Coding and Coding Guidelines

Abstracting Health Information

Providers document every patient encounter within an electronic health record (EHR). The primary intent of the EHR is to assist providers with documentation and to create a repository of medical information that can be utilized and shared across relevant agencies, other health care providers, and various organizations.

Documentation for each encounter must be comprehensive and include the following elements:

• The reason for the encounter

• Patient history

• Physical examination findings

• Diagnostic or laboratory tests performed

• A treatment plan to support each CPT, ICD-10-CM, or HCPCS code reported on the claim.

According to third-party payers, if a treatment is not documented in the record, it is legally considered not done. Providers are expected to complete all documentation in a timely manner. This documentation must validate the appropriateness of the medical services or treatment, a concept known as medical necessity.

Medical Necessity and EHR Systems

Every patient encounter must explicitly state the reason for the visit and support medical necessity. Medical necessity is described by the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) as reasonable and appropriate services based on clinical standards. If documentation fails to support medical necessity, insurance payers may deny claims, resulting in a lack of reimbursement for the organization.

Electronic Health Record (EHR): A digital version of a patient’s chart that includes information documented by multiple providers at different facilities regarding one patient.

Medical Necessity: The process of providing diagnosis codes that support the services rendered to the patient. Coding for medical necessity involve's associating applicable diagnosis codes to service/procedure codes within the billing software, which is referred to as linking or linkage.

While the organization of documentation varies by EHR vendor and the type of health care organization, the data required to assign codes and submit claims is commonly structured using the SOAP format. Even if the acronym SOAP is not explicitly used, its content is the standard for abstracting details for code assignment.

The SOAP Format

The SOAP acronym stands for Subjective, Objective, Assessment, and Plan:

• S: Subjective: This section includes symptoms or the history of the condition using the patient’s own words. It describes the improvement or decline of the condition since the last treatment, provides explanations for any gaps in treatment, and records the patient’s compliance with provider recommendations.

• O: Objective: This section contains vital signs, physical examination findings, laboratory and other diagnostic data, imaging results, and documentation from other clinicians that have been reviewed and considered by the provider.

• A: Assessment: This consists of the diagnostic impression or working diagnoses developed based on the subjective complaints and the objective findings.

• P: Plan: This describes the procedure or plan for treatment. It includes treatment frequency, duration, expected outcomes, and goals. The plan often encompasses medications, referrals, and patient education or counseling.

Questions & Discussion: Abstracting Health Information

Challenge: Documentation Matching

Question: Match the documentation type with the correct information.

1. Subjective

2. Objective

3. Assessment

4. Plan

A. Impression or diagnosis B. Patient reports feeling better C. Patient education D. Documented lab values

Answer: 1: B (Subjective - Patient reports feeling better); 2: D (Objective - Documented lab values); 3: A (Assessment - Impression or diagnosis); 4: C (Plan - Patient education).

Take Note Scenario: Navigating the EHR

Codee is searching through the new EHR system and cannot find the operative report needed to code surgical services. Billee assists Codee in navigating the interface.

BILLEE: You seem frustrated. Is there something I can do to help you? CODEE: The billing software shows a pacemaker that was placed last week. The only patient encounter under the NOTES tab in the EHR is the hospital admission. And that does not help me to verify the coding for the pacemaker insertion. BILLEE: The NOTES tab includes admissions and progress notes for subsequent provider encounters. The SURGERY tab in the EHR will include both inpatient and outpatient surgery reports by the date of the procedure. Let’s look in the SURGERY tab to see if we can find the correct documentation. CODEE: Yes, I found it under the SURGERY tab. Thank you. It is going to take some time to learn this new EHR system because I am used to the old one. BILLEE: You are welcome. It is going to take time to for everyone to become familiar with the new system, but the results are worth it.

Medical Necessity Example

Patient Record Excerpt:

• Chief Complaint: Fall with scraped skin on elbow and hip pain.

• History of Present Illness (HPI): Patient presented to the office for an abrasion on the left upper arm from a fall $2$ days ago in the driveway. Patient also reports left hip pain that began yesterday. The patient describes the hip pain as throbbing and is an $8$ on a scale out of $10$.

• Assessment & Plan:     - Abrasion: Left upper arm. Keep area clean and dry, cover with clean dressing daily until healed.     - Left hip pain: Ibuprofen every $4$ hours as needed for pain. Left hip x-ray to rule out fracture.

Clinical Documentation Types

The medical record is comprised of administrative data and clinical documentation. Clinical documentation is the key information for coding and describes the health status of a patient as determined by a provider. Common report types include:

• History and Physical (H&P): Information pertaining to the patient’s health history and current condition.

• Progress Notes: Documentation of a patient encounter including history, exam, and medical decision making.

• Consultation Report: Includes physical examination and test results, along with a consultant’s expert opinion on the patient’s condition.

• Orders: A request made by a provider for services, labs, tests, therapies, or medications. Orders include a diagnostic statement indicating why the order is needed; services cannot be performed without an order.

• Operative Reports: A report dictated by a surgeon containing details about the procedure performed, the necessity of the procedure, operative findings, and the patient's condition at the end of the procedure.

• Radiology/Nuclear Medicine Reports: Written by a radiologist to describe findings and assessments of radiology films or nuclear medicine tests.

• Discharge Summary: A summary of an inpatient or surgical encounter including the last face-to-face encounter, physical exam, medication review, discharge orders for home health or therapy, and patient instructions. This is frequently used by the primary care provider.

Documentation and Coding Concepts

Coding is typically completed using software applications, but software features (such as guidelines and conventions) vary by vendor. Coding often relies on search features that assume the most relevant key terms were used, which can lead to the assignment of less specific codes. Best practice requires the use of a coding manual as a reference to ensure code validation, accurate reporting, and clean claims.

Clinical Concepts in Coding

Providers and coders must recognize various clinical concepts inherent to medical codes. These include:

• Acuity

• Anatomy

• Complicated by

• Contributing factors

• Episode

• External causes

• History of

• Laterality

• Localization

• Loss of consciousness

• Manifestations

• Morphology

• Remission status

• Severity

• Stage

• Status post

• Substance

• Symptoms

• Temporal factors

• Type

Terminology Standards

Standardizing language in medical records facilitates effective communication of healthcare data and aids in the prevention and treatment of health issues. These standards are incorporated into EHR and practice management systems.

Examples of Terminology Standards

• ICD-10, CPT, HCPCS: Standard code sets used for billing.

• SNOMED-CT: Systematized Nomenclature of Medicine-Clinical Terms, used primarily for clinical documentation.

• LOINC: Logical Observation Identifiers Names and Codes, used for laboratory tests, measurements, and observations.

• NDC: National Drug Code, used for drugs.

• CVX: Centers for Disease Control and Prevention (CDC) Vaccines Administered, used for vaccines.

The Joint Commission ‘Do Not Use’ List

The Joint Commission maintains a list of abbreviations and acronyms that should not be used due to the high potential for causing medical errors.

Specific Coding Examples

CPT Example: Add-on Symbols and Notes

Code 11000: Debridement of extensive eczematous or infected skin; up to $10\%$ of body surface.

• (Note: For abdominal wall or genitalia debridement for necrotizing soft tissue infection, see 11004 – 11006)

Code + 11001: Each additional $10\%$ of the body surface, or part thereof.

• (Note: List separately in addition to code for primary procedure. Use 11001 in conjunction with 11000)

ICD-10-CM Example: Diabetes Mellitus

Category E11: Type 2 diabetes mellitus

• Includes: Diabetes (mellitus) due to insulin secretory defect; Diabetes NOS; Insulin resistant diabetes (mellitus).

• Use additional code to identify control using: Insulin (Z79.4); Oral antidiabetic drugs (Z79.84); Oral hypoglycemic drugs (Z79.84).

• Excludes: Diabetes mellitus due to underlying condition (E08.-); Drug/chemical induced (E09.-); Gestational (O24.4-); Neonatal (P70.2); Postpancreatectomy (E13.-); Secondary diabetes NEC (E13.-); Type 1 diabetes (E10.-).

E11.0: Type $2$ diabetes mellitus with hyperosmolarity.

• DEF (Definition): Diabetic hyperosmolarity: Extremely high levels of glucose in the blood without ketones.

• E11.00: Type $2$ diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolarity coma (NKHHC).

• E11.01: Type $2$ diabetes mellitus with hyperosmolarity with coma.

Code Sets and Revenue Cycle

Code sets classify treatments, tests, procedures, and diagnoses. They are used for billing, research, and population health management.

HIPAA Regulated Code Sets

• ICD-10-CM: Diagnosis codes.

• ICD-10-PCS: Inpatient procedure codes.

• CPT: Outpatient services and procedures.

• HCPCS: Healthcare Common Procedure Coding System; services not included in CPT (Level II includes products, supplies, and services).

• CDT: Dental procedures.

• NDC: Drug products.

Valuation and Payment Models

The Resource-Based Relative Value Scale (RBRVS) is the foundation for the valuation of CPT and HCPCS Level II codes in traditional fee-for-service models. It assigns value based on three components:

1. The time/amount of work performed by the provider.

2. The overhead cost of the practice.

3. The expense of medical malpractice or professional liability insurance.

Value-Based Models use Hierarchical Condition Category (HCC) codes to adjust reimbursement for patients with increased risk. This risk level is determined by the reported diagnosis codes.

Precision in Data: SNOMED-CT

Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) allows data to be abstracted regardless of the different terms used by providers. It maps sets of clinical phrases together by like terms.

• Example: A myocardial infarction may be documented as "MI," "cardiac infarction," or "heart attack." SNOMED-CT assigns the same concept code to all these phrases, improving the accuracy of data sharing and analysis.

Challenge: Acronym Matching

Question: Match the acronym with the correct purpose or use.

1. NDC

2. ICD-10-CM

3. CPT

4. SNOMED-CT

5. ICD-10-PCS

6. HCPCS Level II

A. Sets of clinical phrases grouped together by like terms B. Identify products, supplies, and services C. Reporting of inpatient procedures D. Identify individual drug products E. Report professional services and procedures F. Classification of conditions, illness, and injuries

Answer: 1: D; 2: F; 3: E; 4: A; 5: C; 6: B.