDI program either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient (8% and 3% respectively) areas. How has the climate changed?
According to more than 400 respondents to the question this past month on the ACDIS website poll, 35% now say they conduct outpatient reviews and 61% do not (1% say they only review emergency department records, and 2% plan to start outpatient reviews within the next year).
With the advent of Medicare Administrative Contractors (MAC), which review both Part A (hospital) and Part B (physician) billing, payers are now looking to ensure that physician and facility billing match, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, an ACDIS Advisory Board member and independent consultant based in Madison, Wisc., in a previous edition of the CDI Journal. This combined review could mean new vulnerabilities for hospital and physician reimbursement, but it also represents a new opportunity for CDI specialists.
“We [as CDI specialists] are trying to get buy-in, support, from physicians,” Krauss says. “But we don’t explain how documentation affects their business. Outpatient documentation review is a good segue for helping physicians understand the importance of documentation in the medical record.”
Although the majority of those participating in the recent ACDIS poll remain focused on inpatient record reviews the trend has shifted from that illustrated in the 2008 poll. As more government initiatives roll out, no doubt CDI will continue to advance into the outpatient arena. If you are currently conducting such reviews, please share with us your story in the comment section below.
Editor’s Note: This article first appeared in the bi-monthly email newsletter CDI Strategies.
The 2014 early bird registration deadline for the 7th annual ACDIS Conference is Wednesday, March 5. The regular rate is $995 but ACDIS members who register early can register for $795.
Pricing for this year’s ACDIS conference is as follows:
- $995, regular rate
- $895, early bird rate
- $895, ACDIS member regular rate
- $795, ACDIS member early bird rate
Additional discounts are available for registering for the conference as a team. For additional information, call 800-650-6787.
One of the most convincing reasons for establishing a concurrent documentation review program is the ability to discuss a patient’s record while the details of the patient’s case are still fresh in the physicians’ mind. Such interactions are as important for resolution of the medical record documentation as it is for providing ongoing education for the physician. Not surprisingly then, many experts encourage facilities to maximize opportunities for verbal interactions between the CDI team and the physician staff, whether it is on the patient care unit or through meetings in the physician lounge. To do so, however, CDI specialists need to exhibit a unique set of interpersonal skills. the CDI specialist must be both positive and professional in his or her interactions with physicians but they must also be able to interpret the physician’s body language at the time of the discussion and be able to weigh and recall a particular physician’s communication preferences over time. Such skills may be summarized by the colloquialism “know your audience.”
For example, Dr. Smith may respond well to e-mail communication but become visibly uncomfortable, aggressive, or reclusive when approached on the floor of a nursing unit. Conversely, Dr. Adams consistently ignores written queries left in the medical record and does not return phone calls. Approach him during his routine rounds, however, and he will answer multiple CDI questions happily.
Beyond understanding the physician’s preference for type of communication, the CDI specialist must also be aware of the personality type of the physician. A process-orientated physician, for example, may respond positively to a CDI specialist who explains how his or her documentation in the medical record translates through the HIM department, billing, and, ultimately, reimbursement and quality data reporting. A results-orientated physician, however, would see such discussions as a waste of time, preferring to understand how the process will affect him or her directly, instead. The ability of the CDI staff member to not only be aware of these different dynamics, but also to adjust their queries and education accordingly can appease wary physicians and earn physician support for the CDI program overall.
The 2-Midnight rule continues to cause consternation for many case managers, utilization review professionals–well, actually to most anyone who works within the healthcare revenue cycle. It seems to be causing CMS a few headaches also, since it announced recently that it would continue its probe and educate audits through September (read more in the CDI Strategies eNewsletter). In it’s MLN Connects release last week, CMS announced a provider conference call on the matter scheduled for today Thursday, February 27; 2:30-4 p.m., Eastern. (To Register: Visit MLN Connects™ Upcoming Calls.)
The “2-Midnight Rule,” modifies longstanding policy on Medicare Administrative Contractor review of inpatient hospital and critical access hospital (CAH) admissions to being deemed “appropriate” when the physician expects the patient to require a stay that crosses at least two midnights. For CDI specialists, the change could mean additional responsibilities for examining the medical record documentation to ensure that medical necessity related to the “2-Midnight Rule” gets captured. In some facilities, CDI staff stepped forward immediately pulling interdisciplinary teams together to brainstorm ways to capture the necessary information (read more about how Alamance Campus of Cone Health in North Carolina proceeded in the October 2013 edition of the CDI Journal).
Q: I have heard that we should use materials from the physician’s world support our queries, such as publications from the American Medical Association. I tried searching for documentation tips related to medical necessity but was not able to find anything relevant. Do you have any suggestions about where I should start?
A: Physicians tend to “listen” or respect such definitions if they come from medical literature/research than if we describe definitions based on AHA Coding Clinic for ICD-9-CM or the Official Guidelines for Coding and Reporting.
Let’s say your CDI program wants to develop guidelines, standard definitions, for what constitutes acute and chronic respiratory failure. The CDI staff members will look to these definitions to determine whether a query is warranted, include them on physician educational tools such as newsletters or posters, and cite them as references on related query forms. Examples of good resources are the National Kidney Foundation, American Heart Association, and American College of Cardiologists. When I search for specific diagnostic guidelines, I like to pull examples from physician professional journals such as The Journal of the American Medical Association (JAMA).
When you cite these journals it lends you and your team a bit more credibility. So when the physician asks why you have initiated a query for a particular diagnosis you can show him/her where you obtained your information and demonstrate that it came from a clinical source. Including a copy of the article with any additional follow up conversations or education is another way to reinforce that you (and your CDI team) have done your research and the guidelines (both diagnostic and expected treatment) are based on evidence in medicine.
While such literature represents a good starting place, increasingly best practice is for CDI professionals to work with coders, physicians, and other non-physician clinical providers to develop a consensus definition for commonly queried diagnoses. So, for example, you might research clinical indicators for acute and chronic respiratory failure and cite the sources you find. Then you could review these with the coding team to assess the related coding definitions. Then bring all this information to bear, working with your pulmonologists on staff using their professional associations or publications to define the terms in question. [more]
In its continuing quest to halt ICD-10 implementation, the AMA is touting a new study by Nachimson Advisors that shows much higher transition costs to physician practices than initially estimated in 2008.
In addition, the AMA contends in a February 12 letter to HHS Secretary Kathleen Sebelius that ICD-10 will not improve patient care, but instead “could disrupt efforts to transition to new delivery models.”
In the initial 2008 study, Nachimson Advisors estimated that small physician practices would spend a median of $83,000 to implement ICD-10. The amount went up to $285,195 for medium practices and $2.7 million for larger practices.
In the updated 2014 study, Nachimson estimated the transition costs at:
- $56,639‐ $226,105 for small practices
- $213,364‐ $824,735 for medium practices
- $2,017,151‐$8,018,364 for large practices
The biggest potential costs are software upgrades and lost productivity. Providers had an extra year to implement ICD-10, thanks in no small part to the AMA’s complaints. Smart organizations and practices used that time to spread out their costs, test their systems, and train their coders, billers, front-end staff, physicians, pretty much everyone but the custodial and kitchen staff.
The ones who counted on the AMA forcing another delay—or stopping ICD-10 altogether—didn’t. And in the end, they are the ones who will likely see higher costs. If you can spread out payments, like a mortgage, you can keep the costs more manageable. If you try to do everything all at once at the last minute, costs go up. It’s also more difficult to find a big chuck of money in one year’s budget.
The AMA also points out that physicians and coders will be going from approximately 16,000 ICD-9-CM codes to 68,000 ICD-10-CM codes. True, but the AMA fails to acknowledge two things:
- No coder or physician is going to use all 68,000 codes. Most coders and physicians will use a small subset of codes the same way they do now. Cardiologists aren’t going to be using neurology codes. That cuts down on the number of possible codes.
- Some part of that increase in codes is due to laterality—you go from one ICD-9-CM code to three or four ICD-10-CM codes for a condition just by adding laterality. Physicians should already be documenting laterality. Coders just need to start looking for it.
What physicians will need to do is document better. That’s not a new concept. It’s good patient care. Isn’t that what physicians want?
The most interesting line in the report comes almost near the end: “A poorly executed ICD‐10 implementation effort will increase those risks [of payment disruptions] and expose practices to large costs in 2014 and beyond.”
The report also states that planning must take place now to mitigate risks and allow practices to continue to operate efficiently. If you are just starting to plan now, you are in big trouble. ICD-10 implementation isn’t going to happen overnight, but regardless of the AMA’s wishes, it is going to happen.
Editor’s Nte: This article first appeared on the ICD-10 Trainer Blog
Many ACDIS 2014 conference attendees will no doubt be new to the CDI profession. Thrust into a whole new world and vision of what it means to work in healthcare, CDI professionals frequently struggle to merge their knowledge base from their previous roles into the new clinical documentation investigative mind-frame. For those with multiple years’ experience, finding the courage to consistently perfect and expand the influence of CDI within your organization often seems like an insurmountable task, a real-world myth of Sisyphus.
Every year, the ACDIS conference serves as an oasis from such troubles providing session after session of inspirational ideas to help you expand your CDI program’s perspective. Every year, the ACDIS conference provides a venue for new and experienced CDI professionals to network with one another, share their stories, and learn from each other.
In this tradition, ACDIS is pleased to announce this year’s keynote speaker Rich Bluni, RN, Studer Group, author of Inspired Nurse and Oh No! Not More of That Fluffy Stuff. In his presentation, Bluni reminds all healthcare employees why we chose this profession. He provides a wealth of action-oriented “spiritual stretches” to help participants more fully integrate the gifts of healthcare—joy, wonder, gratitude, insight and grief—into their daily lives. His personal stories illuminate those sacred moments we all experience.
Bluni has more than 17 years of clinical, legal, risk management, patient safety and nursing management experience. With clinical experience in a broad range of areas such as pediatric intensive care, trauma, behavioral health, and emergency medicine, Bluni understands the challenges, joys and value of purpose, worthwhile work and making a difference in healthcare.
Watch this short video for a taste of what we know will be an inspiring keynote session and… see you in Vegas!
The healthcare system in the United States is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation. This relationship then makes documentation and coding truly dependent upon each other; without one you don’t have the other. It sounds plain and simple, but of course it is not.
The use of coded data continues to be very important as the healthcare industry works to obtain information for quality measures, outcomes, research, management of resources, reimbursement methodologies, and payment. Such important data require accurate clinical coding, which requires complete and accurate clinical documentation. Indeed, more specific documentation will lead to more specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and soon ICD-10-CM and ICD-10 Procedure Coding System (PCS) code assignment. The result will be more accurate severity of illness (SOI), acuity, and risk of mortality (ROM) -patient data.
Clinical coding makes possible the reporting of mortality data in the United States and to the World Health Organization (WHO). Coded data also allow government and other third-party payers to reimburse healthcare providers for the care and services given in all settings. Coded data and information are also the primary sources for -administrative management of medical services and are sources of epidemiologic research and statistical data pertaining to inpatient stays. The National Center for Health Statistics (NCHS) and the Centers for Medicare & Medicaid Services (CMS) are the U.S. government agencies responsible for overseeing all changes and modifications to ICD-9-CM and for implementing ICD-10-CM and ICD-10-PCS.
As the healthcare industry in the United States transitions to ICD-10, awareness of the need for greater clinical documentation specificity and the code specificity that correlates to it is increasing. The ICD-10-CM diagnosis coding system and ICD-10-PCS procedural code system were designed to provide more clinical information via coded data. A strong understanding of specific coding challenges and areas that require more attention can facilitate a strategic approach to ICD-10 success.
Editor’s Note: This excerpt was adapted from ICD-10 Coding and Physician Language Strategies for Complete Documentation, Third Edition by Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS.