In this issue:
Coding News
Documenting a Complete Review of Systems to Ensure Reimbursement for High Acuity Cases
By Candace E. Shaeffer, RN, MBA, RHIA
Vice President, Coding Operations/Quality Management
Coders report that the most frequently encountered physician documentation deficiency is in the Review of Systems or ROS. The ROS includes documentation of the patient’s or family/significant other’s responses to questions about the patient’s other body systems as they relate to or contribute to the presenting problem. These systems include:
- Constitutional symptoms
- Eyes
- Ears, Nose, Mouth and Throat
- Cardiovascular
- Tespiratory
- GI
- GU
- Musculoskeletal
- Integumentary
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
The CMS Documentation Guidelines state that “for a complete ROS (level 5) at least 10 of the 14 systems must be reviewed. The systems with positive or pertinent negative findings must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.” The guidelines further state that “The ROS may be recorded by ancillary staff or the patient. To document that the physician reviewed the information there must be a notation supplementing or confirming the information recorded by others.”
The Medical Decision Making category of the CMS physician documentation guidelines is usually what determines the overall visit level as long as the History and Exam categories are documented sufficiently to support it. Given this visit level limiting factor and the expertise of LYNX coders, you do not have to worry about your records being coded too high because you “over documented” the history or exam. If you document a complete ROS (note at least 10 of the above systems) for all of your highest acuity patients, coders will always have enough ROS data elements to code your level 5 cases to the level 5 they deserve.
FYI…
And a few “sound bytes” of hopefully useful information for you:
The conversion factor (CF) used to determine physician payments will be $37.8975 beginning January 1, 2005. This represent a 1.5% increase over the $37.3374 2004 CF. The information, published in the November 15 Federal Register, states that Medicare spending for total physician payments will increase approximately 4% over 2004 payments. Relative Value Units (RVUs) for some services have also changed. According to the 11/8/04 Part B News publication, the CF and RVU changes together are forecasted to provide about a 2% increase for the Emergency Medicine specialty in 2005.
If you practice in a physician scarcity area (more info in the October 2004 Lines from LYNX), you will automatically receive a 5% bonus payment for your services. To find out if your zip code is in one of these areas, check the CMS Web site at http://www.cms.gov/providers/bonuspayment/.
Just in case you or your patients want to know, in 2005 the monthly Part B premium (outpatient and physician services) that Medicare beneficiaries pay for Part B services will increase to $78.20. This represents an $11.60 increase over the 2004 monthly premium of $66.60. In addition, the Part B deductible the patient pays will increase by $10 to $110 per year—this is the amount a beneficiary pays out of pocket for Part B services before their Medicare benefits kick in.
If you have questions about these or any other Emergency Medicine coding or reimbursement issues, please contact me or your LYNX coding manager or at 800.767.5969.
Smooth Operations
Review of Residents/Teaching Physicians Documentation Requirements
By Shannon Weintraub, MBA
Director of Coding Operations/QM
The LYNX policy for assignment of Evaluation and Management (E/M) services for teaching physicians was established to meet guidelines set by CMS. When services are provided jointly, the services coded are dependent on the documentation provided by the teaching physician.
In order for LYNX coders to process and complete the records, the teaching physician must personally document at least the following:
- That they performed the service or were physically present during the key or critical portions of the service when preformed by the resident; and
- The participation of the teaching physician in the management of the patient.
Documentation by the resident of the presence and participation of the teaching physician is not sufficient. If your ED is using the E/Map template system, please be sure to complete the resident supervision note in its entirety and sign the record in the appropriate location. By doing this, you will meet the necessary documentation criteria.
If you have questions or would like to discuss the policy/documentation standards, please contact your coding manager.
The information contained herein is provided for informational and educational purposes only, and nothing contained herein should be construed as advice. All information contained herein is obtained by LYNX Medical Systems (LYNX) from sources believed by LYNX to be accurate and reliable. Because of the possibility of human and mechanical error as well as other factors, LYNX is not responsible for any errors or omissions. LYNX makes no representations and disclaims all expressed, implied, and statutory warranties of any kind to user and/or any third party including warranties as to accuracy, timeliness, completeness, merchantability or fitness for any particular purpose.