CLINICAL

DOCUMENTATION
REFERENCE GUIDE
A comprehensive resource for clinical documentation experts

FIRST EDITION
 Disclaimer
Decisions should not be made based solely upon information within this reference guide. All judgments impacting career
and/or an employer must be based upon individual circumstances including legal and ethical considerations, local condi-
tions, payer policies within the geographic area, and new or pending government regulations, etc.

AAPC does not accept responsibility or liability for any adverse outcome from using this reference guide for any reason
including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the individual’s misun-
derstanding or misapplication of topics.

Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’
bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may
vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement,
etc., may change at any time in any particular area.

AAPC has obtained permission from various individuals and companies to include their material in this reference guide.
These agreements do not extend beyond this program. It may not be copied, reproduced, dismantled, quoted, or presented
without the expressed written approval of AAPC and the sources contained within.

No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted
in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording or taping)
without the expressed written permission from AAPC and the sources contained within.

Medicare Disclaimer
This publication provides situational examples and explanations, of which many are taken from the Medicare perspective.
The individual, however, should understand that while private payers typically take their lead regarding reimbursement
rates from Medicare, it is not the only set of rules to follow.

While federal and private payers have different objectives (such as the age of the population covered) and use different
contracting practices (such as fee schedules and coverage policies), the plans and providers set similar elements of the
quality in common for all patients. Nevertheless, it is important to consult with individual private payers if you have ques-
tions regarding coverage.

AMA Disclaimer
CPT® copyright 2019 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not
part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for
Medicare & Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims
responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information
contained in this product.

© 2020 AAPC
2233 South Presidential Drive, Suites F–C, Salt Lake City, Utah 84120
800-626-2633, Fax 801-236-2258, www.aapc.com
Published: 03242020. All rights reserved.
Print ISBN: 978-1-626889-798
e-Book ISBN: 978-1-626889-927

II Clinical Documentation Reference Guide AAPC | 1-800-626-2633

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX

Chapter 1
The Purpose of Clinical Documentation Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Quality of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Least Expected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Financial Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Legal Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Routine Checks for Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Mastering the Documentation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter 2
Implementation of a CDI Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Conduct Appropriate Training and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Enforcement of Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3
Evaluation and Management Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
An Overview of the Anatomy of the Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1995 and 1997 Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 4
2021 Office or Other Outpatient Services Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
American Medical Association’s (AMA’s) 2021 Office/Outpatient E/M Codes: New Patient . . . . . . . . . . . . . . . . . . . . . . 33
AMA 2021 Office/Outpatient E/M Codes: Established Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2021 AMA CPT® E/M Guidelines Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Time and Separate Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Office/Outpatient History and Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Medical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2021 Level of Medical Decision Making (MDM) Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
MPFS 2020 Accepts CPT® MDM Guidelines for 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5
Procedural Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Global Surgery Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Medicare Surgical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

AAPC | 1-800-626-2633 www.aapc.com V

 Global Surgery Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Monitor Op Reports for Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Chapter 6
Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Medical Necessity and CMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Recovery Audit Contractors (RAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
RAC Audit Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
CERT & RAC Common Documentation Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Medical Necessity Practice Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Chapter 7
Clinical Conditions and Diagnosis Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Use Both Alphabetic Index and Tabular List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Level of Detail in Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Excel With Auditing Advice for ICD-10-CM and CDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
How to Prepare for an Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Post-Audit Provider Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Chapter 8
Incident-to Guidelines and Shared Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Incident-to Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Split/Shared Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Split/Shared Services vs. Incident-to Billing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 9
Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Fast Facts About EMR Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Templates are NOT one-size-fits-all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
EMR Templates: A Boon or a Bane? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Copy and Paste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Ace EMR Documentation With These Guidelines and Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Concision Is Key: Document Efficiently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Keep a Separate Section for the CC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Don’t Just Correct – Perfect – Your EMR Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

VI Clinical Documentation Reference Guide AAPC | 1-800-626-2633

 10 Tips for Keeping EMR Compliance Issues at Bay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Outsmart the Auto-Populate Feature in EMRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Guard Against These Top EMR Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Chapter 10
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Clinical Documentation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

1.   Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for
Evaluation and Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
2.   Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for
Evaluation and Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
3.   Centers for Medicare & Medicaid Services. 2019 MPFS Final Rule. Nov. 23, 2018,
Federal Register, Vol.83, No. 226. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
4.   Centers for Medicare & Medicaid Services. 2020 MPFS Final Rule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
5.   Centers for Medicare & Medicaid Services. Electronic Health Records Provider. . . . . . . . . . . . . . . . . . . . . . . . . . . 253
6.   Centers for Medicare & Medicaid Services, FAQ on 1995 & 1997 Documentation Guidelines
for Evaluation & Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
7.   Centers for Medicare & Medicaid Services. National Physician Fee Schedule Relative Value Files. . . . . . . . . . . 260
8.   Department of Health and Human Services, Office of Inspector General,
OIG Compliance Program for Individual and Small Group Physician Practices.
Oct. 5, 2000, Federal Register, Vol. 65, No. 194. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
9.   Medicare Benefit Policy Manual, MCM, 60 - Services and Supplies Furnished
Incident-To a Physician’s/NPP’s Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

AAPC | 1-800-626-2633 www.aapc.com VII

 Introduction

Designed for all clinical documentation improvement (CDI) team members, this
NOTES
book will help you and your team better understand the role documentation plays
in care management, coding, and billing. Proper documentation ensures quality
patient care and optimal reimbursement through more accurate coding and
compliance. Accurate documentation is also your one best defense in the event of
litigation. The Clinical Documentation Reference Guide walks you through the
minefield of common documentation pitfalls and teaches you the skills necessary
to create, overhaul, or enhance your organization’s documentation improvement
program to protect your reimbursement and operate ethically.

This extensive guide is filled with page after page of insights to guide you in devel-
oping or expanding the qualities necessary to meet and manage clinical documen-
tation. This start-to-finish CDI primer covers medical necessity, joint/shared visits,
incident-to billing, preventative care visits, the global surgical package, complica-
tions and comorbidities, and CDI for EMRs.

Prevent documentation deficiencies and keep your claims on track for optimal
reimbursement with this expert guidance:
l Understand the legal aspects of documentation.

l Anticipate and avoid documentation trouble spots.

l Keep compliance issues at bay.

l Learn proactive measures to eliminate documentation problems.

l Work the coding mantra — specificity, specificity, specificity.

l Avoid common documentation errors identified by CERT and RACs.

l Know the facts about EMR templates — and the pitfalls of auto-populate
features.
l Master documentation in the EMR with guidelines and tips.

l Conquer CDI time-based coding for E/M.

Learn the all-important steps to ensure your records capture the work your
providers perform during each encounter. Benefit from methods to effectively
communicate CDI concerns and protocols to your providers. Leverage the prac-
tical and effective guidance in the Clinical Documentation Reference Guide to
triumph over your toughest documentation challenges.

AAPC | 1-800-626-2633 www.aapc.com IX

 The Purpose of
CHAPTER 1 Clinical Documentation Improvement

The Quality of Documentation NOTES

Quality assurance in patient care is only evident if it is documented in the medical
record. Quality services may have been provided; however, if this is not evident
within the medical record, problems may arise.

For example, another provider (or the same provider several weeks later) will not
necessarily know the details of the previous encounter. Providers can’t always rely
on the patient to fill them in. For example, the provider may ask the patient what
medications she is taking, and the patient responds, “I take the purple one in the
morning.” If the provider has not documented the type of medication and proper
dose in the patient’s record, he will have no idea what the patient is taking and
whether she is taking it correctly.

If the provider instructs the patient on risks and benefits of a procedure and how to
properly take medication but fails to document the instructions given and that the
patient understood all the instructions, the provider has made himself vulnerable
if the patient has any type of misadventure.

Records are scrutinized by multiple entities. Providers and facilities are being
challenged to put their best foot forward in many ways. The only evidence the
providers have of their veracity and the quality of care provided is the medical
record.

Another reason for a quality assessment review of the clinical documentation is the
number of requests for medical documentation from contractors paid by CMS for
Hierarchical Condition Category (HCC) and Healthcare Effectiveness Data and
Information Set (HEDIS) studies. These programs are abstracting data from the
medical records for calculating risk adjustments based on the severity of diseases.

“The ultimate purpose of the CMS-HCC model is to promote fair payments to

Medicare Advantage (MA) plans that reward efficiency and encourage high quality
care for the chronically ill. Its use is intended to redirect money away from MA
plans that disproportionately enroll the healthy, while providing the MA plans that
care for the sickest patients the resources to do so” as stated in the Evaluation of
the CMS-HCC Risk Adjustment Model.

Requests for medical records come from many sources, for different reasons other
than reimbursement. For example:
l CMS contractors, HCC, HEDIS

l Patients

l Attorneys

l Other providers

l Workers’ compensation

l Payers for precertification

l Pre-employment applications

l Military application

l SSI applications

AAPC | 1-800-626-2633 www.aapc.com 1

The Purpose of Clinical Documentation Improvement CHAPTER 1

follow up to make sure the claim is not lost in the shuffle. These concerns must be
NOTES
tailored to each practice based on size and need.

Policies should be developed concerning typographical errors in transcription and

the overutilization of EMR templates and pre-populated data. This task should be
assigned to an individual who will monitor such use. A timeframe should be estab-
lished for making corrections.

Policies for corrections of handwritten notes and policies concerning addendums

must be systematically in place to facilitate the process of documentation improve-
ment, producing clarity and accuracy.

Protocols for documentation are needed to establish policies for the practice’s use
of abbreviations. Abbreviations and symbols can be an effective and efficient form
of documentation if their meaning is well understood by the health provider who
is using and/or reading them. Abbreviations should have clear definitions and be
used practice wide for consistency in documenting and abstracting.

Frequently Asked Questions

Question: What is medical record documentation?

Answer: Documentation provides a valuable account of a patient’s concerns, as

described to the physician, and the physician’s assessment of, and findings about,
the patient’s condition and resulting treatment plans.

Furthermore, because it is ultimately the physician’s responsibility to establish

the cause and effect relationship of the disease process, a fully documented record
provides him with the tools he needs to make that determination.

Providers are mandated by law and regulatory bodies to capture some form of
record about an encounter with each patient. These notes provide a baseline from
which any provider can build, review, and follow up on treatment plans.

Important: From this record, physicians determine or modify treatment plans,

chart disease progression, and craft an entire case history.

The record allows the entire healthcare delivery team to provide quality patient care.
Additionally, the fully documented patient record is the physician’s best chance of
receiving complete reimbursement for services rendered on the patient’s behalf.

Question: How is documentation used in malpractice litigation?

Answer: Providers should regard documentation as a means of getting paid, but

also as their best defense in a malpractice litigation. Poor record-keeping can mean
the difference between a lawsuit that is indefensible and one that can be substanti-
ated in court.

Pitfall: The biggest risk factor in a medical practice is insufficient or inaccurate

documentation. Physicians that rarely keep accurate, comprehensive medical
records place themselves at great risk of malpractice in negligence cases.

Providers would be well-served to document all patient encounters as though

anticipating litigation. Providers should ask themselves: What information would
be considered essential in a malpractice suit? How would we defend ourselves
against negligence? Then document all cases accordingly.

6 Clinical Documentation Reference Guide AAPC | 1-800-626-2633

 CHAPTER 2 Implementation of a CDI Program

Professionals who assist in ensuring the quality, accuracy, and integrity of the
NOTES
medical record are in great demand. Documentation improvement is far reaching
and may involve several people or several departments within your organization
to be a comprehensive, effective program. Designate an individual to oversee the
documentation improvement process.

Assign a physician advocate and the compliance officer to assist with the manage-
ment and enforcement of the policies. Including a physician advocate will help
encourage the other providers to participate, assist with provider education,
and build a stronger program with physician engagement and investment in the
program.

Employ a coder or auditor to manage aspects of the documentation improvement

process associated with coding, billing, and reimbursement. This teamwork uses
the skills and expertise of the coding and auditing professionals when the CDI
process overlaps. Involve all departments that play a role in the documentation
process (nurses, data entry staff, etc.).

1. Assign one individual in each department the responsibility of working

with the documentation specialist to assist in resolving documentation
issues for that department.
2. Identify the practice or facility needs within each department.
3. Work with the highest risk area first, utilizing authoritative guidelines and
instructions.
4. Develop policies and protocols that meet the needs of your practice that are
effective but not overwhelming. For example, policies for:
l Adding late entries
l Corrections to medical records
l Timeliness of documentation
l Who has the permission to input data in the EMR
l Policies concerning the use of acronyms
l Policies for risk prevention

5. Create templates that will assist with better detail and compliance with
specialty-specific documentation mandates.
6. Review provider reports based on the quality and accuracy of information.
7. Schedule regular educational meetings for CDI team, providers, and staff.
8. Perform regular audits for monitoring.
9. Monitor the policies and procedures for effectiveness and change when
needed.

AAPC | 1-800-626-2633 www.aapc.com 9

Evaluation and Management Documentation CHAPTER 3

a documented CC which, if not documented as a separate statement, may be pulled

NOTES
from the HPI.

Tip: If the CC has not been documented, the visit is not billable.

The HPI is a description of the patient’s current problem or illness. Table 3.1 charts
out the eight different elements of HPI:

Element Examples of Documentation

Location Eye pain, shoulder pain
Quality Yellow-thick sputum
Severity Pain scale 5 out of 10
Duration For the past three weeks
Timing This morning, yesterday
Context Fell while riding bike
Modifying factors Patient took pain meds
Associated signs and symptoms Also, complains of itchy-watery eyes

Table 3.1: HPI Elements and Examples

The 1997 guidelines allow the provider the option of documenting four or more
elements from the HPI, or the status of three chronic conditions for an extended
HPI. CMS also allows the an extended HPI for the status of three chronic condi-
tions in the 1995 guidelines as well.

The ROS is a review of the 14 body systems. Table 3.2 shows a list of the body
systems with examples.

Body Systems Examples of Documentation

Constitutional Weight loss, weakness, fever
Eyes Itching, blurred vision
Ears, nose, and throat Congestion, sore throat
Cardiovascular Chest pain, flutter, fibrillation
Respiratory Shortness of breath, cough
Gastrointestinal Diarrhea, vomiting
Genitourinary Dark urine, burning on urination
Musculoskeletal Muscle pain and weakness, joint swelling
Integumentary Rash, acne
Neurological Syncope, tingling
Psychiatric Stress, anxiety, depression
Endocrine Increase in thirst, decreased appetite
Hematologic/Lymphatic Bruising, swollen glands
Allergy/Immune Medication allergies, itching, anaphylaxis

Table 3.2: Review of Body Systems and Examples

During the ROS, the provider asks the patient if they are experiencing any signs or
symptoms in any of the body systems. Ancillary staff, physician assistants, nurse
practitioners, and physicians can document the ROS.

18 Clinical Documentation Reference Guide AAPC | 1-800-626-2633

CHAPTER 3
Level of Presenting Problem(s)
Risk
Minimal One self-limited or minor problem, eg,
cold, insect bite, tinea corporis
Level of Presenting Problem(s)
Risk
Low Two or more self-limited or minor
problems
One stable chronic illness, eg, well
controlled hypertension or non-insulin
dependent diabetes, cataract, BPH
Acute uncomplicated illness or injury,
eg, cystitis, allergic rhinitis, simple
sprain
Moderate One or more chronic illnesses with mild
exacerbation, progression, or side effects
of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with
uncertain prognosis, eg, lump in breast
Acute illness with systemic symptoms,
eg, pyelonephritis, pneumonitis, colitis
Acute complicated injury, eg, head
injury with brief loss of consciousness
High One or more chronic illnesses with
severe exacerbation, progression, or side
effects of treatment
Acute or chronic illnesses or injuries
that may pose a threat to life or bodily
function, eg, multiple trauma, acute
MI, pulmonary embolus, severe
respiratory distress, progressive severe
rheumatoid arthritis, psychiatric illness
with potential threat to self or others,
peritonitis, acute renal failure
An abrupt change in neurologic status,
eg, seizure, TIA, weakness, or sensory
loss
Table 3.6: Medical Decision Making Table of Risk
AAPC | 1-800-626-2633
Evaluation and Management Documentation
Diagnostic Procedure(s)
Ordered
Laboratory tests requiring
venipuncture
Chest X-rays
EKG/EEG
Urinalysis
Ultrasound, eg, echo
KOH prep
Diagnostic Procedure(s) Ordered
Physiologic tests not under stress,
eg, pulmonary function tests
Non-cardiovascular imaging
studies with contrast, eg, barium
enema
Superficial needle biopsies
Clinical laboratory tests requiring
arterial puncture
Skin biopsies
Physiologic tests under stress,
eg, cardiac stress test, fetal
contraction stress test
Diagnostic endoscopies with no
identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies
with contrast and no identified
risk factors, eg, arteriogram
cardiac cath
Obtain fluid from body cavity, eg,
lumbar puncture, thoracentesis,
culdocentesis
Cardiovascular imaging studies
with contrast with identified risk
factors
Cardiac electrophysiological tests
Diagnostic endoscopies with
identified risk factors
Discography
NOTES
Management Options Selected
Rest
Gargles
Elastic bandages
Superficial dressing
Management Options Selected
Over-the-counter drugs
Minor surgery with no identified
risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Minor surgery with identified
risk factors
Elective major surgery (open,
percutaneous, or endoscopic)
with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or
dislocation without manipulation
Elective major surgery (open,
percutaneous, or endoscopic with
identified risk factors)
Emergency major surgery (open,
percutaneous, or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive
monitoring for toxicity
Decision not to resuscitate or to
de-escalate care because of poor
prognosis
www.aapc.com 23
 Clinical Documentation Resources

1.   Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for
Evaluation and Management Services.
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

1995 DOCUMENTATION GUIDELINES

FOR EVALUATION AND MANAGEMENT SERVICES

I. INTRODUCTION

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and

observations about an individual's health history including past and present illnesses,
examinations, tests, treatments, and outcomes. The medical record chronologically
documents the care of the patient and is an important element contributing to high
quality care. The medical record facilitates:

the ability of the physician and other healthcare professionals to evaluate and
plan the patient’s immediate treatment, and to monitor his/her healthcare over
time;

communication and continuity of care among physicians and other healthcare

professionals involved in the patient's care;

accurate and timely claims review and payment;

appropriate utilization review and quality of care evaluations; and

collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles"

associated with claims processing and may serve as a legal document to verify the care
provided, if necessary.

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require reasonable
documentation that services are consistent with the insurance coverage provided. They
may request information to validate:

the site of service;

AAPC | 1-800-626-2633 www.aapc.com 87

Clinical Documentation Reference Guide

9 781626 889798
ISBN: 978-1-626889-798
E-Book ISBN: 978-1-626889-927