Chapter 28. Clinical Documentation for Hospitalists

The medical record of an individual patient serves numerous functions. Ideally, the record should provide a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities (such as hospitals). The medical record also serves as the basis for a variety of financial, legal, and administrative functions including the documentation for both professional and facility fee reimbursement, quality and safety assessments (including pay for performance), malpractice litigation and disability determinations, and community-based care and public health initiatives.

Currently, the medical record of an individual patient is fragmented, with various pieces shared only sometimes among numerous providers. Hospitalists typically care for a patient during a single episode of facility-based care. Fortunately, the proliferation, adoption, and increasing interoperability of electronic medical records (EMRs), and their evolution into personalized health records, holds promise for consolidation and availability of all relevant clinical information to each provider participating in the care of a single patient.

Some General Principles

This chapter focuses upon the documentation requirements incumbent upon hospitalists for professional fee billing of their clinical services. Some general principles of physician documentation warrant discussion despite this focus, and apply to both paper and electronic medical records.

The documentation of physician services should always comprise the essential components of a patient's chief complaint, history, physical examination, and medical decision making. The concerns of both patient and provider should be clearly recorded, including expectations (realistic or not) and satisfaction (and dissatisfaction). All diagnostic test orders and results should reside in the chart, as well as documentation of various specific services (eg, physical, occupational, speech, or rehabilitation therapy; home health services, durable medical equipment needs, and social work evaluations).

Corrections

At some point in time, every medical record requires a correction. In a paper document, draw a single line through the inaccurate portion and write a correction nearby, dating and signing the revision. The original entry thereby remains legible for future reference. For example, consider misidentification of a right swollen knee joint, when actually it is on the left: when the physician recognizes the mistaken documentation, the right side should have a single line drawn through it (ie, overstrike text) and a note written nearby indicating that the left side is the accurate side. Sign and date these changes on the day of correction. Methods and appearances of corrections and amendments in electronic medical records continue to evolve, but all incorporate password-protected signatures with electronic date- and time-stamped entries.

Late-Entry Documentation

Like corrections, addenda or late entries can be made at any time and labeled as such, with a dated and timed signature. Also, explain why the entry was made late and not contemporaneously. For example, following a hospital visit, a hospitalist responds to a rapid response call and neglects to document the visit in the hospital medical record. When recognized the next day, document the hospital visit as a late entry and specify that the care was delivered the previous day.

An Overview of Hospital Payment Systems

As the most prominent payer in the United States, Medicare payment systems are of paramount importance to understand. Fortunately, Medicare policies are established by the Centers for Medicare and Medicaid Services (CMS) and available online through the CMS On-Line Manual System, so that everyone can in principle understand how claims are processed and payments are made. Medicare policies are largely consistent across the United States, and many private payers follow CMS's lead to a greater or lesser extent. However, remember that regional Medicare contractors develop local coverage determinations from CMS payment policy, and can create idiosyncratic interpretations of the documentation guidelines for evaluation and management (E/M) services. One such example would be the nuanced medical decision making (see below) evaluations implemented by Trailblazer Medicare. Similarly, various third party payers have the right, as allowable under their contract with physician groups, to create unique documentation mandates and payment policies. Facilities also generate requirements, such as a history and physical are required before a procedure, which do not comprise medically necessary, billable physician services.

Medicare pays hospitals for inpatient services using an inpatient prospective payment system (IPPS), which relies primarily on the diagnosis in order to group the services delivered to an inpatient into a Medicare severity-diagnosis related group (MS-DRG). Many diagnostic categories have two or three severity levels, differentiated by the presence or absence of a specified set of complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Hospitals and other facilities frequently request hospitalists to clarify, expand, or specify their clinical documentation to ensure the assignment of a hospitalization to the proper MS-DRG. This single MS-DRG payment covers all facility services during the inpatient stay. Many payers have adopted a similar mechanism of providing a single, fixed payment for an entire hospitalization, often referred to as a case rate.

Some non-Medicare payers still reimburse hospitals and facilities with a fixed payment for each day, commonly described as a per diem rate. The daily payment potentially varies depending upon the types of services provided to the patient (eg, intensive care versus skilled nursing care). Other payment models are likely to emerge as a result of health care reform, including the evolution of accountable care organizations and the emergence of patient-centered medical homes.

An Overview of Physician Payment Systems

Physician services are typically reported using the American Medical Association (AMA) Current Procedural Terminology (CPT), fourth edition, which lists descriptive terms and identifying codes to report medical services and procedures. CPT provides a uniform language to accurately describe all medical, surgical, and diagnostic services and procedures. Even physicians receiving capitated payments still typically report CPT codes for their services.

Hospitalists predominantly report E/M codes (CPT 99201-99499), which for Medicare exceed $32 billion annually and account for more than 40% of the Medicare physician fee schedule allowed charges. Other bedside procedures and diagnostic testing, sometimes performed by hospitalists, are found in CPT. In selecting the proper E/M code, the site and nature of service determine the visit category; and the key components of history, physical examination, and medical decision making determine the specific level of CPT code within a visit category.

Many payers are now adopting Medicare's recognition and regulation of nurse practitioners and physician assistants as nonphysician providers, independently able to provide, document, and bill for E/M services. The number of nonphysician providers performing hospitalist services is rapidly increasing. Therefore, when we refer to providers throughout this chapter, we include both physicians and these qualified nonphysician providers functioning in an independent billing role.

Diagnosis Coding

The International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9) codifies every disease, disorder, condition, symptom, and health care encounter. Payers initially determine the medical necessity of services and procedures based upon the ICD-9-CM code(s) that accompany every provider and hospital claim. Each entry into the medical record should clearly state the diagnoses considered and addressed in the service. The successor International Classification of Diseases, Tenth Revision (ICD-10), which has been available for more than 10 years, is slated for implementation in 2013.

Selecting an E/M level focuses upon the content of the three key components: history, physical examination (PE), and medical decision making (MDM). Time is considered a fourth key component, but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician's total visit time (see below). When counseling and/or coordination of care involves less than 50% of the physician's total visit time, both time and the nature of the presenting problem are only considered as contributory factors and do not determine the E/M level.

Two sets of documentation guidelines have been elaborated by Medicare and largely adopted by other payers. The earlier 1995 guidelines are the most widespread, and generally applicable to hospitalists along with most medical and surgical specialists. The later 1997 guidelines elaborate specialty-specific physical examinations, as well as clearly articulate detailed physical examination requirements lacking in the 1995 guidelines. Several nuanced differences also exist between the two guidelines in aspects of history. The 1995 guidelines will be described in detail throughout this section, and the 1997 guidelines are highlighted below in a separate section for completeness.

History

The elements of history include the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and the past, family, and social histories (PFSH). A chart note may not segregate these elements into unique subtitled areas, but rather the information may be interspersed amid the written, typed, or even dictated narrative.

Chief Complaint (CC)

Typically, the reason for the visit is often quoted from the patient's own words as a sign or symptom, such as, “my belly hurts.” Always document a CC in the progress note, even absent an acute complaint, such as, “pneumonia follow-up.” Avoid statements lacking a specific clinical reference (eg, “postop visit Day#3”).

History of Present Illness (HPI)

The HPI conveys information about the CC, from either the origin (at an initial encounter) or the interval between sequential patient encounters. This information is arbitrarily allocated into eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms. The HPI is then quantified as brief (one to three elements) or extended (four or more elements). For example, consider this extended HPI: “Patient complains of increased (severity) pedal (location) edema that began two days ago (duration). Less able to walk. No chest pain (associated signs/symptoms).”

Review of Systems (ROS)

The ROS refers to signs or symptoms experienced in conjunction with the CC. Fourteen systems are recognized: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient's current or previous conditions, determines the number of systems required for review.

An ROS may be problem pertinent, extended, or complete. A problem-pertinent ROS documents one system directly related to the CC. An extended ROS requires documentation of two to nine systems, that is, the system that is directly related to the CC, along with one or more additional systems. A complete ROS documents 10 or more individual systems. When obtaining a complete ROS, to decrease the amount of time spent listing each system individually, both the 1995 and 1997 (see below) E/M documentation guidelines allow the physician to comment on the positive and pertinent negative systems, with an additional comment that the “remainder is negative.” However, insurers may not accept alternative phrases, and even some Medicare contractors (eg, Trailblazers Medicare) require individual documentation of each system.

Past, Family, and Social Histories (PFSH)

The past history includes documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations. The family history provides information regarding potential hereditary illnesses. The social history may list details of the patient's substance use (tobacco/alcohol/illicit drugs), sexual history, employment status, level of education, marital status, or living arrangements.

A pertinent PFSH includes a comment in any one of the three histories (ie, past, family, or social). Full credit for a complete PFSH requires a comment in each history (ie, past, family, and social). When reporting initial hospital, observation, or nursing facility care, consultations, and new office, home, and domiciliary visits, a complete PFSH comprises one comment documented in each of the three histories. In contradistinction, emergency department (ED) services or established patient visits in the home, domiciliary, office, or other outpatient area require one comment in two of the three histories for credit as a complete PFSH.

Providers may review and comment that the “family history is noncontributory” and still receive credit for the family history from most insurers. Certain Medicare contractors, such as Trailblazers Medicare and Wisconsin Physicians Service Insurance Corporation, prohibit this terminology and require specific documentation regardless of clinical relevance (eg, “family history negative for liver disease”). Also note that with subsequent services, both for hospital care and nursing facility visits, indicating an “interval history” does not require redocumentation of the PFSH unless it is clinically relevant.

Determination of History Level

The number of historical elements present in the chart note determines the level of history (Table 28-1). If all of the requirements are not met for a given level of history, select the level associated with the deficient element. For example, a comprehensive history requires documentation of the CC, ≥4 HPI elements, ≥10 ROS, and a complete PFSH. If the ROS only includes documentation for 9 systems, a comprehensive history cannot be selected; report a service that requires only a detailed history: CC, ≥4 HPI elements, 2-9 ROS, and a pertinent PFSH.

Other Circumstances

A PFSH obtained during an earlier encounter does not need to be rerecorded if the provider demonstrates review and updating of the previous information. Update the history by describing any new information or noting the absence of change, along with the date and location of the earlier PFSH; this earlier PFSH must be contained in the body of the medical record. CPT requires only an interval history for subsequent hospital or subsequent nursing facility visits, and it is usually unnecessary to record information about the PFSH, which is unlikely to change in these settings. For established outpatient encounters, documentation regarding the PFSH is unnecessary when PE and MDM are used as the basis for the level of the encounter, unless the patient provides the physician with updated information.

Most auditors disallow a single statement as both an HPI element and ROS element. The ROS and/or PFSH may be recorded by ancillary staff, or on a form completed by the patient. The provider must annotate, supplement, or confirm this information recorded by others, either by a reference to the history form in the progress note or by initialing and dating the form.

If unable to obtain history from the patient, the record should describe the patient's condition or the circumstance that precludes obtaining a history. For example, ″… patient sedated and paralyzed, unable to obtain additional history.″ However, reviewers expect providers to incorporate historic information to the extent possible, from all reasonably available sources (eg, old records, Emergency Medical services documents, other provider documentation, or conversations).

Finally, although the physician may collect all of the information required for a complete ROS, the most common under-documentation error is failure to document at least 10 systems. The second most common mistake is a missing family history or social history.

Physical Examination (PE)

Individual PE elements will be assigned to body areas (head and face, neck, chest, abdomen, genitalia/groin/buttocks, back/spine, and each extremity) or organ systems (constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, and hematologic/lymphatic/immunologic). Providers may document specific findings (eg, “abdomen soft”) or make a generalized comment (eg, “HEENT normal”). Abnormal findings must be specifically documented, such as “S3”; however, a comment indicating “abnormal” without elaboration is insufficient.

The PE documented in the medical record is categorized as problem-focused, expanded problem-focused, detailed, or comprehensive. One comment in an area constitutes a problem-focused exam. The distinction between the expanded problem-focused and detailed examination under the 1995 Guidelines is the greatest ambiguity in physical examination documentation. Both the expanded problem-focused and detailed exams require documentation of two to seven systems. However, “detailed” is defined as an extended examination of the affected body area or organ system, in addition to other symptomatic or related organ systems. The number of required comments regarding the affected body area or organ system to consider the examination detailed has never been defined by either CPT or Medicare. Attempting to decrease ambiguity and variability among auditors, Highmark Medicare Services scores a detailed exam using the “4 × 4” rule: 4 elements examined in 4 body areas or 4 organ systems (totaling 16 documentation elements). In contrast, Trailblazers Medicare and some other contractors suggest using the 1997 guidelines (discussed later) for detailed exam requirements.

The comprehensive examination is a general multisystem examination or a complete examination of a single organ system. Medicare requires the minimum documentation for the general multisystem examination to include one comment in each of eight systems; of course, additional comments in each system and more than eight systems may be described, as clinically indicated. For example, a comprehensive examination may be documented as follows: “P=76, BP=120/80, RR=12 (constitutional); HEENT normal (eyes and ENMT); neck supple (musculoskeletal); regular rate and rhythm (cardiovascular); lungs clear (respiratory); soft abdomen (gastrointestinal); no icterus (integumentary), normal gait (neurological).” The requirements for a comprehensive single organ system still remain undefined for use with these 1995 guidelines.

Medical Decision Making (MDM)

The complexity of MDM drives selection of a level of service. MDM is categorized as straightforward, low, moderate, or high. Three categories must be considered to determine the level of MDM complexity: the number of diagnoses, the amount and complexity of data, and the risk to the patient.

Number of Diagnoses Considered

This first category identifies the number of diagnoses and/or management options considered in the encounter, based upon the documentation. Up to four points are assigned to each problem, with more points assigned for new problems than for established problems, and a new problem requiring additional workup (ie, diagnostic testing) given the maximum four points. Established problems identified as worsening receive a higher value than stable or improving problems. A self-limited or minor problem (eg, sunburn) receives minimal credit as these issues typically do not warrant a defined plan of care (Table 28-2).

New problems require initiation of a care plan, while established problems may require modification or continuation of a care plan. An established problem has been previously considered by the physician or provider group (to allow for cross coverage and handoffs between same specialty providers in the same group). Note that credit is given for a problem considered, although not primarily under treatment by the physician. For example, in a patient receiving steroids for an inflammatory disease, the hospitalist receives credit for noting the potential adverse consequence upon serum lipids, even if a cardiologist is primarily treating the dyslipidemia. Similarly, a chronic condition such as diabetes, cared for by an endocrinologist, is categorized as a new problem to the hospitalist newly treating the patient during an admission for ketoacidosis.

Established patients may also have new problems. For example, an asthmatic with a resolving flare may experience heartburn. This additional new complaint of heartburn may be considered new if commented upon in the progress note and no prior care plan for gastroesophageal reflux exists.

Physicians receive credit only for issues considered in the care plan. Diagnoses merely listed in the assessment and plan without elaboration of the care, or simply ascribing the care to others (eg, “diabetes – per endocrinologist”) are considered part of the patient's problem list in the PFSH. Additionally, new hospitalizations warrant new care plan development, and physicians can receive new problem credit even if the patient has been previously hospitalized by the same group. This is a nuance of inpatient and observation care only.

Data Considered

The second category of determining the MDM complexity is the amount and/or complexity of data reviewed or ordered by the provider during the patient encounter. Both the type and source of information considered are valued (Table 28-3).

Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit. Irrespective of the test volume in each category, only one point is allocated per category (ie, pathology/laboratory, radiology, or medicine) for the encounter. For example, the provider ordering a dozen serologic collagen vascular studies in the morning may also review the three results received in the afternoon; nonetheless, only one point is granted for this care. A single, separate point may be assigned each to pathology/laboratory, radiology, and medicine data, respectively, are cumulative in nature, and the chart note should refer to all the data reviewed or ordered to capture all of the provider work. In other words, if the chart note comments upon a radiology result (one point) and an echocardiogram order (one point), two points may be awarded for the amount of data in that encounter. Independently visualizing images, tracings, or specimens is considered separately, and additional to reviewing the formal interpretation, as long as the chart note clearly documents this occurrence (ie, ″…films and report reveal…″). Without such specific reference distinguishing personal review of the images and of the formal interpretation, an auditor only provides minimal credit for merely reviewing the report.

Providers also receive credit for the additional effort of obtaining information from sources other than the patient or old records, such as conversations with other health care professionals. The chart note should specifically mention the source, along with the information reviewed (eg, ″…spouse confirms loud snoring″).

Risk to the Patient

The third MDM category assesses the patient's risk of complications, morbidity, or mortality, with respect to the presenting problem, diagnostic procedures ordered, or management options chosen. Four levels of patient risk exist (minimal, low, moderate, and high), with examples of each risk type included in Medicare's “Table of Risk” (Table 28-4). The limited number of examples serves as illustrative references for common clinical scenarios, but not as a comprehensive list.

When determining the level of risk, consider comorbidities as well as the plan of care in assessing a patient's risk, thereby potentially increasing the complexity of MDM. Similarly, diagnostic studies or alternatively, procedures under consideration or excluded based upon excessive risk, impact the complexity of MDM (eg, ″…will defer MRI, as potential morbidity of transport to magnet exceeds risks of empiric treatment″). Although many bulleted items on the table may pertain to a particular chart note, the single bulleted item in any risk category associated with the highest risk determines the patient's risk level. For example, a note documenting the monitoring of liver function tests to assess for statin toxicity comprises high risk (drug therapy requiring frequent monitoring for toxicity). However, remember risk does not equal complexity: risk is but one category (among three) of MDM and not the sole contributor to complexity.

Assigning MDM Complexity

Based upon the chart note, points are assigned for diagnoses managed and data considered, and patient risk is assessed. The final result of MDM complexity hinges on the two highest-valued categories. In other words, two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level, as illustrated in Table 28-5.

To illustrate the assignment of MDM complexity, consider the following example. The chart note considers three stable established diagnoses (three points), several blood tests (one point), and high patient risk. The lowest of the three categories (data considered) is eliminated, and the lower of the two remaining categories (number of diagnoses) determines the moderate MDM complexity for the note. While most contractors utilize the same standardization when assigning points, beware of contractors (eg, Trailblazers Medicare) who impose different standards.

1997 Guidelines

Medicare issued a second set of revised documentation guidelines for E/M services in 1997. MDM and the level categories remained unchanged from the prior 1995 documentation guidelines, as detailed above. While ambiguity plagues many aspects of the 1995 guidelines, excessive proscription limits the 1997 guidelines. The 1997 guidelines made a single minor revision to the history, while the physical examination content received extensive modification. The requirements for each level of physical examination were heavily revised, and specialty-specific single organ system examinations defined. In response to widespread complaints from the physician community, CMS allowed physicians to document using either the 1995 or 1997 guidelines, according to their individual preference, and directed auditors to review the physician documentation based on the set of guidelines most favorable to the physician for the E/M code reported for the encounter. Most physicians, including hospitalists, find the 1995 guidelines most applicable.

History

The 1997 guidelines do not limit the provider to identifying individual factors associated with the CC (eg, duration, timing, context). Rather, a provider may document the status of one or more chronic conditions; this option is most useful to subsequent hospital visits. A brief HPI documents one or two conditions, while an extended HPI documents a minimum of three conditions. Some reviewers allow this option only if applying the 1997 guidelines to the entire note.

Physical Examination

The 1997 guidelines allow a provider to select either a general multisystem examination or any one of the single organ system examinations. Hospitalists typically utilize the general examination, which specifies examination elements to perform and document. Negative or normal comments remain acceptable for the 1997 guidelines, along with the mandate to specify comments on any abnormal findings. Documentation in the medical record of 1 to 5 specified (referred to as bulleted) physical examination elements comprises a problem-focused examination; 6 to 11 bulleted elements defines the expanded problem-focused examination; and a detailed examination requires 12 or more bulleted items.

Two important, major differences distinguish the 1997 comprehensive examination (Tables 28-6 and 28-7) requirement from the 1995 guideline. First, for the 1997 general multisystem exam, the provider must perform all the elements specified in at least nine organ systems or body areas. Second, the provider needs to document only a minimum of two elements from each of those nine systems or areas.

Determining Level of Service

For both the 1995 and 1997 guidelines, assign a specific level to each of the three key components. Rate history and examination each as either problem-focused, expanded problem-focused, detailed, or comprehensive. Rate the complexity of MDM as either straightforward, low, moderate, or high. CPT correlates specific levels of the key components with certain levels of most E/M services.

Initial patient encounters (initial hospital care, CPT 99221-99223; initial observation care, CPT 99218-99220; consultations, 99241-99245 and 99251-99255) require consideration of all three key components. Consider only two of the key components for subsequent hospital (CPT 99231-99233) or observation visits (CPT 99224-99226). The lowest component of the two or three key components required determines the visit level. For example, a level three initial hospital service (CPT 99223) includes a comprehensive history, comprehensive exam, and high-complexity decision making (Table 28-8). If the documentation merely supports a detailed level of history, yet meets the requirements for a comprehensive examination and high-complexity decision making, report only a level one initial hospital service (CPT 99221). In contrast, if a subsequent hospital visit note contains a complete examination and high-complexity MDM, then report CPT 99233 and history need not even be considered. When selecting visit levels for services that only consider two key components, MDM should be one of those two key components. While not stated in the documentation guidelines, medical necessity underlies every physician service and is most appropriately demonstrated through MDM. Reporting subsequent services with MDM as a key component thereby precludes the allegation of an unwarranted high-level subsequent encounter based upon merely a comprehensive history and examination (eg, common cold).

Time Counseling/Coordinating Care

CPT assigns most E/M codes a typical time to render a service, but importantly, the service duration need not last that length. For inpatient services, time accrues as unit or floor time in addition to face-to-face time. When more than 50% of the total service time involves counseling and/or coordination of care, the provider may select a code reflecting the total time spent with the patient, rather than the three key components. Time and the corresponding counseling details must be documented in the medical record when selecting the E/M code on the basis of time (eg, “25 of 40 minutes spent urging the patient to undergo a diagnostic biopsy”). Of course, record patient responses to counseling and all relevant history, examination, and MDM as necessary for good patient care.

Initial Hospital Care

Only patients admitted to an inpatient hospital may receive initial hospital care (CPT 99221-99223) (Table 28-8); other CPT codes describe services provided to patients in other facility settings (eg, skilled nursing facility). The attending physician admitting the patient reports this service. Many payers now mandate consulting physicians to report this service for their initial encounter during a hospitalization (see Consultations below). Documentation requirements of all three key components (history, physical examination, and MDM) must be met.

Consultations

A provider requesting an opinion or advice from another provider defines an inpatient consultation. The request for consultation need not originate from a physician but may also come from another qualified health care provider (eg, nurse practitioner, physician assistant, resident, etc.) involved in the patient's care, as appropriate. Inpatient consultations (CPT 99251-99255) (Table 28-9) occur in the hospital or nursing facility, once per admission per specialty for both new and established patients. Similarly, outpatient consultations (CPT 99241-99245) (Table 28-10) occur in the emergency room or outpatient hospital settings, such as observation units. All three key components (history, physical examination, and MDM) must be met.

Effective January 1, 2010, CMS ceased recognizing consultation codes (CPT 99241-99255), and mandated the report of initial hospital care codes (CPT 99221-99233) in lieu of inpatient consultations and of new or established outpatient visits (CPT 99201-99215) in lieu of outpatient consultations. New patients are defined as individuals who have not been seen within the last three years by a provider with the same specialty designation within the same provider group. Most managed Medicare programs and several other payers have implemented a similar consultation policy.

Subsequent Hospital Care

All admitting providers (and consultants) report subsequent hospital care (CPT 99231-99233) (Table 28-11) each day after an initial hospital care (or consultation) is reported. However, only one subsequent hospital care code per patient per day per specialty group will be reimbursed. Subsequent visits include surgical comanagement pre- and postoperative visits. Documentation of two of the three key components (history, physical examination, and MDM) must be met, unless reporting the visit based upon time.

Intrafacility Transfers

For patients transferred from one attending physician or provider group to another during the same inpatient stay, the receiving provider cannot report a consultation. However, some payers may allow the reporting of an initial inpatient service (CPT 99221-99223) as an associated consequence of their abolition of consultations, but only when transferred from a different provider group or specialty.

Patients discharged from an acute inpatient stay and admitted to another location (eg, long-term acute care hospital, psychiatric care, hospice, or rehabilitative care outside or within the same physical plant) pose equally difficult coding dilemmas. Provider groups who provided care during the initial acute stay, and then participate in medically necessary postacute care, report their services as subsequent hospital care (CPT 99231-99233). They make also report an initial hospital care (CPT 99221-99223) service if they are the attending physician of record for the postacute care.

Hospice

Providers caring for patients reassigned to inpatient hospice must distinguish their services from those of the hospice-employed providers. Report these medically necessary E/M services (CPT 99231-99233) with the modifier GW (service unrelated to the terminal condition; eg, 99233–GW).

Discharge Day Management

Hospital discharge day management services (CPT 99238-99239) describe discharge care, and may only be reported by the attending of record at discharge. The discharge service must include face-to-face service and it may also include a final examination, a discussion of the treatment course and follow-up plans, and preparation of the discharge records, prescriptions, and referral forms. When payers allow the hospital-required discharge summary to serve as supporting documentation for discharge day management codes, include the date and details of the final face-to-face service. Providers from other groups report subsequent hospital care services (CPT 99231-99233) on the day of discharge.

The cumulative time for discharge day services represents only a single provider's time. If the discharge service requires 30 or more minutes on the patient's floor/unit by a single provider, report 99239 and specifically document the time (start/stop or total cumulative time); otherwise, report 99238.

Report observation care services (CPT 99217-99236) for patients admitted to hospital outpatient units, often referred to as observation, 23-hour, or short stay units.

Admission and Discharge from Observation Care on the Same Day

Use CPT 99234-99236 (Table 28-12) to report observation care, if discharged on the same calendar day. Proper use of these codes depends upon individual payer regulations. For example, Medicare requires the patient to be in observation for at least eight hours on one calendar day. The provider must personally document the total amount of observation time.

Documentation of all three key components (history, physical examination, and MDM) must be met, and the physician must write two separate admission and discharge notes. If the patient is in observation for less than eight hours, only the initial observation care code (99218-99220) can be reported to Medicare with no discharge service reportable. Some insurers may not recognize CPT 99234-99236, and only allow a provider to report an initial observation code (99218-99220) under any circumstance.

Initial Observation Care

CPT 99218-99220 (Table 28-13) describe the initial day of observation care. All three key components (history, physical examination, and MDM) must be met for each of the observation admission codes. After admitting a patient to observation status, if the same provider group subsequently converts the patient to a hospital inpatient (ie, admits the patient) on the same calendar day, report only the appropriate admission service (99221-99223) for the calendar day. Similarly, if admitting a patient to observation following an office evaluation on the same day, report only the appropriate observation code.

Observation Discharge Care

Report discharge from observation with CPT 99217, typically on the calendar day following admission to observation. The provider must perform a final examination (albeit a minimal examination suffices) of the patient, discuss the course of treatment and ongoing care, and prepare the discharge records.

Subsequent Observation Care

In rare circumstances, a patient remains in observation for more than two calendar days. Report the second calendar day with the appropriate subsequent observation day service (CPT 99224-99226) (Table 28-14) and the observation discharge day code (99217) on the final (third calendar) day.

Critical care services represent the care of the critically ill or injured patient, utilizing different sets of codes, depending upon the patient's age and/or condition. Adult critical care codes (CPT 99291-99292) are selected according to the time spent by the physician in directing the care of the patient, while the neonatal (CPT 99468-99469) and pediatric (CPT 99471-99476) critical care codes are chosen based upon the age of the patient and apply to the entire calendar day.

A critical illness or injury acutely impairs one or more vital organ systems, such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Critical care treats single- or multiorgan system failure to prevent clinically significant or life-threatening deteriorations, and requires the provider to devote his or her full attention to the patient; therefore, the provider cannot provide services to any other patient during that same time.

Adult critical care is a time-based service of minimum 30 minutes duration. Report CPT 99291 for the first 30 to 74 minutes of critical care; report CPT 99292 for each additional 30 minutes beginning with 75 minutes of critical care. Critical care occurs on the floor/unit, and need not occur solely at the bedside. Critical care time includes reviewing databases, chart notes, telemetry, laboratory studies and radiographic images, and conversations with other providers such as consultants and ancillary care providers. However, all time associated with separately reportable procedures (such as placement of central venous and arterial catheters, cardiopulmonary resuscitation, and thoracentesis, paracentesis, and lumbar puncture) must be excluded from critical care time.

The prolonged care codes (CPT 99354-99359) may be reported when the provider's visit extends more than 30 minutes beyond the typical time allotted by CPT for the service provided. These codes must be reported in addition to the primary E/M service. Medicare only reimburses the codes representing the physician's direct (face-to-face) contact during inpatient (CPT 99356-99357) and outpatient (CPT 99354-99355) visits. Other payers recognize these codes on an individual, contracted basis. No payer recognizes the non-face-to-face prolonged service codes (CPT 99358-99359).

The teaching physician regulations define the circumstances under which a physician provider may bill for professional services rendered to a patient in a teaching setting. Generally, the teaching physician may report E/M services and procedures they either personally perform, or personally supervise a resident performing. However, under no circumstance can time spent teaching ever be used as a basis for reporting a service.

Definitions

Resident

The regulation defines a resident as any physician enrolled in an accredited graduate medical education program, at any year of postgraduate training. Students (medical, nursing, physician's assistant, or nurse practitioner) are never considered physiciansin-training, and the teaching physician regulations cannot apply to students. Similarly, nonphysician providers are not subject to the regulation, and may neither supervise residents nor be supervised under application of the regulation (see Nonphysician Providers later in this chapter).

Teaching Physician

Any independently practicing physician may supervise residents. Neither an academic faculty appointment nor compensation for teaching is required; therefore, these regulations clearly apply to private practice physicians with resident participation in hospitalized inpatient services.

GC Modifier

The GC modifier should be appended to every reported service with any participation by a resident, even if the entire service was provided and documented by the teaching physician, with the resident as a silent passive observer.

E/M Services

Physical Presence

The teaching physician must personally provide the critical or key portion of an E/M service and then participate in the management plan for that patient. Typically, the teaching physician will perform portions of the E/M service, partially overlapping the resident, or at a completely different time than the resident with no overlapping services. The teaching attending need not obtain or verify every element of the service provided by the resident.

Documentation

The teaching physician need not document the entire service, but rather a short linking (tethering) statement. However, this tethering statement must specifically reference the resident's note and demonstrate the teaching physician's physical presence, evaluation of the patient, and active involvement in the care plan (Table 28-15). Simply cosigning a resident note with a minimal statement of agreement is insufficient. Similarly, a scribed note authored by a student or resident cannot adequately identify the teaching physician as the provider of a clinical service.

Report the E/M service based upon the pooled documentation by the teaching physician and the resident, as well as any patient-completed history forms and the elements of past, family, and social history and any review of systems obtained from students. The teaching physician should specifically add any clinically relevant elements of history, physical examination, or medical decision making left out of the resident documentation and specify to which (among many possible) resident note(s) his or her statement links. In addition, although not required, teaching attendings should also directly sign the resident note with a comment referring the reader to the tethering statement in the medical record.

Electronic Medical Records (EMRs)

The 2006 update to the regulation specified additional documentation guidelines in EMRs. The teaching physician must personally add the tethering statement in a secured (ie, password-protected) manner. In addition, the composite EMR note, comprising the resident documentation tethered by the teaching physician, must contain some unique aspect of the patient encounter and not comprise entirely predetermined, unedited text (ie, a “macro”).

Procedures

Major Procedures

The regulation defines a major procedure as typically requiring more than five minutes to perform. Therefore, most inpatient procedures performed by hospitalists (such as arthrocentesis, thoracentesis, paracentesis, and lumbar puncture) comprise a major procedure. The teaching physician must define and be physically present for the critical or key portion of the procedure, document their presence for the critical or key portion of the procedure, and be immediately available (eg, on the unit/floor) for the entire procedure. The critical or key portion(s) of the procedure may vary among different patients undergoing the same procedure, and the teaching physician may supervise the critical or key portion of only one procedure at a time. It is useful, albeit not mandatory, to specify the critical or key portion of the service. A resident statement of the teaching physician's physical presence is inadequate.

Minor Procedures

The regulation defines a minor procedure as typically requiring less than five minutes to perform, and mandates the teaching physician be physically present for the entire procedure, with no overlap of another service.

Time-Based Coding

Many E/M services may be reported based upon counseling/coordinating or critical care time as discussed earlier. The regulation specifies that only time spent by the teaching attending in direct patient care accrues toward time-based coding; no instructional or didactic time may be included. The teaching physician must document his or her time (start/stop or total cumulative) and describe his or her service (counseling/coordinating inpatient care, providing critical care, discharge management). For example: “I spent more than 45 minutes personally urging Ms. Smith to undergo a biopsy to diagnose her breast mass as the cause of her hypercalcemia.” A linking statement, while commonly made in the medical record, is inadequate for reporting time-based services, nor may a resident statement document the time spent by the teaching physician.

Physicians increasingly utilize nurse practitioners (NPs) and physician's assistants (PAs) as nonphysician providers (NPPs). Some NPP services may be incorporated into the clinical activities provided by the physician, while other clinical services can be performed and reimbursed independently. Several options for these services exist for Medicare, which we will describe in depth. Other insurers may mimic Medicare, or define completely separate, specific contractual mechanisms for addressing these services.

Independent Billing

The 1997 Balanced Budget Act (BBA) allowed for NPPs to independently bill for their services. NPPs must enroll and obtain a Medicare National Provider Identifier (NPI) and provider number to submit claims. Many payers enroll NPPs for independent billing in primary care practices; some may also recognize NPPs linked to hospitalist groups. Currently, only Aetna plans to consistently recognize all specialty NPPs for independent billing purposes and issue a provider number to any qualified NPP.

Services

NPPs may perform all services typically considered physician's services, within the limitations of their state-regulated scope of practice. Such services include E/M visits, many procedures, and performance of diagnostic testing; for each of these services, the NPP would generally perform and document the service exactly as a physician would. However, many states articulate different scopes of practice, supervisory requirements, documentation standards, and cosignature requirements for NPs distinct from PAs, and may require additional documentation beyond that of a physician. Facilities may further impose internal guidelines involving documentation standards or cosignature requirements.

Billing

NPs may directly bill Medicare and receive payment. In contrast, only the qualified employer of a PA may receive payment. Medicare limits reimbursement for NPPs to 85% of the Physician Fee Schedule; Aetna plans to similarly discount their services.

“Incident to” Billing

Medicare allows NPPs to provide services “incident to” those of the physician, in the physician office setting. Qualifying “incident to” services include follow-up services typically performed by office staff, such as vital signs, injections, and simple dressing changes, as well as more advanced services within their state-regulated scope of practice. Medicare mandates the physician's physical presence in the office suite (direct supervision), during performance of all “incident to” services. “Incident to” services are not applicable to the majority of hospitalist services, characteristically provided in facility settings.

Shared/Split Billing

In October 2002, CMS created a shared/split billing policy for NPP services provided in a facility setting and third party payers increasingly recognize variations of this policy. Under split/shared billing, both the physician and the NPP render portions of a service. The designated NPPs must have a Medicare provider number (see Independent Billing earlier in this chapter) linked to the same group practice as the sharing physician.

Services

Shared/split billing applies only to specified E/M services, and never procedures or diagnostic testing. Critical care and consultations performed by an NPP must be reported using independent billing. Services must occur in either the inpatient (place of service [POS] 21), hospital outpatient (POS 22), or emergency department (POS 23) sites of service. Services may be rendered concurrently or at separate times during the same calendar day, but both the NPP and the physician must each have a face-to-face encounter with the patient (or else the NPP must report the service as an independent provider).

Documentation

Shared/split service documentation must clearly identify the providers involved and evidence the physician's portion of the service. The NPP and the physician should each note their involvement in the patient's care. If the NPP and physician each write separate notes, the two notes should refer to each other such that the supporting documentation for the service rendered comprises the composite of both notes. Legible signatures and dates must accompany each provider's note.

Billing

Shared/split services may be reported under either the physician or the NPP provider number, but Medicare reimburses NPP services at 85% of the Physician Fee Schedule. The usual Medicare payment at 100% of the Physician Fee Schedule occurs if the physician provider number appears on the claim.

Non-Medicare Payers

Insurers not recognizing the various Medicare billing options for NPP services typically do not issue NPP provider numbers. In order to obtain reimbursement for NPP services in this situation, delineate the details of these circumstances in the contract terms with each payer.

Cardiopulmonary Arrest

Hospitalists typically supervise, and at times partially perform, cardiopulmonary resuscitation (CPT 92950). A dedicated clinical resuscitation or code call team usually renders this complex, time-intensive effort. Most hospitals have a designated cardiopulmonary resuscitation form to achieve complete, optimal documentation of these expected but uncommon events. Simply signing a suitable form authenticates the supervision or performance of the cardiopulmonary resuscitation (CPR) service.

E/M Service

Any E/M service provided on the same calendar day as CPR should be separately documented in the medical record. Correct billing of the E/M service requires appendage of a 25 modifier (eg, 99291-25) to demonstrate the service as separately identifiable from the procedure.

Other Procedures

Certain procedures frequently accompany cardiopulmonary resuscitation, including endotracheal intubation (CPT 31500), chest tube insertion (CPT 32551), pericardiocentesis (CPT 33010), central venous catheter insertion (CPT 36556), and arterial puncture (CPT 36600). Remember each of these separately billable procedures also requires a separate procedure note for documentation, and that all time associated with these procedures must be excluded from any reported critical care time.

Rapid Responses

Rapid responses assemble a multidisciplinary, critical care team to evaluate deteriorating patients outside of an intensive care unit. Also, at times, a patient, visitor, or employee in any location within the hospital may require a rapid response and transport to the hospital emergency room.

Inpatients

For rapid response services provided to inpatients, document the service provided in the medical record. Report an appropriate inpatient E/M service (including potentially critical care and use the hospital inpatient place of service (POS 21) on claim submissions.

Outpatients

For employees or visitors, as well as patients in observation status, use the outpatient hospital site of service (POS 22). Document an appropriate outpatient E/M service in the medical record. If the visitor or employee is admitted that same calendar day, both the site of service and the E/M code for the service may change.

As noted throughout the text above, at times certain modifiers must be appended to a CPT code to allow proper claims processing. Several modifiers are occasionally utilized by hospitalists.

25, Separately Identifiable E/M Service

Append this modifier to indicate performance of a significant, separately identifiable E/M service on the same day as a procedure, when performed by the same provider group. The E/M service must be medically necessary, beyond the usual preoperative and postoperative care associated with the procedure. The two chart notes (for the procedure and the E/M service) should clearly elaborate the rationale for the two services. For example, the procedure indication might be ascites while the E/M service provided evaluation and management of hepatic encephalopathy.

59, Separately Identifiable Procedure

Modifier 59 is most frequently employed with code pairs identified in the National Correct Coding Initiative (NCCI) edits, representing procedures typically bundled together. Do not use modifier 59 to bypass an NCCI edit without establishing the proper criterion for its appropriate clinical use with two procedures or services (other than an E/M service) as distinct or independent from each other, when performed on the same day. For example, following a large volume, therapeutic thoracentesis (CPT 32422) later that same day the patient develops an iatrogenic pneumothorax requiring chest tube insertion (CPT 32551); report both 32422-59 and 32551, after documenting two independent procedure notes.

GC, Separately Identifiable E/M Service

Append modifier GC to any E/M service or procedure in which a resident participated, under the direction of a teaching physician.

GV, Physician Not Employed by Hospice

Use this modifier when the hospitalist serves as the attending physician, rather than the hospice physician.

Templated chart notes, whether formatted as preprinted paper progress notes with check boxes or electronically constructed as combinations of macros and click-boxes, are common, appropriate documentation tools. Such tools enhance legibility and facilitate efficient documentation in accord with the E/M guidelines. Unfortunately electronic notes often become the source for increasingly prevalent “cut-and-paste” errors, highlighting the need to balance efficiency with accuracy in providing safe, efficient care to complex patients.

Audit Tools

Audit tools are useful adjuncts to ensuring adherence to E/M billing guidelines, patient safety and quality initiatives, and other process assessments. Such tools are often custom designed in the context of chart reviews and institutional initiatives, or implementing coding and billing audits associated with practice compliance plans. CMS has not developed or endorsed any formal audit tool for E/M services, although several Medicare contractors (eg, Trailblazers and Highmark) make their E/M score sheets available to assist providers in adhering to documentation guidelines.