Coding and Documentation

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Coding and Documentation

Business of Medicine
Author Credentials 

Richard Waguespack, MD
Professor of Otolaryngology
Department of Otolaryngology-Head and Neck Surgery
University of Alabama-Birmingham
Birmingham, AL

Lawrence M. Simon, MD
Clinical Assistant Professor of Otolaryngology
Department of Otolaryngology-Head and Neck Surgery
LSU Health Sciences Center
New Orleans, LA

Module Learning Objectives 
  1. Review the relationship between coding and documentation.
  2. Cite the role of proper documentation for evaluation and management (E/M) and other non-procedural services.
  3. Explain the role of proper documentation for procedural services.
Types of Coding
  1. Current Procedural Terminology (CPT) See related module CPT Process for Code Creation
    1. Used to report healthcare related services by physicians and other qualified healthcare providers (QHP)
  2. Diagnostic codes are generally reported with ICD-10 codes 
    1. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems
    2. Although there are procedural codes in ICD-10, doctors mainly use the diagnostic codes
    3. Created by the World Health Organization (WHO), they vary in usage and content from country to country
  3. Healthcare Common Procedure Coding System (HCPCS) codes are 
    1. Five-character, alpha-numeric codes mainly representing medical supplies and drugs, durable medical goods, non-physician services, and other services not represented in the CPT code set. 
       
General Principles of Documentation

The following constitute important elements to guide appropriate documentation:

  1. Legibility is paramount; this includes clinical context, whether dictated or entered by keyboard.
  2. Cite the reason for the encounter with relevant history, physical examination, medical decision making (including diagnostic testing, clinical assessment or diagnosis, and management plan) and provider(s).
  3. Documentation of relevant co-morbidities or risk factors.
  4. Progress, response to treatment, and changes in diagnosis or management. 
  5. Payors typically require medical necessity and evidence that a service is a covered benefit, so documentation should support both concepts.
  6. Documentation also serves a medico-legal role and is the backbone by which providers communicate with one another and over time.
  7. Used to report outcomes, utilization review, or quality of care (eg, quality measures required by CMS or commercial payors).
  8. Documentation should be as contemporaneous as feasible.
  9. Copying and pasting should be minimized and a timeline maintained; use of the term “today” is discouraged since a specific date is less likely to be ambiguous.
  10. Repeated poor or misleading documentation may trigger an audit for quality or payment purposes.
  11. The doctor or QHP is ultimately responsible for coding submitted under their name and documentation must be supportive.
  12. In summary and perhaps over-simplified, “If it was not documented, it was not done.” 
CPT Coding
  1. Evaluation and Management (E/M) codes
    1. Describe services related to physician visits specifying site of service (eg, office, hospital), type of service (new or established patient), intensity of service (eg, limited, comprehensive).
    2. Although there are CPT descriptions outlining levels of service, the most definitive descriptors are defined by CMS and are the 1995 and 1997 guidelines.
      1. 1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES
      2. 1997 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES
    3. One may use both sets of guidelines but many coding experts feel using a single one provides more consistency in coding; many also feel the 1997 guidelines are more applicable to Otolaryngologists.
    4. Most E/M services are defined by face-to-face time but some are not and in “the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family. encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.”  (From the 1997 guidelines cited above).
    5. General elements of E/M coding include history, physical examination, and medical decision making.
      1. Levels of each element are defined in the CMS guidelines.
      2. Medical decision making includes ordering and interpreting labs, imaging, and other diagnostic studies as well as management planning and execution.
      3. Document if reviewing diagnostic studies rather than just the report; for example, document that images were reviewed and interpreted personally in addition to citing the radiologist’s report.
      4. Generally two or three components are needed to qualify for a specific E/M service.
    6. Modifiers (eg, 24 or 25) may be used with E/M services to tell payors there are unusual or distinct conditions relating to reporting them.
    7. Whether used alone or with modifiers, E/M service documentation must fully support the code submitted.
    8. It should be clear who rendered the service, especially when Advanced Practice Providers (APPs such as nurse practitioners or physician assistants) are utilized and presence of an attending is necessary in academic settings.
  2. Procedural codes
    1. Procedures are reported with CPT codes and are often based on anatomic sites.
    2. Imaging services and procedures are generally based on both type of imaging and anatomic site.
    3. CPT requires specificity such that if a procedure is not well described with an existing code, be it Category I or Category III, with or without modifier usage, an unlisted code should generally be reported.
      1. When an unlisted code is submitted, submit a comparator code for fee calculation.  The comparator code should represent similar time and effort.  
    4. Whether used alone or with modifiers, procedural service documentation must fully support the code submitted
    5. Regarding procedure notes, documentation should provide the rationale for the procedure as well as a descriptor of the service sufficient to fully support code(s) reported.
      1. Many coders do not recommend CPT codes in a procedure note, but rather sufficient detail to allow proper coding.
      2. Operative descriptors should generally follow their CPT coding counterparts
    6. Operative reports should include pre- and post-operative diagnosis(es), specific procedure(s) performed, surgeon(s) and assistant(s), anesthesia, intraoperative monitoring, indications for surgery, intraoperative findings, narrative of the service, laterality, and specimens removed, complications, estimated blood loss, and anything atypical about the case.
      1. It may be necessary to document why an assistant was required.
      2. Presence of an attending is necessary in academic settings.
      3. If other specialists are involved with a procedure, documentation should clearly define their role and work performed, generally with separate documentation by provider
    7. Modifiers (eg, 22 increased procedural services, 59 distinct procedural service, 79 denotes a service during the global period of an unrelated procedure) may be used with procedural services to tell payers there are unusual or distinct conditions relating to reporting them
      1. National Correct Coding Initiative (NCCI) edits are used by Medicare and many commercial carriers to denote when codes may be used together or not and if a modifier can allow coding together
      2. Documentation must support the use of the modifiers (e.g. increased procedural services)
    8. In situations wherein an E/M service and procedural code are to reported during the same encounter or on the same day by the same provider, the documentation should clearly delineate the respective diagnoses and physician work of each component
    9. Procedures typically have a global period, which describes the time frame following the procedure for typical additional services (such as office visits) should not be reported
      1. Know the global periods for major carriers and the procedures one performs to correctly report services during global periods
      2. Often the global periods mirror those of CMS of 0- and 10-days (“minor procedures” and 90-day (“major procedures”)
    10. Some procedures are reported based on pathology (eg, integumentary excisions for benign or malignant lesions), so code submission should wait until pathology is determined in such instances
  3. ICD-10 coding
    1. This system is much more specific and robust than its predecessor ICD-9, which may be used in unusual cases defined by HIPAA
    2. Generally, the most specific diagnostic code should be reported and linked to the CPT code with which it is reported
    3. Documentation should support both the diagnostic and CPT code (eg, use of cerumen removal code 69210 with ICD-10 code defining the ear upon which it was performed)
  4. HCPCS coding
    1. Frequently used for medications (eg, J codes) that are administered by physician or QHP
    2. May report specific services not described by CPT (eg, G codes used by Medicare or S codes used by commercial carriers)
    3. A similar level of documentation is required for HCPCS coding (eg, dose of medication, how delivered, manufacturer and lot number, etc)
Additional Information
  1. https://www.entnet.org/content/reimbursement
  2. 1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES
  3. 1997 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES
  4. Current Procedural Terminology (CPT®) 2018 Professional Edition. American Medical Association. 
Resources 

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