By Nettie McFarland, RHIT, CCS-P, CHC, Director of Provider Education
Clinical documentation serves many purposes, supporting everything from risk management and medicolegal review to coding and billing. As you might expect, clinicians find it challenging to manage the needs of many constituents within a single document.
Billing-related documentation can be particularly challenging, as details provided for medical and legal purposes may inadvertently interfere with the language coders need to see to support appropriate reimbursement.
To help clear up confusion, Ventra Health’s Provider Education team offers the following tips for Hospital Medicine documentation excellence. Start here to build your proficiency.
For a more detailed discussion, please watch the webinar hosted by Nettie McFarland, RHIT, CCS-P, CHC, Director of Provider Education.
1. Document “clinically appropriate” histories and physical exams.
The old requirement for exhaustive, box-counting histories and physicals changed in January 2023 when the AMA rolled out new E/M guidelines to reduce the administrative burden. Focus your documentation now on the details relevant to this patient visit, not overall patient status, and subsequent visits do not need a repeat history.
2. Zero in the elements of level assignment.
In Hospital Medicine, level assignments for billing can be based either on treatment time or Medical Decision-Making (MDM) criteria.
For time-based level assignments, the E/M guidelines specify Low, Moderate, and High time lengths for three types of patient visits: Initial (99222), Subsequent (99232), and Admit/Discharge Same Day (99235).
MDM is composed of three elements—Complexity of Problems Addressed (COPA), Data to be interpreted and analyzed, and Risk of patient management. Within each element, the AMA guidelines clearly delineate the symptoms and treatment activities that constitute Low, Medium, or High CPT severity levels for each type of patient visit. The highest severity level in two of the three medical decision-making elements determines the appropriate billing code level.
The chart below illustrates both the time lengths and the symptoms/activities that reflect a Moderate MDM designation. For proper reimbursement, hospitalists must learn the elements of level assignment and include the guidelines’ precise language in their documentation. Additionally, they should get in the habit of documenting their treatment times. Coders can take over from there and determine which method of level assignment will be most appropriate.
One additional note about documenting time: Length of stay becomes critical for billing under the 8 Hour Rule, which dictates different CPT codes for patient stays or observation of greater than or less than eight hours. This is one more reason to be diligent about documenting physician treatment time, admission/discharge times, and the time patients were put into an observation status.
| Level of MDM (Based on 2 out of 3 Elements of MDM) |
|---|
| Moderate 99222 – Initial Documented Total Time: 55 minutes 99232 – Subsequent Documented Total Time: 35 minutes 99235 – Admit/Discharge Same Day Documented Total Time: 70 minutes |
| Number and Complexity of Problems Addressed at the Encounter |
|---|
| Moderate • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or • 2 or more stable, chronic illnesses; or • 1 undiagnosed new problem with uncertain prognosis; or • 1 acute illness with systemic symptoms; or • 1 acute, complicated injury |
| Amount and/or Complexity of Data to Be Reviewed and Analyzed *Each unique test, order or document contributes to the combination of 2 or combination of 3 in Category 1 below |
|---|
| Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following: • Review of prior external note(s) from each unique source; • Review of the result(s) of each unique test; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) |
| Risk of Complications and/or Morbidity or Mortality of Patient Management |
|---|
| Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health |
3. Document the process.
As the chart demonstrates, a notable change with the new guidelines is the emphasis on clinical judgment and decision making. In determining severity level, clinicians now get credit for activities such as tests and treatments considered and ruled out; consultations with specialists, independent historians (such as an adult child), or social workers; and independent interpretation of test results ordered by another physician. Hospitalists may overlook these elements when documenting a patient visit, but they can now significantly impact reimbursement.
4. Learn the new E/M documentation vocabulary.
To further complicate documentation, the new E/M guidelines brought us a new vocabulary used for MDM leveling that is sometimes directly at odds with the language hospitalists are accustomed to using for care continuity purposes.
These are among the most important new definitions:
- Stable – To categorize medical decision making, stable is defined by the specific treatment goal. A patient who is not at their treatment goal is not stable.
- Self-limited or minor – A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
- Acute, uncomplicated illness or injury – A recent or new short-term problem with a low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and a full recovery without functional impairment is expected.
- Acute illness with systemic symptoms – For systemic general symptoms such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate the symptoms, shorten the course of the illness, or to prevent complications, refer to definition for “self-limited or minor.”
- Acute complicated injury – An injury requiring treatment that includes evaluation of bodily systems that are not directly part of the injured organ, the injury being extensive, or the treatment options being multiple and associated with risk of morbidity.
- Chronic illness with severe exacerbation, progression, or side-effects of treatment – The severe exacerbation or progression of a chronic illness or severe side-effects of treatment that have significant risk of morbidity and may require escalation of care.
5. Document the redefined “substantive portion of the MDM” when billing for split/shared visits.
The guidelines for billing split/shared visits have changed recently. In the past, providers could bill as the physician of record by doing either the history or the exam portions of the patient visit. That is no longer the case.
Now, the primary provider is defined for billing as the provider who spent more than half the total time treating the patient or who performed a substantive portion of the medical decision making. For billing purposes, a substantive portion of the MDM means the provider managed at least two of the three medical decision-making elements—COPA, Data, or Risk.
To clearly demonstrate compliance with these new guidelines, and to reduce payer audit challenges, we recommend documenting responsibility for the substantive portion of the medical decision making in an opening statement such as this:
“I performed the substantive portion of the MDM. For the problems addressed, I personally developed, reviewed, and/or approved the plan and assessment as documented by the APP and take responsibility for the plan.” This statement should be supplemented by adding information specific to the patient.
Questions?
Nettie McFarland, RHIT, CCS-P, CHC, Director of Provider Education at Ventra Health, walks providers through these tips and more in this recorded webinar. Or, reach out to us here.
