Physician Documentation & Billing FAQ: Answers

No. Per the CPT definition of the surgical package, “dictating operative notes” is included in the global surgery payment. The most appropriate documentation method, based on the CPT definition of a surgical package, is to have the primary surgeon dictate the operative report. The assistant surgeon does not have any documentation requirements. If the assistant surgeon dictates the operative note, we run the risk of an outside auditor claiming that the primary surgeon did not fulfill the requirements set out in the CPT to receive payment as the primary surgeon for the global surgical package.
Residents are allowed to dictate for the primary surgeon because Medicare provides specific direction on the acceptable use of resident documentation for operative notes where the primary surgeon will still receive payment for the global procedure.

Back to FAQ

Hospital discharge day management codes are used to report the physician’s total duration of time spent preparing the patient for discharge. These codes include, as appropriate:

• Final examination of the patient;
• Discussion of the hospital stay, even if the time spent by the physician on that date is not continuous;
• Instructions for continuing care to all relevant caregivers; and
• Preparation of discharge records, prescriptions, and referral forms.

Discharge day management codes are used to report the total duration of time spent by the teaching physician for all services performed as part of the hospital discharge.  Time spent by the teaching physician does not have to be continuous and does not necessarily have to occur on the date of discharge (however, the billing date for the discharge service will be the date that the teaching physician saw the patient).  Services for more than 30 minutes must be documented in the patient’s chart.  If time is not documented it will be assumed that less than 30 minutes was spent on discharge day management.  Only time spent by the teaching physician may be counted for billing purposes.

The discharge day management services include a code for Discharge Day Management, 30 minutes or less (99238) and Discharge Day Management, more than 30 minutes (99239).   In order for the Teaching Physician to bill Medicare for discharge day management services he/she must personally perform and document any or all of the components stated above.  For services more than 30 minutes (99239) the teaching physician must personally perform and document time since discharge day management is reported using a time based code.

A progress note with ‘tie language’ that does not specify that the patient is to be discharged in conjunction with a co-signed discharge summary performed by a resident is insufficient documentation to bill for a discharge service. Tie language must be used on the discharge summary if the plan for discharge is not clear in the progress note (a note labeled Final Progress Note would also satisfy this requirement)

Back to FAQ

Medicare Annual Wellness Visits

Effective January 1, 2011, an annual wellness visit (AWV) will be covered for Medicare recipients with certain restrictions. The goal of the AWV is to promote health and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B.

An AWV must be performed by a health professional; a physician who is a doctor of medicine or osteopathy; or, a physician assistant, nurse practitioner, or clinical nurse specialist; or, a medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.

Coverage Restrictions:
In order for the service to be covered, the beneficiary may not be within the first 12 months of their effective date and the beneficiary may not have received an AWV or initial preventive physical examination (IPPE) within the past 12 months. Within the first 12 months of eligibility, instead of an AWV, a Medicare patient should receive an IPPE instead. A link to the IPPE requirements has been included in the references section.
An ABN is recommended for beneficiaries when it is not clear if they have not received an IPPE or AWV within the last 12 months. The beneficiary will have no deductible for the annual wellness visit.

The Medicare Transmittal on this subject does not clearly state that a first annual wellness visit service may be billed by a provider who has also provided the welcome to Medicare IPPE, but seems to imply that if all components are performed a ‘new’ annual wellness visit may be billed even for patients that have previously received an IPPE or other face to face services from the same provider.

The AWV services are included under the primary care exception. 

Billing and Reimbursement:
Two new HCPCS codes, which will be effective January 1, 2011, have been developed to bill for AWV services:
G0438 - Annual wellness visit, includes personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first)  2.43 work RVUs
G0439 - Annual wellness visit, includes PPPS, subsequent visit, (Short descriptor – Annual wellness subsequent)  1.50 work RVUs
The initial annual wellness visit will be paid at the rate of a level 4 office visit for a new patient (99204), currently $156.48 for physician clinic services and $125.66 for hospital based clinics.
The subsequent annual wellness visit will be paid at the rate of a level 4 office visit for an established patient (99214), currently $101.59 for physician clinic services and $76.23 for hospital based clinics.
AWV services do not have a specific ‘covered’ diagnosis code list. It is recommended that V70.0, Routine general medical examination at a health care facility, should be used for patients who have no signs and symptoms or other applicable diagnoses. Keep in mind that “Family History of …” may not be used as a primary diagnosis.

Coding Guidelines:
The initial AWV must include, at a minimum, the following elements:

• Establishment or update to the patient’s medical and family history, which must at least include:
  • Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments.
  • Use or exposure to medications and supplements, including calcium and vitamins
  • Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk. 
• A list of current providers and suppliers that are regularly involved in providing medical care to the individual
• Measurement of height, weight, and blood pressure
• BMI or waist circumference
• Other routine measurements as deemed appropriate
• Examination for detection of cognitive impairment by direct observation with consideration of information obtained by way of patient reports and concerns raised by family members, caretakers, or others.
• Voluntary advanced care planning, upon agreement with the individual, which must include information on the following areas through written or verbal communication:
  • An individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions.
  • Whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive. 
• Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
• Review of the individual’s functional ability and level of safety based on direct observation or the use of appropriate screening questions or a screening questionnaire which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations which must at least include an assessment of the following topics:
  • Hearing impairment
  • Ability to successfully perform activities of daily living
  • Fall risk
  • Home safety
• A written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• A list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element determined appropriate through the National Coverage Determination (NCD) process. (none yet)

The subsequent AWVs must include, at a minimum, the following elements:

• An update to the individual’s medical/family history
• An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual
• Weight or waist circumference
• Blood Pressure
• Other routine measurements as deemed appropriate
• Examination for detection of cognitive impairment as defined above
• An update to the following:
  • The written screening schedule for the individual as that schedule is defined in this section, that was developed at the first AWV providing PPPS, and,
  • The list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS. 
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined for the first AWV providing PPPS.
• Voluntary advance care planning upon agreement with the individual (as defined above).
• Any other element determined appropriate by the Secretary through the NCD process. (none yet)

References:
Find the full text of the Medicare transmittal with the above information here

Back to FAQ

What is the correct coding for billing flu shots?
The appropriate diagnosis code for administering the flu vaccine service is V04.81 (Prophylactic Vaccination for Influenza). Please note that the below instructions only address the coding and billing of influenza vaccination when the influenza vaccination is the only vaccine administered on that date and no counseling regarding the vaccination is performed. The correct method for billing the flu shot is as follows:

Medicare Effective January 1, 2011
Administration via injection or intranasal route is billed using two CPT codes; one for the administration and one for the vaccine product.

Medi-Cal
Vaccines for Children (VFC)- The CPT for the vaccination is used for the administration code as the vaccine product is provided at no cost to the provider by Medi-Cal.
Administration via injection is billed using one CPT code; even though the CPT for the product is being billed, Medi-Cal is reimbursing for the administration of the product.

Medi-Cal Continued…
 Administration via intranasal route is billed using one CPT code; even though the CPT for the product is being billed, Medi-Cal is reimbursing for the administration of the product.

Non-VFC Medi-Cal - Same as for commercial payers.

Commercial Payers**
Administration via injection is billed using two CPT codes; one for the administration and one for the vaccine product.

Administration via intranasal route is billed using two CPT codes; one for the administration and one for the vaccine product.

** Starting in 2011 new CPTs will be available to differentiate between vaccines administered to persons 18 and under when the patient/family was counseled (90460-90461), and when the vaccine was administered, but no counseling occurred. Neither Medicare nor Medi-Cal has yet issued guidance regarding these new codes.

Additional References:

• Medicare Immunization: 
  • Regarding the new Q codes 
• New CPTs for Vaccine Counseling for patients under 18:
  • AAP

Back to FAQ

Use of Scribes at Loma Linda University Health (LLUH)

Documentation Requirements

OVERVIEW:

There are various reasons why a provider may benefit from using a scribe such as: efficiency, legibility and the additional time to focus on patient care. The Compliance Department recognizes the value of using scribes to assist in accurate and efficient documentation of patient encounters.

PURPOSE:

The purpose of this policy is to ensure proper documentation of clinical services when the billing provider has elected to utilize the services of a medical scribe. For the purpose of this policy, a scribe is defined as an individual who is present during the provider’s performance of a clinical service and documents (on behalf of the provider) everything said during the course of the service. Any individual serving as a scribe must not be attending to the patient in any clinical capacity and must not interject their own observations or impressions. A scribe does not need to be an employee of the physician or physician group for whom he or she is scribing.  

POLICY:

Individuals serving as scribes must sign a scribe agreement prior to scribing.  Scribed documentation must clearly support the name of the scribe, the role of the individual documenting the service (i.e., scribe), and the provider of the service. The provider is ultimately responsible for all documentation and must verify that the scribed note accurately reflects the service provided. A scribe can only document the information that is spoken by the dictating provider.  If the attending provider note is scribed, the resident cannot share the note; the documentation must remain separate from the documentation generated by the physician and used for billing purposes. 

GENERAL GUIDELINES:  

A scribe is acting as a "living recorder", recording in real time the words and actions of the physician as they are performed. A scribe may not document personal assessments or independent opinions/findings. It is inappropriate for an individual scribing for a physician to round at one time and make entries in the record, and then for the physician to round several hours later and note "agree with above." Scribes may be used by any provider that bills Medicare under his/her name and number.  Scribes must have their own User ID and password in the EMR where the document is created.  Scribes may not enter information in the medical record gained independently from the physician. For example, a scribe may not enter any information gathered when the physician is not present in the exam room, such as past medical history.

PROCEDURE:

1. Any individual that desires to serve as a scribe must review the policy on the use of scribes and sign a policy agreement.
2. A scribed note must accurately reflect the service provided on a specific date of service.
3. A scribe’s entry can be hand-written, dictated, or created/typed in an electronic health record (EHR). Documentation of a scribed service must include the following elements:
   • The name of the scribe and a legible signature
   • The name of the provider rendering the service
   • The date and time the service was provided
   • The name of the patient for whom the service was provided
   • Authentication of the scribe
4. The provider is ultimately responsible for the contents of the documentation. The provider note should indicate:
   • Affirmation that the provider was present during the time the encounter was recorded
   • Verification that the information was reviewed
   • Verification of the accuracy of the information
   • Any additional information needed
   • Authentication including date and time
5. Individuals can only create a scribe note in an EHR if they have their own password/access to the EHR for the scribe role. Documents scribed in the EHR must clearly identify the scribe’s identity and authorship of the document in both the document and the audit trail. Under no circumstances shall a scribe document in the EHR using another individual’s credentials.
6. Scribes are required to notify the provider of any alerts. Alerts must be addressed by the provider.
7. Providers and scribes are required to document in compliance with all federal, state, and local laws, as well as with internal policy.
8. Failure to comply with this policy may result in corrective and/or disciplinary action (See Human Resources Disciplinary Action Policy).
9. An attestation such as the attestation below must be added and signed by the attending physician or NPP:

“By signing below, I acknowledge that I have reviewed the above note, dictated by me and scribed by (insert scribe name) for accuracy and edited where necessary. The note accurately reflects the services provided by me at this encounter.”

1. The scribe may not insert the attestation, but the attestation may be added by the billing provider using auto text, SmartPhrase, or similar functions.

WHO MAY NOT ACT AS A SCRIBE:

The following individuals may not serve in the capacity as a scribe:

For the full list, please see the below link, beginning on page 81: http://www.cms.gov/manuals/downloads/clm104c26.pdf

Employees with dual roles:

If an employee has dual roles, the employee must indicate when they are acting as a scribe and when they are entering data independently or a separate User ID for each role must be created. The correct User ID for each role must be used for the appropriate type of data entry. The vitals, ROS, PFSH obtained independently from the physician should never be entered into the medical record using a scribe User ID.

References:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049807.hcsp?dDocName=bok1_049807

https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/documentation-guidelines-for-medicare-services

Use of Copy, Paste, and Cloning Functionalities in the Medical Record

Overview

The Compliance Department recognizes that the practice of cloning, copying and pasting, or copying forward previously written documentation about a patient can improve the efficiency and completeness of clinical records. However, documentation created by this method must be accurate and complete. It must reflect the services provided to the patient on the day and time of the current specific encounter. If documentation contained in a clinical record is incomplete, contradictory, or otherwise does not accurately reflect the services provided at the current encounter, that documentation will not be used to support billing for those services. To assure accuracy, practitioners must take care to review the completed documentation carefully when information is copied into a new record.

For the purposes of these guidelines, cloned documentation refers to medical record documentation that has been (a) copied and pasted; (b) copied forward; (c) saved as template; (d) or any other function that allows an individual to copy information from one patient visit note to the current visit date for either the same or different patient. Consequently, the documentation may or may not accurately reflect information specific to the individual patient encounter once it is completed in its cloned location. Cloned notes often contain excessive carry-over of extraneous information.

Guidelines

1. Providers are responsible for the total content of their documentation, whether the content is original, copied, pasted, imported or reused.
   1. If any information is cloned or reused from a prior note, the provider is responsible for its accuracy and medical necessity. Documentation of any patient encounter, including, but not limited to: H&Ps, Progress Notes, Procedures, etc, are to provide an accurate depiction of the severity of illness and intensity of service surrounding a specific date of service.
   2. Cloned information must be reconfirmed and revised as necessary to accurately reflect what occurred on the specific date of service. Information copied forward from the provider’s prior note(s) should be closely examined for accuracy, completeness and relevance to the current encounter. If a provider copies all or part of an entry made by another clinician, the provider making the entry is responsible for assuring the accuracy of the copied information.
2. Notes should be clear as to what history was taken and physical exam performed on a specific date of service, and what the author or another observer recorded at a different time. This means that if a note is copied forward and the cloned note includes information that was not discussed or services not performed during the current encounter, that information must be deleted from the copied note for the current encounter.
   1. An electronic note is stamped with a date and time when it is signed. Unless indicated otherwise, the reader will assume that the history of present illness was obtained and the findings were observed shortly before it was written. If the history or physical is from a previous note from another time, the information given may inaccurately reflect the patient’s status at the time of the note. Such inaccurate notes can create clinical, financial, and legal problems for the patient, the provider, and the institution.
3. Cloning teaching physician attestations from previous notes is prohibited.
4. Medical record information shall not be cloned from one patient’s medical record to a different patient’s medical record within any EHR system.
5. Use of Student Notes:
   1. Cloning of any part of a medical student, a PA student, or any other type of student note, other than the review of systems (ROS), and past, family, and social history (PFSH) is prohibited. This applies to both residents and teaching physicians.
   2. A medical student may participate in the provision of Evaluation and Management (E/M) services, including consultations, new patient visits and any other type of visits, when under the supervision of a teaching physician. Per Medicare guidelines, medical student documentation for evaluation and management services may be referred to and used by the teaching physician only for the ROS, and PFSH. The student’s documentation relative to the chief complaint, history of present illness, physical exam or medical decision-making cannot be used for billing purposes. The teaching physician does not need to re-document the medical student’s ROS and PFSH, but rather may refer to the documentation in his/her personal note.
6. If there are errors in a note copied from another source, the error must be corrected in the new documentation and contact should be made with the original author to correct the origination documentation. For example: a lab, pathology or radiology report, the author should be contacted to discuss and correct the original document. The corrected information should be noted in the provider’s current note.
7. For services performed in hospital and ambulatory care settings, Joint Commissions requires that the author of each medical or clinical record entry is identified in the health record. UHC Policies and Procedures also require author identification on all medical records.

Back to FAQ