Demystifying Medical Documentation
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Demystifying Medical Documentation
Created by The Lung Doctor for e-Medtools
A Quick Review of
Medical Documentation
Requirements
Created by The Lung Doctor for e-Medtools
Patient Encounters
The Centers for Medicare and Medicaid
Services (CMS) has published definitions and
documentation guidelines for the key
components of a medical encounter note,
using CPT codes.
Created by The Lung Doctor for e-Medtools
Key Components of Documentation
History Key components in
selecting the level of
Exam E/M services
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
1997Guidelines
1997 Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
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The History
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History Components and Levels
HPI ROS PFSH Type of History
Brief N/A N/A Problem Focused
Brief Problem N/A Expanded
pertinent Problem Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
New patient evaluations MUST have at least a Detailed History
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History of Present Illness
EVERY encounter MUST contain a Chief Complaint!
Preferentially stated in patients’ words
Elements of HPI
Location
Quality Brief
Brief
Severity Contains1-3
Contains 1-3elements
elementslisted
listed
Duration Extended
Extended
Timing Contains≥≥44elements
Contains elements
ORdiscusses
OR discusses33chronic
chronicor orinactive
inactiveconditions
conditions
Context
Modifying factors
Associated Signs and Symptoms
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Review of Systems
Constitutional Symptoms
ProblemPertinent
Problem Pertinent
Eyes
Documentsresponses
Documents responsestotothe
thesystem
system
Ears, Nose, Mouth, Throat directlyrelated
relatedto
tothe
thepresenting
presenting
directly
Cardiovascular problem
problem
Respiratory
Gastrointestinal Extended
Extended
Documentspositive
Documents positiveand
andnegative
negative
Musculoskeletal
responsesto
responses to2-9
2-9systems
systemsrelated
relatedto
to
Integumentary (Skin, Breast) theproblem
problem
the
Neurological
Psychiatric Complete
Complete
Endocrine Documentsall
Documents allpositive
positiveand andnegative
negative
responsesto
responses tosystems
systemsrelated
relatedtotothe
the
Hematologic/Lymphatic
presentingproblem
presenting problemAND ANDall allother
other
Allergy/Immunologic systems(10
(10orormore
moretotal)
total)
systems
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Past, Family and Social History
Past Medical History
Illnesses, Operations, Injuries and Treatments
Family Medical History
Include heritable diseases and those that place the patient at increased risk
Social History
An age appropriate review of past and current activities
Pertinent
Pertinent
Documentatatleast
Document least11item
itemfrom
fromANYANYofofthe
the33areas
areas
ItItmust
mustbe
bedirectly
directlyrelated
relatedtotothe
theproblems
problemsidentified
identifiedininthe
theHPI
HPI
Complete
All initial inpatient services require a Complete PFSH
Document at least 1 item from EACH of the 3 areas
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The Exam
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Recognized Single Organ Systems
Cardiovascular
Ears, Nose, Mouth, Throat
Detailed
Detailed
Eyes Anextended
An extendedexam
examof ofthe
theaffected
affectedbody
bodyarea
area
Genitourinary (Female) ororgans/organ
or organs/organsystem
systemandandanother
another
symptomaticor
symptomatic orrelated
relatedarea
area
Genitourinary (Male)
Hematologic/Lymphatic/Immunologic
Musculoskeletal Comprehensive
Neurologic A general multi-system exam
A complete exam of an organ system and
Psychiatric other related body areas or organ systems
Respiratory
Skin
Mostlevels
Most levelsrequire
requireaaminimum
minimumof
ofaaDetailed
DetailedExam
Exam
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Multi-organ System Exam
Detailed
≥3 vital signs
BP, sitting or standing
BP, supine
Pulse, rate and regularity
Respirations
Temperature
Height
Weight
≥2 elements* of at least 6 organ systems or body areas examined
OR ≥1 element of at least 12 organ systems
Comprehensive
≥2 elements* in at least 9 organ systems or body areas
*Referto
*Refer to1997
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Created by The Lung Doctor for e-Medtools
Single Organ System Exam
Detailed
Document ≥12 elements* (NOT Eye and Psychiatric exams)
Eye and Psych exams document ≥9 elements
Comprehensive
Document ALL elements*
*Referto
*Refer to1997
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Created by The Lung Doctor for e-Medtools
Elements of Individual Organ Systems
Constitutional Cardiovascular
¾ Vital signs ¾ Palpation of heart
¾ General appearance of patient ¾ Auscultation
¾ Nutrition, Body habitus, Development, Deformities,
Grooming ¾ Carotid artery exam
Eyes ¾ Abdominal aorta exam
¾ Inspection of conjunctivae and lids ¾ Femoral arteries exam
¾ Exam of pupils and irises ¾ Pedal pulses exam
¾ Ophthalmoscopic exam of optic discs ¾ Extremities for edema or varicosities
Ears, Nose, Mouth and Throat Chest (Breasts)
¾ External inspection of ears and nose ¾ Inspection
¾ Otoscopic exam ¾ Palpation
¾ Assessment of hearing Gastrointestinal
¾ Inspection of nasal mucosa, septum, ¾ Abdominal exam
and turbinates ¾ Liver and spleen exam
¾ Inspection of lips, teeth and gums ¾ Hernia presence or absence
¾ Exam of oropharynx ¾ Anus, perineum, rectum exam
Neck ¾ Stool for occult blood
¾ Exam of neck
¾ Thyroid
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Respiratory 1997
¾ Assessment of effort
¾ Percussion of chest
¾ Auscultation
¾ Palpation of chest
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Exam elements, continued
Lymphatic Psychiatric
¾ Neck ¾ Judgment and insight
¾ Axilla ¾ Orientation to person, time, place
¾ Groin ¾ Memory, recent and remote
¾ Other ¾ Mood and affect
Musculoskeletal Genitourinary
¾ Gait and station
¾ Inspection, palpation digits and nails Male
¾ Exam of bones, joints, muscles AND 1 ¾ Scrotal contents
or more ¾ Penis
¾ Inspection or palpation ¾ Digital rectal exam of prostate gland
¾ Range of motion and
presence/absence of pain
¾ Stability Female
¾ Muscle strength and tone ¾ External genitalia
Skin ¾ Urethra
¾ Inspection ¾ Bladder exam
¾ Palpation ¾ Cervix
Neurologic ¾ Uterus
¾ Cranial nerves ¾ Adnexa/parametria
¾ Deep tendon reflexes
¾ Sensation 1997Guidelines
1997 Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Created by The Lung Doctor for e-Medtools
Medical Decision
Making
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Elements of Medical Decision Making
• Number of diagnoses or Management Options
• Amount or Complexity of data to be reviewed
• Risk of Complications, Morbidity or Mortality
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Complexity of Medical Decision Making
Number of Amount or Risk of Complexity of
Diagnoses Complexity of Data Complications Decision Making
Or Management to be Reviewed Morbidity or
Options Mortality
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low
Multiple Moderate Moderate Moderate
Extensive Extensive High High
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
22out
outofof33elements
elementsmust
mustbe
bemet
met 1997
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Worksheets
Calculating Documentation Levels
Adaptedfrom
Adapted from
HGSAdministratorsDocumentation
HGSAdministrators DocumentationWorksheet
Worksheet
CMSMedicare
MedicarePart
PartBB
CMS
Created by The Lung Doctor for e-Medtools
History
HPI: Status of chronic conditions □ □
1-2 3
□1 condition □2 conditions □3 conditions
HPI elements □ □
□Location □Severity □Timing □Modifying factors Brief Extended
1-3 4 or more
□Quality □Duration □Context □Associated signs & symptoms
Review of Systems □ □ □ □
□Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes None Pertinent to Extended Complete
Problem 2-9
□CV □MS □Neuro □Aller/Immun □Resp □Psych 1 system Systems
10 or more
Systems
□All others negative
PFSH □ □ □
□Past History □Family History □Social History None Pertinent Complete
1 2 or 3
Problem Expanded Detailed Comprehensive
Focused Problem
Focused
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Examination
Body Areas □ □ □ □
□Head, Face □Chest, Breasts, Axilla 1 Up to 7 Up to 7 8 or more
Body Area Body Areas Body Body Areas
□Abdomen □Neck □Back, Spine or or Areas or
□Genitalia, Groin, Buttocks □Each Extremity System Systems or Systems
Systems
Organ Systems
□Constitutional □ENT □Resp □MS □GI □Skin
□GU □Psych □CV □Eyes □Heme/Lymph □Neuro
Problem Expanded Detailed Comprehensive
Focused Problem
Focused
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Medical Decision Making
Reminder:
There are 3 components used to determine the complexity of medical decision making
• Number of diagnoses or Management Options
• Amount or Complexity of data to be reviewed
• Risk of Complications, Morbidity or Mortality
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Number of Diagnoses or Treatment Options
Complexity of Medical Decision Making
A B x C = D
Problem status Number Points Result
Self-limited or minor Max = 2 1
Established problem (to examiner) 1
Stable or improved
Established problem (to examiner) 2
Worsening
New problem (to examiner) Max = 1 3
No additional workup planned
New problem (to examiner) 4
Additional workup planned
Total
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Amount and/or Complexity of Data Reviewed
Complexity of Medical Decision Making
Reviewed Data Points Result
Clinical lab tests reviewed and/or ordered
1
Review and/or order of tests from radiology section of CPT
1
Review and/or order of tests from medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain history from source other than patient
1
Review and summarization of history obtained from source other than patient
2
Independent visualization of image, tracing or specimen (NOT reviewing report)
2
TOTAL
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Guide to Determining Risk of Complications
Complexity of Medical Decision Making
Risk Presenting Problem Dx Procedure Ordered Management Options Selected
Minimal -1 self-limited or minor problem -Venipuncture -Rest
-X-rays -Gargles
-EKG -Elastic bandages
-EEG
-Urinalysis
-ECHO
Low -2 or more self-limited or minor problems -Physiologic tests NOT under stress i.e., PFTs -OTC drugs
-1 stable, well- controlled chronic illness -Noncardiovascular imaging studies + contrast -Minor surgery without identified risk factors
-Acute uncomplicated illness or injury Barium enema -Physical therapy
-Superficial needle biopsies -Occupational therapy
-Clinical lab tests requiring arterial puncture -IV fluids without additives
-Skin biopsies
Moderate -Mild exacerbation of 1 or more chronic -Physiologic tests under stress -Minor surgery WITH identified risk factors
illnesses Cardiac stress test -Elective major surgery with NO identified risk factors
-2 or more stable, chronic illnesses Cardiopulmonary exercise test -Prescription drug management
-Previously undiagnosed NEW problem with -Diagnostic endoscopies with NO risk factors -Therapeutic nuclear medicine
uncertain prognosis (i.e., breast lump) -Deep needle or incisional biopsy -IV fluids with additives
-Acute illness with systemic symptoms -Cardiovascular imaging studies with contrast -Closed treatment of fracture
-Acute complicated injury NO identifiable risk factors
Cardiac catheterization
-Obtaining body cavity fluid
Thoracentesis
High -Severe exacerbation or progression of -Cardiovascular imaging studies + Risk factors -Elective surgery + Risk factors
1 or more chronic illnesses -Cardiac electro-physiologic tests -Emergency Major surgery
-Acute or chronic illness or injury that -Diagnostic endoscopies + Risk factors -Parenteral controlled substances
threatens life or limb -Discography -Drug therapy requiring intensive monitoring
-Abrupt change in neurologic status -Decision to not resuscitate or to de-escalate care
due to poor prognosis
Thehighest
highestlevel
levelininANY
ANYcategory
categorydetermines
determinesthe
theoverall
overallrisk
risk 1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
The 1997
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Final Determination
Complexity of Medical Decision Making
Number of ≤1 2 3 ≥4
A diagnoses or Minimal Limited Multiple Extensive
treatment options
Highest risk Minimal Low Moderate High
B
Amount and ≤1 2 3 ≥4
C complexity of Minimal or Low Limited Multiple Extensive
data reviewed
Type of decision making Straightforward Low Moderate High
Complexity Complexity Complexity
Circlethe
theappropriate
appropriatedescriptions
descriptionsfor
forRows
RowsA,A,B,B,CC
Circle
TheColumn with22oror33circles
Columnwith circlesdetermines
determinesthe
thefinal
finalComplexity
ComplexityofofMedical
MedicalDecision
DecisionMaking
Making
The
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Determining Overall Service Levels
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Inpatient Encounters
Initial Hospital Encounter Subsequent Inpatient
Or Observation Or Follow up
Requires 3 components within shaded area Requires 2 components
History D or C C C PF EPF D
Examination D or C C C PF EPF D
Complexity of SF/L M H SF/L M H
medical decision
LEVEL I II III I II III
Init Hosp Care
99221 99222 99223 99231 99232 99233
Observation 99261 99262 99263
99218 99219 99220
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Outpatient,
Consults (Outpatient, Inpatient) and ER
New Office / Consult / ER Established Office
Requires 3 components within shaded area Requires 2 components
History PF EPF D C C Minimal PF EPF D C
problem
ER: PF ER: EPF ER: EPF ER: D ER: C that may
not
Examination PF EPF D C C require PF EPF D C
ER: PF ER: EPF ER: EPF ER: D ER: C presence
of
Complexity SF SF L M H physician SF L M H
of medical ER: SF ER: L ER: M ER: M ER: H
decision
LEVEL I II III IV V I II III IV V
New Pt 99-201 -202 -203 -204 -205 99211 -212 -213 -214 -215
Outpt Consult 99-241 -242 -243 -244 -245
Inpt Consult 99-251 -252 -253 -254 -255
ER 99-281 --282 -283 -284 -285
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Documenting Time
As a Determinant of Level of Service
“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%)
the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis,
risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”
Does documentation reveal total time?
Time: Face to face in outpatient setting
□Yes □No
Unit/floor in inpatient setting
Does documentation describe the content of
counseling or coordinating care □Yes □No
Does documentation reveal that more than half
the time was counseling or coordinating care? □Yes □No
Documentation of Time requires that ALL of the answers to the above questions are YES
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted
Created by The Lung Doctor for e-Medtools
Summary Examples
Documentation Requirements
Created by The Lung Doctor for e-Medtools
Initial Hospital Care
Must meet ALL criteria
99223
Comprehensive History and Exam
High complexity Medical decision making
99222
Comprehensive History and Exam
Moderate complexity Medical decision making
99221
Detailed OR Comprehensive History and Exam
Straightforward or Low Complexity Medical decision making
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Initial Inpatient Consultation
Must meet ALL criteria
99255
Comprehensive History AND Exam
High complexity medical decision making
99254
Comprehensive History AND Exam
Moderate complexity medical decision making
99253
Detailed History AND Exam
Low complexity medical decision making
Created by The Lung Doctor for e-Medtools
New Outpatient Encounter
Not a Consult
Must meet ALL criteria
99205
Comprehensive History and Exam
High complexity medical decision making
99204
Comprehensive History and Exam
Moderate complexity medical decision making
99203
Detailed History and Exam
Low complexity medical decision making
Created by The Lung Doctor for e-Medtools
New Outpatient Consult
Must meet all criteria
99245
Comprehensive History
Comprehensive Exam
High complexity medical decision making
99244
Comprehensive History
Comprehensive Exam
Moderate complexity medical decision making
99243
Detailed History
Detailed Exam
Low complexity medical decision making
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Established Outpatient Encounter
Must meet 2 out of 3 criteria
99215
Comprehensive History
Comprehensive Exam
High complexity medical decision making
99214
Detailed History
Detailed Exam
Moderate complexity medical decision making
99213
Expanded Problem Focused History
Expanded Problem Focused Exam
Low complexity medical decision making
Created by The Lung Doctor for e-Medtools
We hope you found this presentation helpful!
Remember to thank all the patient and knowledgeable billing and coding
specialists who make themselves available to answer your questions in
more detail!
