A Documentation Toolbox

Here are tools for making compliance with the new documentation guidelines easy -- well, easier.

Robert L. Edsall and Kent J. Moore

For the past three months, FPM articles have taken you on a tour of Medicare's new guidelines for documenting E/M codes. By now, your Medicare carrier is probably well into a program designed to introduce the guidelines to you. And we're now a little more than three months away from the time when a focused review of your E/M services will, as one carrier medical director put it, "have the same weight and consequences as a review of any service provided to Medicare beneficiaries." If you don't feel comfortable with the guidelines or can't imagine how you'd fare if your E/M services were in fact audited, you probably have a lot of company. Yes, the guidelines are relatively simple by contrast with the general run of Medicare regulations. And yes, input from the AMA, the Academy and other medical societies has kept them reasonably close to what you were taught about documentation in the first place. But they're still complex enough, unfamiliar enough and idiosyncratic enough to be daunting.

Time and practice will increase your familiarity with the guidelines, as they did with the new E/M codes when they came out. And your carrier is likely to be doing whatever it can to help. What we hope to do here is to provide you with some tools you can use to master the guidelines more quickly -- to internalize them and put them to use for you. In the process, we'll make one last, brief stop on our tour of the guidelines to explore the solitary guideline devoted to documenting when time is the controlling factor. We'll also give you an opportunity to try your skill at applying the guidelines in the evaluation of a sample progress note. Let's start by finishing the tour.

While the CPT manual specifies average times for E/M visits of various types, the length of the visit becomes significant only when more than half of the "intraservice" time is devoted to counseling or coordination of care. Then time becomes the sole determinant of the level of service.

According to CPT, counseling is a discussion with a patient or family concerning one or more of the following areas:

Coordination of care refers to arranging and organizing the patient's care with other providers and agencies. Intraservice time is defined as face-to-face time when the encounter takes place in the office or another outpatient setting and as floor/ unit time in the hospital or nursing facility.

The times mentioned as part of the descriptions of most E/M codes are typically referred to as averages, the implication being that, while some encounters take more time, some take less, so everything evens out. Nevertheless, in the context of counseling and coordination of care, the average face-to-face times given in the CPT manual are treated more like floors than averages. For instance, if you have an established-patient visit involving total face-to-face time of 12 minutes, 7 minutes of which is spent on counseling, plan to code it as a 99212 -- if you plan to use time as the determining factor. Don't neglect the possibility of coding on the basis of history, exam and decision making if that seems to describe the visit better. Even though you have spent more than the 10 minutes specified in the manual as average for 99212, you have not reached the 15 minutes specified as average for 99213. Your carrier is unlikely to accept the argument that this really was a 99213 that took less than the average amount of time. This assumption that all visits take longer than average is a useful safety factor in submitting claims predicated on the length of the visit (see "When time is a factor" below).

If you do report a level of service based on counseling or coordination of care, the guidelines ask that you 1) record the total intraservice time and 2) describe your activities in counseling or coordination of care. They don't ask you to give the number of minutes you spent in those activities. For example, imagine you code a 99213 based on counseling and/or coordination of care and document that you spent 16 minutes in total face-to-face time. Your description of the counseling or coordination of care you provided should be complete enough to substantiate your implied claim that you spent more than 8 minutes of that time in counseling or coordination of care.

One reason the documentation guidelines can be difficult to adapt to at first is that they make level of service depend on counting the systems covered in the ROS and the exam, counting elements of the PFSH covered and so on. The typical note is not set up with countability in mind, and in any case, you may be used to thinking in terms of a set of systems slightly different from the ones used by Medicare. Moreover, counting the systems covered has no clinical rationale: If the guidelines didn't imply that it was important, you'd have no reason to count.

To help make the transition easier, we've designed a checklist form that simplifies the counting required by the documentation guidelines while allowing you to produce a SOAP note or whatever form of progress note you're comfortable with. To use the checklist portion of the form, just make sure you put a check mark in the appropriate column for every system you cover in the ROS, every area of the PFSH you touch on and every system or body area you examine. In circumstances where you would normally write, for instance, "GI normal" with no further elaboration, a check mark in the Normal column should save you the need to write anything. (Remember that the guidelines require that you note specifically negative responses on the ROS and negative findings on the exam if they are relevant to the presenting problem.) Naturally, each time you check See note, you'll need to explain your findings in the open area to the right. Leave blank any items you do not cover in the history or exam.

Since the form is set up so that you check only those items you touch on, you will be able to determine the number of systems covered in the ROS, the number of areas covered in the PFSH and the number of systems and body areas examined simply by counting the check marks in each section.

Note that, in the exam section, body areas are printed in gray bands to distinguish them from systems, so here it's a matter of counting up "gray check marks" for body areas and "white check marks" for systems. Since it may be hard to see a distinction between the GI system and the abdomen body area and between the GU system and the genitals/groin/buttocks body area for the purposes of the exam, each of these pairs is enclosed in brackets. The brackets should remind you that, under most circumstances, you'll probably want to check only one of each pair -- whichever makes more sense in the clinical situation.

The one guideline-related counting task not handled by the checklist is counting the elements of the HPI included in the note. The form does provide help in this respect, however, by listing the seven elements of the HPI at the bottom of the page as a reference against which to check the HPI you enter at the top of the note section.

The form also provides a documentation shortcut for encounters dominated by counseling or coordination of care. For such an encounter, you need only check the box labeled Couns/coord > 50% (i.e., "Counseling and/or coordination of care took more than 50 percent of the visit") and enter the total face-to-face time of the encounter to provide all the information Medicare deems necessary to code such an encounter. If you do check the counseling/coordination box, be sure to include in the note an account of what you did along these lines.

The checklist is designed to accompany your note without materially affecting what you write down in the note. Another way of making your documentation more responsive to payer needs -- and, presumably, less liable to downcoding on audit -- is simply to include more information in your note. Naturally, you can do so with or without adopting the checklist (see "Taking SOAP to SNOCAMP" below).

While the new documentation guidelines are complex enough that we've devoted four articles to exploring them, the crux of the guidelines can be expressed in an abbreviated form small enough to slip into your coat pocket. To round out our introduction to the guidelines, we've developed a pocket guide and bound a copy into this issue of Family Practice Management.

As you will probably recognize, the pocket guide consists largely of tables adapted from FPM's previous articles on the guidelines or from the guidelines themselves. If you have folded the guide properly, the front should show two "Code selection" tables at the top with a table headed History at the bottom and an arrow indicating that the History table contributes information to the History column of the code selection tables. Open the first flap, and you should see the table headed Exam with an arrow indicating its relationship to the Exam column of the code selection tables. Open the second flap, and you should see a similar arrangement for medical decision making, together with the three tables that contribute information to the decision-making table. This arrangement replicates the logical connection that the guidelines make between the key components of a note and the code that note justifies.

To save space, the tables included in the pocket guide are abbreviated as much as we thought possible while maintaining their usefulness. In particular, the table of risks is a significantly abridged version of the one provided in the documentation guidelines. In some cases, you may want to refer to the original for more information. This pocket guide is intended to jog your memory, not to teach you everything you need to know about the guidelines. For a detailed analysis, refer to earlier articles in this series.

While the checklist form we discussed above is designed to help as you write or dictate your note, this pocket guide is intended to serve after the fact. It contains the essentials you need for determining what code to submit, based on what you have documented. It should also be useful in your own chart audits as a way of determining whether your practice is generally underbilling or overbilling Medicare.

To see how the pocket guide works, let's use it to evaluate a sample note:

This is a particularly appropriate example, since it represents a common type of Medicare visit -- the routine follow-up visit for a patient with multiple problems and no significant new complaints. It also highlights some limitations of the guidelines. If you've read the earlier articles in our series or attended workshops offered by your carrier, you ought to be able to use the pocket guide to evaluate this note and come up with a suggested coding level. Now's your chance. In fact, you might find it interesting to read the note and assign a code to it without reference to the guidelines, and then apply the guidelines and see if you come up with a different code. When you've finished, read on to compare your analysis with ours.

History: The History table on the front of the pocket guide doesn't include a column for chief complaint, since that is required for all levels of history and pretty unlikely to be missing from any progress note. Even though the patient in our example has no new complaints, there is a chief complaint in the note, since the guidelines define chief complaint very broadly as a statement "describing the symptom, problem, condition, diagnosis, physician-recommended return or other factor that is the reason for the encounter" (emphasis added). The chief complaint is given in the first sentence of our sample note.

Determining how many elements of the HPI are represented is relatively difficult with a follow-up visit like this when the patient has no new complaints, since the definition of HPI given in the guidelines seems to have been written with acute illness in mind. This limitation of the guidelines is something that HCFA is apparently working to correct, so we may eventually see changes. For the moment, though, the most reasonable course may be to rate the HPI for an encounter like this in terms of the patient's responses to pertinent questions, even though those responses are negative. Here location is addressed (headache, visual changes, extremity numbness, joint pain), as are severity (no increased joint pain) and associated signs and symptoms (since all the problems the patient denied having are presumably raised because of their potential association with the diabetes, hypertension and osteoarthritis). That's a total of three elements of the HPI.

From the History table on the pocket guide, you can see that the three-element HPI limits the possible levels of history for this encounter to problem focused (PF) and expanded problem focused (EPF), since the level of the history is defined as the highest that can be supported by all three components of the history. At least four elements of the HPI would have to be present to support a detailed (D) or comprehensive (C) history. Whether the level of the history is PF or EPF then depends entirely on whether at least one system was reviewed, since, as the table in the pocket guide indicates, the PFSH is not required for either of these levels of history. Any one of the several systems that were apparently reviewed would be enough to establish the level of history as EPF.

Exam: Opening the first flap of the pocket guide exposes the table devoted to the exam. Let's see how our sample note rates according to the table. First, findings are documented for at least six of the body areas listed below the table (head, neck and four extremities) and seven of the systems (constitutional, eyes, ENT/mouth, respiratory, cardiovascular, musculoskeletal and neurologic). According to the table, then, this is either an expanded problem-focused or a detailed exam. And here we come up against another limitation of the documentation guidelines: the lack of clear distinction between these two levels. If the number of systems is the determining factor (and that is by no means clear from the guidelines), this note probably represents a detailed exam; after all, it's one system away from qualifying for comprehensive status. If the extent of the examination of each system examined counts in distinguishing between expanded problem-focused and detailed, the question is a good deal cloudier. This is another issue that HCFA hopes to clear up. For our example, let's be optimistic and assume that we're dealing with a detailed exam here.

Medical decision making: Since the history and the exam differ in level, and since this is clearly an established-patient visit, the level of medical decision making will determine the level of the visit. If you'll open the pocket guide fully, we can use the decision-making tables to evaluate the note.

First, the score for number of diagnoses and management options involved works out to be 3: No new problems are reported, and each established, previously diagnosed problem (diabetes, hypertension and osteoarthritis) counts for one point, since they're all apparently under control or at least not worsening. Second, in evaluating the amount and complexity of data to be reviewed, we have only lab tests to consider. That gives a score of 1 (remember, no matter how many tests of a given class are requested or reviewed, the note earns no more than one point per class). Finally, the level of risk involved seems to be moderate, both because the visit involves prescription drug therapy and because it concerns three stable chronic illnesses. Since the level of decision making for an encounter is determined by the highest two of the three components, the level for this visit is moderate complexity (MC).

In sum, then, we have an expanded problem-focused history, a detailed exam and moderately complex decision making to evaluate on the code-selection table at the top of the pocket guide; since two of the three are enough to determine the level for an established-patient visit, we end up with a code of 99214. Simple, right?

You'll get used to it.

Yes, the guidelines represent another hassle, more complexity in your life and the possibility of a brand new kind of Medicare audit. If you feel like throwing down the guidelines, tearing them up, using bad language or even slamming this issue of FPM down on the table top, go ahead. It will probably do you good. Just try not to slam FPM down too hard. The guidelines are here, though, and they're not going away. In fact, they're soon going to gain clout when E/M services become subject to audit. And you will get used to them; like anything else, they'll get easier to deal with. Soon, like the E/M codes themselves, they'll be second nature.

Remember, too, that HCFA is not alone in wanting to examine your documentation. Managed care organizations (MCOs) are increasingly likely to include chart review in accreditation as it becomes more and more a part of the way they themselves are rated (see "Managed care documentation guidelines"). The Medicare guidelines may well help you make sure your charts are the charts of a doctor MCOs want to contract with. And look on the bright side: Without the documentation guidelines, would you have recognized the encounter we just analyzed as a 99214, or would you automatically have coded it as a 99213? By spending a little more time on documentation, you might earn a well-deserved 50 percent more for visits like this. If the guidelines help you see where you've been cheating yourself, they may well repay you for the trouble you take to learn them and abide by them.

Robert Edsall is editor-in-chief of Family Practice Management. Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.