Coding & Documentation

Medical coding identifies and classifies health information used in a physician’s billing process so that a physician’s payment is optimized, but not maximized.  Proper documentation facilitates quality care and verifies the services that were provided.  Complete and accurate documentation regarding the diagnosis and treatment in a patient’s medical record is imperative.

The medical record of a patient may be used to validate site of service, appropriateness of the services provided, the accuracy of the billing, and identity of the health care provider who furnished the services.

All medical records generated by all UBMD physicians must be complete and legible, and include the following elements:

• Reason for the encounter/chief complaint
• Relevant patient history
• Physical examination findings
• Prior diagnostic test results
• Assessment, clinical impression or diagnosis
• Plan for care
• Date and legible identity of the observer
• Statement of rationale for ordering diagnostic tests and other ancillary services, if not documented and easily inferred by a third party reviewer with appropriate medical training
• Past and present diagnoses accessible to the treating and/or consulting physician
• Identification of appropriate health risk factors
• Statements of patient’s progress, response to and changes in treatment, and revision of diagnosis
• Addendums to the medical record should be dated the day the information is added to the record and not for the date the service was provided.

CPT-4 and ICD-10-CM codes reported on all reimbursement claim forms or billing statements should be adequately supported by the documentation in the medical record, and be submitted only in the name of the provider who performed the service.

While the above principles of documentation are applicable to all UBMD providers, it is the responsibility of the individual Practice Plans to implement any documentation guidelines specific to the nature and type of service they provide.  The Practice Plans are responsible for orienting all of their employees – clinicians, coders, billers, administrative staff and auditors – to the documentation guidelines.  Practice Plans may ask UBMD Compliance Office for assistance with this training.

The Centers for Medicare and Medicaid Services (CMS) issue guidelines outlining how and when clinical services are coded, billed and reimbursed for those physicians teaching interns, residents, fellows, and medical students during patient treatment.

• Payment for teaching physicians provided in teaching settings using physician fee schedule is permissible only if:
  • Services are personally provided by physician, not resident;
  • Teaching physician is physically present during key portions of the service that resident performs; or
  • Teaching physician provides care under conditions outlined in “documentation” paragraph in Part V, Section B-1 of this Compliance Plan.
• For purposes of payment, E/M services billed by the teaching physician require that they personally document at least the following:
  • Review of resident’s note;
  • Confirm or edit of resident’s findings;
  • Document performance of participation in key components;
  • Summarize participation in the management of the patient; and
  • Date, time, and signature on note.
• Examples of correct wording:
  • “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
  • “See resident’s note for details.  I saw and evaluated the patient and agree with the resident’s findings and plans as written.”
• Examples of unacceptable documentation:
  • “Agree with above.”
  • “Rounded, reviewed, agree.”
  • “Discussed with resident. Agree.”
  • “Patient seen and evaluated.”
• Primary Care Exception – A graduate medical education program that has been granted a primary care exception may bill Medicare for lower and mid-level E/M services provided by residents.
  • E/M codes new patient: 99201, 99202, 99203;
  • E/M codes established patient: 99211, 99212, 99213;
  • HCPCS Code G0402: Initial preventive physical examination; face-to-face visit services limited to new beneficiary during the first 12 months of Medicare enrollment;
  • HCPCS Code G0438: Annual wellness visit, including personal preventative plan service, first visit;
  • HCPCS Code G0439: Annual wellness visit, including personal preventative plan service, subsequent visit;
  • CPT Codes 99381-99397: Preventative Medicine Services;
  • Residents providing billable patient care service without teaching physician supervision must have completed at least six (6) months of GME program;
  • Residency programs most likely to qualify for exception: family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.

The teaching physician may verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. This is important for teaching physicians and those who provide coding services to teaching physicians. According to the Medicare Claims Processing Manual the following specifics regarding this:

• Students may document services in the medical record.
• The teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making.
• The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.

It is important that there is no question that the teaching physician verified the student’s documentation and personally performed the physical examination and medical decision-making of the E/M service. To ensure that we compliantly bill for these services, the following Student Attestation must be added and signed by the supervising physician:

“I have seen, personally examined and assessed the patient to establish a plan of care. I have reviewed the medical record and verify that all student documentation or findings, including history, physical exam and/or medical decision making are accurate. I have performed or re-performed the physical exam and medical decision making activities to the extent they were conducted by a student.”

There are three (3) ways to bill for the services of non-physician practitioners (NPP).

Incident-to-services: Billed under the MD, paid at 100% of the MD fee schedule.

• Private office, outpatient only. No hospital outpatients, inpatients, emergency department only.
• Follow-up/established patients only. No new patients.
• Requires “direct supervision” by physician
• “Direct supervision” means the doctor must be present in the office suite, immediately available to provide service if needed.
• NPP documents service in medical record; MD does not need to sign.

Direct Billing: Billed under the NPP, paid at 85% of the MD fee schedule

• Not site-restricted; may be inpatient, outpatient, office, hospital, etc.
• New or follow-up/established patient.
• Requires “general supervision” by MD.
• “General supervision” includes the attending physician’s overall direction and control of the training and equipment, but the physician’s presence is not required during the diagnostic procedure. The physician does not have to be present when the service is performed.

Shared Billing: Applies when NPP and MD are members of the same group, and the combined service is billed either under the NPP’s or MD’s number

• Not site-restricted; may be inpatient, outpatient, office, hospital, etc.
• E/M services only.
• No critical care, no procedures, no consultations.
• MD must provide face-to-face portion of the E/M encounter.
• If incident-to requirements are not met, then must bill under the NPP’s number. Local health insurers have adopted this as their “incident to” policy.  Medicare has a separate police that should be followed for Medicare patients.

Scribes are allowed by UBMD to be used by teaching/attending physicians, however there are several guidelines to follow.  Anyone acting as a scribe must sign the UBMD Scribe Agreement, and the agreement should be kept on file by the practice plan.

• Residents, interns and fellows may not act as scribes.
• Ancillary providers such as NNPs, Pas, Mas, RNs and other staff may serve as scribes.
• Medical students may act as scribes recording the actions and words of the physician in real time, but must not be seeing the patient in any clinical capacity and may not document or interject their own observations or impressions. Do not confuse this ability to scribe with the medical student’s ability to individually document information for a billable service.
• A scribed not must accurately reflect the services provided for any given date of services.
• The billing provider is responsible for the content of the scribed note.
• A scribed note can be handwritten and scanned, or typed/created directly in the EMR (if they have password/access to the EMR).
• Documentation of a scribed service must include the following:
  • A dated note from the scribe identifying them as the scribe for [name of physician providing service], attesting that the notes were written in the presence of the physician, and the signature of the billing physician.
  • Documents scribed in the EMR must clearly identify the scribe and their authorship of the note both in the document and in the audit trail.
  • Providers are required to document in compliance with all federal, state and local laws, as well as with UBMD policy.