audit-tool-hgsa

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Description

E/M Documentation Auditors' InstructionsMedicare1. HistoryPart BRefer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, whichbest describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row toidentify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type ofhistory.After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.HPI: Status of chronic conditions:Status ofStatus of 31 condition 2 conditions 3 conditions1-2 chronicHGSADMINISTRATORS DOCUMENTATION WORKSHEETchronicORconditionsconditionsHPI (history of present illness) elements:Location Severity Timing Modifying factorsBrief ExtendedQuality Duration Context Associated signs and symptoms (1-3)(4 or more)ROS (review of systems):Constitutional Ears,nose, GI Integumentary EndoNonePertinent to Extended **Complete(wt loss, etc) mouth, throat GU (skin, breast) Hem/lymphBeneficiary HIC #problemEyes Card/vasc Musculo Neuro All/immuno(2-9 systems)(1 system)Resp Psych All others negativePFSH (past medical, family, social history) areas:Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)Complete*None PertinentFamily history (a review of medical events in the ...

Informations

• Publié par: Mithir
• Nombre de lectures: 99
• Langue: English

Extrait

8985-1 F01/02

Medicare Part B

HGSADMINISTRATORS DOCUMENTATION WORKSHEET

Beneficiary HIC #

Provider Number

Date of Service

Procedure Code Reported

Check one:Agree Disagree

Documented Procedure Code Level

OVERPAYMENT AMOUNT $

Camp Hill, PA17089 www.hgsa.com

E/M Documentation Auditors' Instructions 1. History

Refer to data section (table below) in order to quantify.After referring to data, circle the entry farthest to theRIGHTin the table, which best describes the HPI, ROS and PFSH.If one column contains three circles, draw a line down that column to the bottom row to identify the type of history.If no column contains three circles, the column containing a circle farthest to theLEFT, identifies the type of history. After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5. HPI: Statusof chronic conditions: Status of Status of 3 1 condition2 conditions3 conditions 1-2 chronic chronic OR conditions conditions HPI (history of present illness) elements: Location SeverityTiming Modifyingfactors Brief Extended Quality DurationContext Associatedsigns and symptoms or more) (1-3) (4 ROS (review of systems): Constitutional Ears,nose,GI IntegumentaryEndo None (wt loss, etc)mouth, throatGU (skin,breast) Hem/lymph Pertinent to Extended **Complete problem Eyes Card/vascMusculo NeuroAll/immuno (2-9 systems) (1 system) Resp PsychAll others negative PFSH (past medical, family, social history) areas: Past history ( the patient's past experiences with illnesses, operation, injuries and treatments) Complete* None Pertinent Family history (a review of medical events in the patent's family, including diseases which may be (2 or 3 history areas) (1 history area) hereditary or place the patient at risk) Socal history (an age appropriate review of past and current activities) PROBLEM EXP.PROB. COMPRE- DETAILED FOCUSED FOCUSED HENSIVE *Complete PFSH: 2 history areas:a) Established patients - office (outpatient) care, domiciliary care, home care; b) Emergency department; c) **10 or more systems, or some systems with Subsequent nursing facility care; d) Subsequent hospital care; and, statement "all others negative " e) Follow-up consultations. 3 history areas:a) New patients - office (outpatient) care, domiciliary care, home care;b) Initial consultations; c) Initial hospital care; d) Hospital observation; and, e) Comprehensive nursing facility assessments.

2. Examination

Refer to data section (table below) in order to quantify.After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in Section 5.

Limited to affected body area or organ system (one body area or system related to problem)

Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7) Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above) General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions)

Body areas: Head, including face Back, including spine Organ systems:

Chest, including breasts and axillae Genitalia, groin, buttocks

Constitutional Ears,nose, (e.g., vitals, gen app)mouth, throat Eyes Cardiovascular

 Resp  GI  GU

Musculo Skin Neuro

Abdomen Neck Each extremity

- 1 -

Psych Hem/lymph/imm

PROBLEM FOCUSED EXAM

EXPANDED PROBLEM FOCUSED EXAM

DETAILED EXAM

COMPREHENSIVE EXAM

1 body area or system

Up to 7 systems

Up to 7 systems

8 or more systems

PROBLEM EXP.PROB. COMPRE- DETAILED FOCUSED FOCUSED HENSIVE

5. LE V E LO FS E R V I C E Beneficiary HIC #:Date of Service: 3. MedicalDecision Making Outpatient, Consults (OUTPATIENT, INPATIENT & CONFIRMATORY) and ER Number of Diagnoses or Treatment Options Amount and/or Complexity of Data Reviewed New Office / Consults / EREstablished Office Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the table For each category of reviewed data identified, circle the number in the points Requires 3 components within shaded area Requires 2 components within shaded area below. (Thereare maximum number in two categories.)Do not column. Totalthe points. PF EPF D C C Minimal categorize the problem(s) if the encounter is dominated by History problem PF EPFD C counseling/coordinating of care, and duration of time is not specified. ER:PF ER:EPF that may Amount and/or Complexity of Data Reviewed ER:EPF ER:D ER:C In that case, enter 3 in the total box. not PF EPF D C C Points Reviewed Data require Number of Diagnoses or Treatment Options Examination presence PF EPFD C 1 Review and/or order of clinical lab tests ER:PFER:EPF A B X C= D ER:EPFER:D ER:C of 1 Review and/or order of tests in the radiology section of CPT physician F Number Complexity S SF L M H Problem(s) Status Points Result 1 of medical SF LM H Review and/or order of tests in the medicine section of CPT Self-limited or minor 1 ER:SF ER:MER:H decision ER:LER:M Discussion of test results with performing physician (stable, improved or worsening) Max = 2 1 Average Time 10 New (99201) 20 New (99202) 30 New (99203) 45 New (99204)  60 New (99205) Decision to obtain old records and/or obtain history from Est. problem (to examiner); stable, improved 1 1 15 Outpt cons (99241) 30 Outpt cons (99242) 40 Outpt cons (99243) 60 Outpt cons (99244)  80 Outpt cons (99245) (minutes) someone other than patient Inpat cons (99255)Inpat cons (99251)Inpat cons (99252)Inpat cons (99253)Inpat cons (99254) 20 40 55 80 110 5 104015 25 Est. problem (to examiner); worsening 2 (Confirmatory Conf cons (99271)Conf cons (99272)Conf cons (99273)Conf cons (99274)Conf cons (99275) Review and summarization of old records and/or obtaining ER (99285)ER (99283)ER (99284)ER (99281)ER (99282) (99211) (99212) (99213) (99214)(99215) consults & ER have New problem (to examiner); no additional 3 history from someone other than patient and/or discussion of 2 no average time) workup planned case with another health care provider Max = 1 Level III III IV VI IIIII IV V New prob. (to examiner); add. workup planned 4 Independent visualization of image, tracing or specimen itself TOTAL 2 (not simply review of report) Multiply the number in columns B & C and put the product in column D. TOTAL Enter a total for column D. INPATIENT Bring total toline Ain Final Result for Complexity (table below) Subsequent Inpatient/Follow-upInitial Hospital/Observation Bring total toline Cin Final Result for Complexity (table below) Consult Requires 3 components within shaded area Requires 2 components within shaded area Use the risk table below as a guide to assign risk factors.It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide.Circle the most appropriate factor(s) in each category.The overall measure of risk is the highest level circled. HistoryD or CC CPF intervalD intervalEPF interval Risk of Complications and/or Morbidity or Mortality Enter the level of risk identified in Final Result for Complexity (table below). Level of Management Options Diagnostic Procedure(s) Presenting Problem(s) Risk Examination Ordered Selected EPF DD or C C C PF Laboratory tests requiring venipuncture • • One self-limited or minor problem, • Chest x-rays • Rest Complexity of medical e.g., cold, insect bite, tinea corporis • EKG/EEG • Gargles H SF/L M H SF/L M Minimal decision • Urinalysis • Elastic bandages Ultrasound, e.g., echo Superficial dressings • • 30 Init hosp (99221)50 Init hosp (99222)70 Init hosp (99223) 15 Subsequent(99231) 25Subsequent (99232) 35 Subsequent (99233) Average time (minutes) • KOH prep Observ careObserv careObserv care 10 FUcons (99261)20 FUcons (99262) 30 FUcons (99263) (Observation care has no average time) (99218) (99219)(99220) Level • Physiologic tests not under stress, e.g.,pulmonary III I III II • Two or more self-limited or minor problems III function tests • Over-the-counter drugs • One stable chronic illness, e.g., well controlled • Non-cardiovascular imaging studies with contrast, • Minor surgery with no identified risk factors hypertension or non-insulin dependent diabetes, e.g., barium enema Physical therapy • cataract, BPH Superficial needle biopsies Low • • Occupational therapy • Acute uncomplicated illness or injury, e.g., cystitis, allergic IV fluids without additives NURSING • Clincal laboratory tests requiring arterial puncture Annual Assessment/Admission • rhinitis, simple sprain • Skin biopsies Subsequent Nursing Facility FACILITY New PlanOld Plan ReviewAdmission Requires 3 components within shaded area Requires 2 components within shaded area • One or more chronic illnesses with mild exacerbation, • Minor surgery with identified risk factors Physiologic tests under stress, e.g., cardiac stress test, • progression, or side effects of treatment • Elective major surgery (open, percutaneous or fetal contraction stress test • endoscopic) with no identified risk factors History D intervalD intervalinterval EPFC PFintervalinterval D Two or more stable chronic illnesses Diagnostic endoscopies with no identified risk factors • Undiagnosed new problem with uncertain prognosis, • Deep needle or incisional biopsy • Prescription drug management • Moderate e.g., lump in breast • Cardiovascular imaging studies with contrast and no • Therapeutic nuclear medicine Acute illness with systemic symptoms, e.g., • identified risk factors, e.g., arteriogram cardiac cathIV fluids with addititives • Examination C CEPF DC PF • • Closed treatment of fracture or dislocation without pyelonephritis, pneumonitis, colitis Obtain fluid from body cavity, e.g., lumbar puncture, Acute complicated injury, e.g., head injury with brief loss thoracentesis, culdocentesis • manipulation of consciousness Complexity of medical SF/L Mto HM to HSF/L MM to H decision One or more chronic illnesses with severe exacerbation, • Elective major surgery (open, percutaneous or • progression, or side effects of treatment endoscopic with identified risk factors) Average time (minutes) Acute or chronic illnesses or injuries that may pose a threat to Cardiovascular imaging studies with contrast with • • Emergency major surgery (open, percutaneous or • life or bodily function, e.g., multiple trauma, acute MI,identified risk factors 30 40 50 15 25 35 (Confirmatory consults & ER have no average (99301) (99302) (99303) (99311) (99312) (99313) endoscopic) pulmonary embolus, severe respiratory distress, progressive time) Cardiac electrophysiological tests High • • Parenteral controlled substances • Diagnostic endoscopies with identified risk factors severe rheumatoid arthritis, psychiatric illness with potential • Drug therapy requiring intensive monitoring for toxicity threat to self or others, peritonitis, acute renal failure Level I III I IIII III Discography • Decision not to resuscitate or to de-escalate care • An abrupt change in neurologic status, e.g., seizure, TIA, • because of poor prognosis weakness or sensory loss DOMICILIARY (Rest Home, Custodial Care) and Home Care Final Result for Complexity New Established Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column.Otherwise, draw a line down the column with the 2nd circle from the left. Requires 3 components within shaded area Requires 2 components within shaded area After completing this table, which classifies complexity, circle the type of decision 4. Time making within the appropriate grid in Section 5. History C PFinterval EPFinterval Dinterval CPF EPF D C Final Result for Complexity If the physician documents total timeandsuggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: 2 3 ≤  1 ≥  4 Number diagnoses or prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction A Minimal Limited Multiple Examination CEPF DC PFPF EPF D C Extensive treatment options or discussion with another health care provider. M H Complexity of SF/L SF/LM H B Face-to-face in outpatient setting Highest Risk Minimal LowModerate High Time: HM H Does documentation reveal total time? Unit/floor in inpatient setting Yes No medical decision SF LM SFL M Amount and complexity ≤  1 Does documentation describe the content of counseling or coordinating care? C 2 3 ≥  4 Yes No No average time Domiciliary (99321)Domiciliary (99322)Domiciliary (99323)Domiciliary (99331)Domiciliary (99332)Domiciliary (99333) of data Minimal Limited Multiple Home careHome careHome care Extensive Home care (99349)Home care (99348)Home care (99347)Home care (99343)Home care (99342)Home care (99341)  established or low  (99344)(99345) (99350) Does documentation reveal that more than half of the time was counseling or Yes No coordinating care? STRAIGHT- LOW MODERATEHIGH Level III IIIIV VI II III IV Type of decision making FORWARD COMPLEX. COMPLEX.COMPLEX. If all answers are "yes", select level based on time. PF = Problem focusedEPF = Expanded problem focusedD = DetailedC = ComprehensiveSF = StraightforwardL = LowM = ModerateH = High 8985-2 E11/03 - 2 - - 3 -