Michelle Peck | Legal Nurse Consultant | Adult & Geriatric Nurse Practitioner | Health Care | Consultant | Speaker | Educator | Researcher Enjoy your journey through this slide deck of Geriatric Population. Geriatric Clinician Practice. Your Medicare, Long-Term Care Documentation. Imagine if writing a progress note was really as simple as the note featured on the title slide. This physician progress note style filled the charts of a 120 bed nursing facility in rural Texas. Walking down the facility hallways I observed many unstable conditions and behaviors. Staff were numb to the yelling. When I questioned about the yelling "we don't medicate behaviors" was the most popular response. I needed to be medicated after a few hours of being there. Collecting data had never been this difficult. Stable and clinical documentation now had a whole new meaning. This month I am instructing Nurse Practitioner students on Medicare and Long-Term Care Coding and Documentation. Revising this lecture reminds me of all of the clinician types I have met during my long-term care travels. 1. Amazing Clinicians ◾ They know state and federal regulations and practice perfectly. ◾ They don't cross your path very often. ◾ When you meet them you must stop, listen and absorb all their knowledge. 2. So-So Clinicians ◾ They don't know that there are regulations on state and federal levels. ◾ They are pretty common and are doing enough with meaningful practices. ◾ When you meet them you must stop, talk and they absorb your knowledge. 3. Corner Cutters ◾ They are not doing enough and practice out of compliance. ◾ Their colleagues are also clueless, there is guilt by association. ◾ When you meet them, run in the opposite direction. What types of geriatric clinicians are crossing your path? The documentation is very telling as to the practice type. Are they awesome, so-so, or of the corner cutter breed? Learn it-Live it-Love it-Your path for a more informed life! Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher

2. LET’S DISCUSS
Tools & Tips to Enhance
Professional Growth
Productivity
Clinical Outcomes
Documentation
Coding

3. CMS
Documentation Rules

4. 1. Always include the chief complaint may
be a symptom or statement
i.e. here for dyspnea at rest; follow-up
HTN, DM, CAD
2. Always document a clinical impression
or diagnosis
3. For an established problem note status
i.e. improved, controlled, resolving,
inadequately controlled, worsening,
failing to change as expected
4. Document the initiation or changes in
treatment include patient instruction,
nursing instruction, therapies and
medications
5. If referrals are made, record to whom

5. 6. Document review of diagnostic tests. I
personally reviewed the Chest x-ray and is
normal.” I personally reviewed the
following…with independent visualization
of…
7. If you review an EKG with a cardiologist in a
face-to-face encounter, write “reviewed
EKG with Cardiologist X”
consultation with other providers raises
level of medical decision-making
8. Document comorbidities, underlying
diseases or other factors which increase
complexity of the medical decision-making
by increasing risk complications, morbidity,
mortality
9. If deferring a specific element of an
examination, document the reason
i.e. intubated and sedated limiting the exam

6. 10. If the patient refuses or cannot participate
document the reason i.e. unable to obtain
ROS or PFSH due to patient’s mental status
11. Write each note such that it can stand alone
12. Always include the patient’s name, the date
and your signature on the progress note
13. Make it clear (use headings) that you are
addressing: CC, HPI, ROS, PFSH, EXAM,
DIAGNOSIS, DIAGNOSTICS,
TREATMENT/THERAPY, ADVICE,
REFERRALS, FOLLOW-UP, TIME SPENT
14. If caring for hospitalized patients then every
day of a patient’s hospital stay document the
reasons why they need hospitalization
15. Review the note, CPT & diagnosis codes to
make sure that the note detail is
appropriate

7. Medicare requires medical
records contain FACTS
about patient’s condition,
not just a conclusion.
FACTS: Bilateral osteoarthritis progressing last 10 yrs. X-ray
12/1/11 shows joint space nearly obliterated, marginal
osteophytes & subchondral sclerosis. Previous treatment:
Ibuprofen 400 mg QID for past two years; PT 3 x week 7/15/11
– 11/30/11. Using cane since August. Knee pain 3/10
continuous (walking = 7/10). Pain keeps him awake & can't
climb five steps to his front door. Bilateral knee replacement.
CONCLUSION: Failed outpatient therapy and bilateral knee
replacement.

8. Is Not Dictated By Patient Preference
Care cannot be provided according to what
is convenient for the patient
Care must be essential, not just beneficial,
and cannot be experimental in nature
Must Be Cost Efficient
Often the lowest level of care available and
still proven to impact the condition
Must be provided in the most cost efficient
manner possible
Medical Necessity Criteria
Not diagnostic criteria
Dictates the care a patient receives by
dictating what a physician can be
reimbursed for

10. Non-Physician Practitioner
(NPP) Billing Options
NPP - may provide services without direct
physician supervision and bill directly for these
services
Direct Supervision – physician must be present
and immediately available
Does not mean that the physician must be present
in room, but there in the office

11. “Incident to” Billing
Services must be an integral, although incidental,
part of the physician’s personal professional
services
Must be performed under physician’s direct
supervision
“Incident to” does not apply to Hospital settings
Physician must have initially seen the patient/active
part in the ongoing care

12. Shared/Split Billing
Physician and the qualified NPP must be in the
same group practice or be employed by the same
employer
Applies select E/M visits & settings
Hospital inpatient-outpatient-observation-
discharge, emergency department, office and
non facility clinic visits, and prolonged visits
DOES NOT APPLY: consultation services, critical
care, procedures, skilled and non-skilled nursing
facility

13. Skilled (SNF)
& Nursing Facility (NF)
No split/shared E&M in the SNF/NF
Initial comprehensive before 30 days
may NOT be delegated to NP in SNF
considered “timely” <10 days
H&P completed within 48 hours of admit if it has
been done within 30 days prior to admit a copy
may be used in the record (initial & date the copy)

14. TEXAS

15. History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family, Social History (PFSH)
Examination: 1995 or 1997 rules
Medical Decision-Making
Number of diagnoses or management options
Amount and/or complexity data review/order
Risk of complications, morbidity or mortality
In/Out-Patient SAME E/M

17. History of Present Illness
Location Left Right Proximal Distal
Duration Since this morning 1 week Several months 48 hours
Modifying Factors Better after eating Relieved by aspirin Worsens when Took ____ with no relief
Quality Sharp Dull Shooting Throbbing
Severity
Pain is 6 on a
scale of 1-10
Severe Slight Intolerable
Timing Daily Began at midnight Sporadic Nocturnal
Context During exercise Occurred at While running
When walking,
but not when standing
Associated Signs &
Symptoms
Without fever Headache Nausea/vomiting No LOC

19. A
Number of
diagnoses
and/or
management
options
 1 Minimal 2 Limited 3 Multiple > 4 Extensive
B
Amount and
complexity of
data reviewed
or ordered
 1
None/Minimal
2 Limited 3 Multiple > 4 Extensive
C
Risk of
complications
and/or
morbidity or
mortality
Minimal Low Moderate High
Type of medical
decision-making
Final MDM requires that 2 of 3 of the above components are met or exceeded
Straight
Forward
(S)
Low
Complexity
(L)
Moderate
Complexity
(M)
High
Complexity
(H)
Medical Decision-Making
Complexity

20. Self-limited or minor: (CPT: A problem that
runs a definite and prescribed course, is
transient in nature, and is not likely to
permanently alter health status or has a good
prognosis with management/compliance)
_____
problems
X 1 point ____
points
(max = 2)
Established problem: Stable or improving
(By documentation)
_____
problems
X 1 point ____
points
(max = 2)
Established problem: Worsening
(By documentation)
_____
problems
X 2 points ____
points
New problem: No additional workup planned
(Documentation does not indicate any
diagnostic tests performed or ordered)
_____
problems
X 3 points ____
points
(max = 3)
New problem: Additional work-up planned
(diagnostic tests performed at encounter are
documented &/or tests ordered are
documented)
_____
problems
X 4 points ____
points
Total Points:
Diagnoses or Treatment

21. Item (Documentation required) Points
Review &/or order of clinical lab tests 1
Review &/or order of tests in Radiology section of
CPT
1
Review &/or order of tests in Medicine section of
CPT
1
Discuss tests with performing physician 1
Decision to obtain old records (Must identify
source and reason for decision)
1
Review & summarize old records (must identify
source, provide summary and relevance to current
problem)
2
Independent visualization and interpretation of
image, tracing, or specimen (Not a review of a
report; must document own interpretation)
2
Total Points:
Data Amount & Complexity

23. MINIMAL
Rest
Gargles
Elastic bandages
Superficial dressings
LOW
Over-the-counter drugs
Minor surgery with no
identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Management Options

24. MODERATE
Minor surgery, identified risk factors
Elective major surgery (open,
percutaneous or endoscopic) with
no identified risk factors
Prescription drug management
IV fluids with additives
Closed treatment of fracture or
dislocation without manipulation

25. HIGH
Elective major surgery (open,
percutaneous or endoscopic) with
identified risk factors
Emergency major surgery (open,
percutaneous or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive
monitoring for toxicity
Decision not to resuscitate
or to de-escalate care

27. THINK
BACKWARD…

28. FROM THE
PROBLEM
TO THE
CODE

29. Tips
Choose a code based on these criteria
How many diagnoses?
How many, what kind therapies required?
How many tests ordered?
How risky is the condition?
How many other experts?
There are no clear point systems given except for diagnoses
Decision-making must be documented even if requirements
for level of service are met through history & exam

30. LEVEL INCREASES AS YOU
Diagnose more problems
Diagnose an acute complicated injury
Do more tests
Do more examination
Order additional therapy
Consult other clinicians
Tips

31. TIME BASED CODING
THINK CCC

32. TIME BASED CODING
THINK CCC
When counseling and/or
coordinating care dominates
> 50% the clinician/patient and/or
family encounter
Face-to-face time in the outpatient
setting or floor/unit time in the
hospital
Then time may be considered the
key factor to qualify for a
particular level of E & M service

33. TIME BASED CODING
Must Document: Total
time, counseling time and
content of the discussion
EXAMPLE: I spent a total
of 30 of 45 minutes on the
floor coordinating
Donald’s care and in
discussion with Donald
regarding…”