Documentation and ​Coding in Hospital ​Medicine

Documentation ​Assurance Team

Our Purpose:

Collaborate with providers to assist in understanding the coding ​methodology in relation to clinical documentation.

Monthly, you will receive documentation feedback as well as

helpful tips pertaining to documentation if applicable

Presentation ​Outline/Agenda

1.Hospital Medicine Documentation

Guidelines for 2023

2. Telemedicine

3.Initial/Subsequent Hospital Care ​4.Discharge Day Management ​5.Critical Care

6.Additional Patient Care Services ​7.NP/PA Documentation

8.Teaching Physician Services ​9.Recap, Reminders and Provider

Feedback Process

10.Provider Portal and mySCP Care

Hospital Medicine ​Documentation ​Guidelines

Documentation Tips for HM

CMS2023 Documentation Changes Overview

Why:

 ​ ​

Streamlining processes and addressing administrative burden ​Reducing documentation requirements of history and physical exam ​Emphasizing medical decision making (MDM) documentation

What:

 ​ ​



Elements of history and physical exam (H&P) are no longer a factor for coding and billing

A medically appropriate and descriptive H&P still needs to be documented

Billing will be solely based on MDM or time

•Time is not a factor for the Emergency Department

•Revision to the rules for using time to assign an E&M code (Hospital medicine, Urgent Care)

•Modifications to the criteria for determining the level of medical decision making ​Observation code sets eliminated moved to combine with inpatient code sets

•Timeneeds to be documentedon all inpatient/observation discharge summaries

Documentation Tips for HM

E&M Documentation Requirements

Evaluation and Management (E&M) Documentation Requires the following:

 ​

Chief Complaint ​History

–is required and can be inferred

No specifics required

Clinician to document what was medically appropriate

• ​•



Exam

No specifics required

Clinician to document what was medically appropriate

• ​•



MDM or Time

No time for Emergency Department

MDM –three tables –requires 2 of the 3 tables ​More stringent MDM requirements

• ​• ​•

Documentation Tips for HM

History and Physical Exam









Documentation Tips for HM

History

 ​

Chief Complaint

History of Present Illness (HPI)

is required and can be inferred

• ​•

Describes the chief complaint in greater detail and paints the clinical pictures of the patient’s story.

There are eight (8) areas that may be addressed (Location, Duration, Severity, Timing, Context, Modifying factors, Associatedsigns

and symptoms, and Quality)



Review of Systems (ROS)

• ​•

An inventory of body systems obtained through a series of questions seeking to identify signs or symptoms which the patient may ​be experiencing or has experienced.

Constitutional, Eyes, ENT, CVS, Resp, GI, GU, Musculoskeletal, Integumentary, Neuro, Psych, Endocrine, Hematologic/Lymphatic,

Allergic/Immunologic



Past Family Social History (PFSH)

• ​•

•

Past history –patient’s past experiences with illnesses, operations, injuries, and treatments

Family history –a review of medical events in the patient’s family, including diseases which maybe hereditary or place the

patient at risk

Social history –an age-appropriate review of past and current activities of the patient in regard to smoking, alcohol, drugs, job

duties, stressors, etc.

Documentation Tips for HM

Exam



Exam

• ​•

Examination of organ systems pertinent to the patient’s presenting problems ​There are twelve (12) organ systems that may be addressed

o Constitutional

o Eyes

oEar, nose, mouth, and throat

o Cardiovascular

o Respiratory

o Gastrointestinal

o Genitourinary

o Musculoskeletal

o Skin

o Neurological

o Psychiatric

o Hematologic/Lymphatic/Immunologic

Documentation Tips for HM

Medical Decision Making (MDM)

Medical Decision Making (MDM) determines the E&M level assignment and without detailed accurate ​documentation a chart maybe coded to a lower E&M level

MDM-Complexity of evaluating the patient’s presentation, establishing a diagnosis, and selecting ​management/treatment options

Three areas for medical decision making

•Number and complexity of problemsaddressed during the encounter

•Amount and/or complexity of datato be reviewed and analyzed

•Riskof complications and/or morbidity or mortality of

patient management

Documentation Tips for HM

Medical Decision Making (MDM) –Problems Addressed



Number and complexity of problemsaddressedduring the encounter (COPA) for each DOS

Patient currently has or that the clinician is consideringand evaluating:

oDiagnosis, signs and symptoms, co-morbidities (evaluated/treated), and differential diagnoses

Document all problems addressed for each date of service

• ​•



Problem addressed:

A disease, condition, illness, injury, symptom, sign, finding, complaint, or other item is addressed at the ​encounter with or without a diagnosis being established at the time of the encounter

Is addressed or managed when it is evaluated or treated at the encounter by the clinician reporting the ​service

Includes considerationof further testing or treatment that may not be elected due to risks or benefit analysis ​Does not include referral without evaluation and a problem that is being managed by another clinician that ​does not get evaluated

oi.e., oncologist handling a bladder cancer that is not evaluated at the time of visit for chest pain

• ​• ​•

•

Documentation Tips for HM

Medical Decision Making (MDM) –Data Reviewed and Analyzed



Amount and/or complexity of datato be reviewed and analyzed

•

•

Ordered/Reviewed/Considered but not selected after shared decision making:

oAncillary tests

oRadiology (X-rays, CTs, Ultrasounds, MRIs, etc.)

oEKGs

Documentation of any of the following:

oIndependent historian(Parent, Guardian, Surrogate, Spouse, Witness, Children of elderly pts)

oIndependent visualization and interpretationof radiology (X-rays, CTs, US) or EKG

oDiscussionswith external clinicians or other qualified health care professionals

oReview/summarization of prior external notes or results (i.e., ED visit, SNF or NF, Consults, PMD)

Documentation Tips for HM

Medical Decision Making (MDM) –Data cont.



Tests Ordered/Reviewed/Considered

• ​•

Documentation should include each unique test ordered/reviewed or considered but not selected after shared decision ​making

Documentation should include these considerations and discussions

•

i.e., Patient requesting diagnostic imaging that is not necessary for their condition and discussion of lack of benefit may be required ​i.e., A test may normally be performed but due to the risk for a specific patient it is not ordered

o ​o

Shared decision making involves patient and family preferences, education, and explaining risk and benefits of management ​options



Independent historian

Provides a history in addition to a history provided by the patient who is unable to provide a complete and reliable history

oi.e., due to developmental stage, dementia, or psychosis

Should provide additional information and not merely restate information that may have been provided by the patient

Does not need to be obtained in person but does need to be obtained directly from the historian

Documentation should reflect who the historian is and what part of the history they provided

Does not include translation services

• ​•

•

•

•

 ​



Documentation Tips for HM

Medical Decision Making (MDM) –Data cont.

Independent visualization and interpretation

not also visualized/interpreted by you

Discussions

does not include radiology studies interpreted by a radiologist that were

• ​•

• ​•

•

•

Requires direct interactive exchange –does notinclude sending chart notes or written exchanges

Includes conversations with other clinicians who have performed an interpretation

oi.e., cardiologist for a review of a cardiac cath; radiologist regarding head CT with evidence of subdural bleed ​Includes conversations with professionals that may be involved in the management of the patient

oi.e., PCP, referral physician, another specialist, lawyer, parole officer, case manager, teacher

Does notneed to be in person

Does notinclude discussion with family or caregivers

Documentation should include who was called and what was discussed

External Notes Reviewed and Summarization

• ​•

External records, communications, and/or test results from an external physician, other qualified healthcare professional, ​facility, or healthcare organization

External physician or other qualified healthcare professional is a distinct group or different specialty or sub-specialty

oi.e., HM clinician reviewing ED visit, SNF or NF, Consults, PMD records

Documentation Tips for HM

Medical Decision Making (MDM) -Risk

Riskof complications and/or morbidity or mortality of patient management

•

Ordered/Considered but not selected after shared decision making:

o ​o ​o ​o ​o ​o ​o

Medications (RX or OTC)

Parenteral controlled substances

Drug therapy requiring intensive monitoring for toxicity

Decision regarding hospitalization, or escalation of hospital level care

Decision not to resuscitate or de-escalate care due to poor prognosis

Diagnosis or treatment significantly limited by Social Determinants of Health (SDOH) ​Decision regarding elective or emergency major/minor surgery

Documentation Tips for HM

Medical Decision Making (MDM) –Risk cont.



Risk of patient management

• ​•

Level of risk is based on the consequences of the problems addressed at the encounter when appropriately treated ​Includes:

oManagement options selected/consideredbut not selected after shared decision making with patient and/or family

i.e., decision not to escalate a patient to higher level of care that would generally warrant ICU care, but goal is

palliative treatment

Shared decision making involves patient and family preferences, education, and explaining risk and benefits of

management options

oThe need to undergo further testing, treatments, or hospitalization



Prescription (RX) Drug Management

•

RX includes a review of the patient’s current medications, those ordered, and those prescribed at discharge

oNote:simply listing current medications withoutdocumentingthat you reviewedis not considered prescription drug

management

Documentation Tips for HM

Medical Decision Making (MDM) –Risk cont.



Social Determinants of Health (SDOH)

Economic and social conditions that influence the health of patients and communities

Patient’s who are mentally challenged, psychiatrically, or chemically impaired

Documentation should indicate the SDOH and how it impacted the medical decision making process ​Common examples include:

oFinancial resource strain / unemploymentoHousing stability/homeless

oFood insecurityoEarly childhood development

oTransportation needsoAddiction, i.e., alcohol, drugs, etc.

oPhysical activity

o Education/literacy

o Stress

oAccess to medical care

oSocial connections

oIntimate partner violence

• ​• ​• ​•

Documentation Tips for HM

2023 MDM Table

Documentation Tips for HM

Time



• ​•

•

Time spent with patient

Time is defined as total time spent by the clinician both face to face and non-face to face activities related to the patient’s visit ​performed on the DOS.

Includes:

oDiscussion with other health care professionals ​oDocumenting in the record

oInterpreting and communicating test results (not separately

billable)

oCare coordination (not separately reported)

oProcedures performed when not separately billable services

o ​o ​o ​o ​o

Preparing to see the patient (reviewing test results)

Obtaining or reviewing histories

Performing a medically appropriate examination and/or evaluation ​Counseling and educating the patient, family, or caregiver

Ordering medications, tests, or procedures

Do not count time spent on the following:

o ​o ​o

Procedures and other services reported separately

Teaching that is general and not part of patient management ​Travel

Prolonged care

Must be 15 minutes additional

can be applied if time spent exceeds the maximum time for the level of care applied.

to apply the prolonged care code

Inpatient/Observation initial visit: minimum of 90 minutes for prolonged care ​Inpatient/Observation subsequent visit: minimum of 65 minutes for prolonged care

 ​ ​

Always document

your time on an

inpatient/observation

discharge visits

Documentation Tips for HM

E&MDocumentationRequirements Summary

 ​ ​

A medically appropriate and descriptive H&P needs to be documented for each DOS

Billing will be based on MDM or Time

Documentation should include as applicable:

•If history is obtained from an independent historian along with what information the historian provided

oi.e., Parent, Guardian, Surrogate, Spouse, Witness, Children of elderly pts, etc.

•Problems addressed that the Patient currently has or that the clinician is considering and evaluating:

oDiagnosis, signs and symptoms, co-morbidities (evaluated/treated), and differential diagnoses

•Document chronic illnesses impacting care

oDiabetes, hypertension, hyperglycemia, chemotherapy

•Diagnostic tests ordered, reviewed or appropriately considered even though not ultimately performed

oAncillary studies, Xray, CTs, MRIs, etc.

•Independent visualization and interpretation of X-Rays, EKGs, CT scans, and Ultrasounds

Documentation Tips for HM

E&M Documentation Requirements Summary –cont.

•

Discussions with external clinicians or other qualified health care professionals -Emergency Department, consultant (GI, Neuro, ​Social Work), PMD, Cardiology/Radiology (test interps)

oi.e., patient management or test interpretations

Review/summarization of prior external notes or results

oi.e., ED visit, SNF or NF, Consult, PMD

Prescription medications reviewed, ordered, RX on discharge, or considered even if not given

oantibiotics, antivirals, pain medication

If care is affected by social determinants of health

oHomeless, literacy, access to medical care, food insecurity, financial resource strain, transportation needs, and intimate

partner violence, etc.

Admission from Observation to inpatient, transfer, or escalation of hospital level care

Document your time if it exceeds 75 minutes on an inpatient/observation initialvisit

Document your time if it exceeds 50 minutes on an inpatient/observation subsequentvisit

Always document your time on an inpatient/observation discharge visit

•

•

•

• ​• ​• ​•

Telemedicine

Documentation Tips for HM

Telemedicine Encounters

What are they?

•

Clinician and Patient are in differentphysical locations ​(ex: the patient is in the hospital, but the clinician is at ​home).

How should I document this type of encounter?

–A statement that the service was provided using

telemedicine

–Type of Software used(Audio/Visual)

–The location of the patient

–The location of the provider

–The names of all persons participating in the

telemedicine service and their role in the encounter

Please Note: These patient encounters should be

documented the same as a routine, in-house encounters

Sample statement to use-

This patient visit was performed using

telemedicine using the secure Vidyosoftware ​platform with 2 way audio/video. The clinician was ​located off-site and the patient is located in the ​hospital. The aforementioned video software was ​utilized to document the relevant history and ​physical exam.

Documentation Tips for HM

Telemedicine Reminders



When entering visit into mySCP Care ​select the check box for

Telemedicine: Encounter was done over ​telemedicine

Documentation Tips for HM

Telemedicine Physical Exam-Example

 ​ ​ ​



General appearance (Constitutional)

Visual exam of face, conjunctiva, lids (Eyes) ​Visual exam of mucosa (ENT/Mouth)

Visual exam of respiratory effort: ​diaphragmatic movement, intercostal ​retractions, use of accessory muscles ​(Respiratory)

Visual exam of the abdomen: appearance ​(Gastrointestinal)





 ​



Gait, extremities with/without deformity, ​visualization of range of motion ​(Musculoskeletal)

Orientation to time, place and person ​(Psychiatric)

CN grossly intact and specify those that can be ​tested (Neurological)

Inspection of skin (rashes, lesions, ulcers)—be ​sure to be clear about how much of the skin ​you can see (Skin)

Add any other additional elements visualized

Initial and ​Subsequent Care ​Visits

Documentation Tips for HM

Initial and Subsequent Visit Requirements

Medical Decision Making

Date of ​Service

•Clearly

documented

•Should match

date entered

in mySCP Care

•

Especially ​important for ​Nocturnist ​around ​midnight

Place of ​Service

•Should match ​the orders in

the EMR for

that date

•Should match

the place of

service listed

in mySCP Care

Chief ​Complaint

•What the

patient is

complaining

of for that

date

•Required, and

can be

inferred

History

•Medically

appropriate

Physical ​Exam

•Medically

appropriate

Diagnosis ​List

•Include all ​diagnosis ​impacting care or ​being managed

•Update daily ​•Sequence in order

of severity

•Include status of

the problem

(improving,

resolved,

worsening, no

change etc.)

Assessment/ ​Plan

•Update daily ​•Avoid cloning

from previous day

•Document any

work up ordered,

reviewed or

considered

•Document

treatment and

management

options

Signature

Documentation Tips for HM

Initial Hospital Inpatient / Observation Care

Code

MDM

99221Straightforward or Low

99222 Moderate

99223 High

Note:

InitialHospital Inpatient / Observation Care codes require:

•Date of service and place of service

•Performance and documentation of a medically appropriate and descriptive History and Exam

•A detailed Medical Decision Making

•Assessment and Plan:

oSequence diagnosis in order of severity

oInclude plan, status, and work-up with results for every problem being managed or impacting

care

Documentation Tips for HM

Initial Observation Care

It is important to document orders/place of servicefor accurate billing of encounters performed

There are additional specifics required for Observation





• ​•

Refer to your hospital case management or admissions department for clarification of your hospital’s ​Observation/Inpatient guidelines.

Documentation Tips for HM

Subsequent Hospital Inpatient / Observation Care

Code

MDM

99231Straightforward or Low

99232 Moderate

99233 High

Note:

Subsequent HospitalInpatient / Observation Care codes require:

•Date of service and place of service

•Performance and documentation of a medically appropriate and descriptive History and Exam

•A detailed Medical Decision Making

•Assessment and Plan:

oSequence diagnosis in order of severity

oInclude plan, status, and work-up with results for every problem being managed or impacting

care

oAvoid copy and carrying forward prior notes without updating specific to current date of service

Documentation Tips for HM

Subsequent Hospital Inpatient / Observation Care

For eachdate of service:

Document all legitimate diagnoses being actively managed or ​impacting care on that date in order of severity.







Document the status of the problem

–Improving, resolved, uncontrolled, etc…

Document the management of the problem

–Medication changes/additions, continue current

management, diagnostics ordered

Sequence resolved diagnosis to the bottom of your problem list

Documentation Tips for HM

Subsequent

Hospital Inpatient / Observation Care

Be careful when “copying and pasting” information (or Cloning) portions of a previous encounter!

If you do copy forward information, please review, update and verify the accuracy of copied content!

•Assessment/Plan -ensure every encounter is updated daily

• Diagnoses

oWhen copying forward diagnosis information, the status of the problem must be updated daily. If resolved, move to bottom of

your problem list

oInclude the problem, evaluation date and management plan for every diagnosis to support medical decision making

Examples may include:

•“Chest pain, evaluated 09/26/2022, still having occasional pain, continue current management but add NTG SL per protocol”

•“Patient developed hyperkalemia today, evaluated 09/26/2022, DC potassium, check potassium level in AM”

•“COPD exacerbation, evaluated 09/26/2022, remains severely SOB, increase O2 to 3L NC, continue Nebulizer treatments”

Discharge Day ​Management

Documentation Tips for HM

Discharge Hospital Inpatient / Observation Care



Discharge Hospital Inpatient / Observation Care codes require:

Date of service and place of service

Documentation of a face to face with the patient on day of ​discharge

Performance and documentation of a medically appropriate ​and descriptive final Exam as appropriate

An overview of the hospital course as appropriate

Instructions for continuing care

Patient or family counseling

Preparation of discharge records/ prescriptions

Referral Forms

Final diagnosis -sequence in order of severity

Total Time spentpreparing the total Discharge in minutes ​(time ranges are not acceptable)

• ​•

•

• ​• ​• ​• ​• ​• ​•

Code

99238 ​99239

Time

30 minutes or less ​More than 30 minutes

Documentation Tips for HM

Discharge Hospital Inpatient / Observation Care cont.

Example of documented time and face-to-face encounter

The discharge service must be billed on the date that the discharge was prepared, even if the patient ​did not go home on that date.

•Ride not available, bed not available, awaiting final test results

Documentation Tips for HM

Pronouncements, Transfers, & AMA Documentation ​Requirements



Pronouncements:

•Final examination to satisfy the “face-to-face” ​•Time spent preparing the discharge

(pronouncement, prep of death records, death

summary)

•Any Critical Care service provided on the date

of death

Note:

•Only the provider who pronounces the patient

may bill for the Discharge service

•Completion of the death certificate alone is not

sufficient for billing

Transfers (to other hospitals, swing bed, or SNF

as well as pts leaving AMA):

•Be sure to document amount of time spent

prepping ptwhen a face-to-face encounter is

performed –this encounter type is also

considered Discharge Day Management

Note:

•If ptleft AMA and you did not have face-to-

face time, please document that you did not

see the patient to avoid being queried.

Critical Care

Documentation Tips for HM

What is Critical Care?

Critical Care is defined as an “illness or injury impacting one or more vital organ systems such that there is ​high probability of imminent, life-threatening deterioration in the patient’s condition”.

Hospital Medicine Clinicians may perform critical care services however, it is important that the

documentation support the service provided.

Definitions of Critical Care (CC)

Critical Care is the direct delivery by a Clinician of medical care for a critically ill or injured patient.

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 at the time of service.

The failure to initiate treatment on an urgent basis would likely result in sudden, clinically significant life-threatening ​deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate and support vital system function(s) to treat ​single or multiple vital organ system failure and/or to prevent further life-threatening deterioration of the patient’s condition.

Documentation Tips for HM

Critical Care Codes

Critical care is a time driven code. A minimum of 30 minutes (excluding procedures) must be devoted exclusively to

the patient. The actual time must be documented in the record, time ranges cannot be used. This time can be

cumulative, but it cannot overlap any other patient care.

2 Critical Care Codes available:

99291-Critical care, evaluation and management of the critically ill or critically injured patient; first 30-103 minutes ​99292-Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30

minutes(add-on code to 99291)

•Minimum of 104 minutes to bill the add on code

Total Critical Care Time

< 30 minutes

30 -103 minutes

104 or more minutes

CPT

Billed as noncritical care (we still encourage clinicians to document ​their time)

99291

99291 and 99292

Documentation Tips for HM

Critical Care Time Includes:

All relevant medical care activities performed by the Provider directly ​related to the individual patient and time spent:



At the bedside ortime spent elsewhere on the floor or unit as long as

immediately available to the patient (in the nurses' station, with family members ​or surrogate decision makers when patient unable to participate in discussions) ​Reviewing old records

Reviewing diagnostic results

Discussing the case with staff (within your hospital or at the receiving hospital

if a transfer)

Discussing with family members (only if the patient is unable or clinically ​incompetent to participate in providing history or making management ​decisions)

Documenting in the medical record (also in hospital medicine this includes ​history & physical and progress notes)

You may also include time spent ​performing the following procedures ​since they are not separately billable ​when coding Critical Care:

•Cardiac output measures

•Pulse Oximetry

•Chest X-rays

•Blood Gases

•Gastric Intubation

•Temporary Pacing

•Ventilator Management

•Blood draw for specimen

•Venous Access/Arterial Puncture

Documentation Tips for HM

Coding and Billing for Critical Care

Clinician responsibility:

Document

the amount of time spent on critical care

the critical nature of the illness or injury

descriptions of all the Clinician's interval assessments

the patient's condition, any "impairments of organ ​systems" based on all relevant data available to the Clinician ​(i.e., symptoms and diagnostic data)

the interventions and the patient's response to treatment.





*Reminder –Be mindful that you are not documenting

more critical care time than possible in your shift*

Coder Responsibility:



Confirm the Clinician’s attestation of critical ​care by looking for documentation to support ​the patient’s clinical condition at the time of ​service and the critical care treatment ​administered.

Once critical care is validated, add up any ​critical care time documented throughout the ​DOS



Documentation Tips for HM

Critical Care: HM Coding Exceptions

Critical Care may be billed instead of the Initial Hospital Care service if the patient complexity, delivery of ​care and documentation of time supports Critical Care at the time of admission.

When Critical Care services are provided on a day where inpatient hospital E/M service was furnished

earlier on the same date at which time the patient did not require critical care, boththe critical care and the

previous E/M service (Initial/subsequent visit) may be charged.

It is not a place of service –Critical care can be performed in any location; the patient does not physically

need to be in the ICU or CCU

Multiple providers of different groups can bill for Critical Care on the same DOS as long as there is

medical necessity.

As of 2022, CMS allows Critical Care time performed by an NP/PA to be combined with Critical Care time

performed by a Physician on the same DOS.

Time spent by the NP/PA and Physician needs to be documented separately and must be non-

duplicative, thus, it is critical that you document your individual time even if less than 30 minutes.

Documentation Tips for HM

Critical Care Documentation Reminders

Documentation Tips for HM

Vital Organ System Failure –Possible Critical Care

SHOCK-Cardiogenic, hypovolemic, Anaphylactic, Septic,

Neurogenic, Spinal



CIRCULATORY FAILURE

•ACS/Acute MI/Unstable Angina

•Cardiac dysrhythmias requiring intervention ​•Dissecting aortic aneurysm

•Critical Burns

•GI Bleed with hemodynamic instability

•Drug ingestion with hemodynamic instability ​•Clinically acute/requiring urgent intervention:

o Hypo/hypertension

o Brady/Tachy‐arrhythmias

oMultiple system trauma







CENTRAL NERVOUS SYSTEM FAILURE

•Unstable cervical fracture

•Coma; metabolic, toxic, anoxic, traumatic

•Intracranial hemorrhage

•Acute Stroke with altered mental status

•Status Epilepticus

RESPIRATORY FAILURE

•Acute CHF with respiratory failure

•Asthma with respiratory failure

•PE with hemodynamic instability

•Respiratory Failure with imminent intubation

RENAL, HEPATIC, METABOLIC FAILURE

•DKA with hemodynamic instability

Documentation Tips for HM

Medications and Interventions: Possible Critical Care

Medications via IV:

 Atropine

 Bicarb

Heparin / Thrombolytics

 Antiarrhythmics

 Vasopressors

Dopamine/ Dobutamine

Epinephrine/ Norepinephrine

Nitroglycerine Drip

Antihypertensive agents

Magnesium Sulfate

Mannitol

 Narcan

Interventions:

Bi-Pap (bi-level positive airway pressure)

C-Pap (continuous positive airway pressure)-not for

Chronic Sleep Apnea

 Intubation

Transcutaneous Pacemaker

 Defibrillation

 Cardioversion

Fluid/Blood Resuscitation for frank shock/burns

Chest tube for hemothorax /pneumothorax

Initiate ventilator in the Unit

*some of these are separately billable proceduresand

must be deducted from total Critical Care time

Documentation Tips for HM

Critical Care Procedures

Commonly performed and associated but separately billable in addition to Critical Care:

Endotracheal Intubation ​Cardiopulmonary Resuscitation

Chest Tube Insertion and Thoracentesis ​Lumbar Puncture

Central Line Insertion

Intra-osseus Access

CPT Code

31500

92950

32551, 32002 ​62270

36556

36680

*Remember: Time spent performing separately billable procedures must be deducted from total Critical Care ​time!

Documentation Tips for HM

Critical Care Documentation Example

“45 minutes of Critical Care was provided in order to assess and ​manage the high probability of imminent or life-threatening ​deterioration of cardio-respiratory status requiring vasodilator ​support and pending intubation. Critical Care time noted does ​not include the time spent performing separately billable ​procedures.”

Additional Patient ​Care Services

Documentation Tips for HM

Advance Care Planning: Time based code

Advance Care Planning (ACP) is a voluntary, face-to-face service ​between a physician or other qualified health care professional (QHP) ​and a patient, family member, caregiver, or surrogate to discuss the ​patient’s health care wishes if they become unable to make their own ​medical decisions.

As part of this discussion, you may talk about advance directives

with or withouthelping a patient complete legal forms. An advance

directive appoints an agent and records a patient’s medical

treatment wishes based on their values and preferences. You can

generally find them on your state attorney general’s office website.

Examples of advance directives include:

Living wills

Medical orders for life-sustaining treatment

Health care proxy

Durable power of attorney for health care

Psychiatric advance directives

It is atime-based service, that requires a time statement ​describing the aggregate total face-to-face time of the NP/PA ​and/or physician while the discussion takes place.

Must be reported for each DOS when performed. Cannot be

reported as a combined service over the entire episode of

care.

Less than 16 minutes of face-to-face discussion time cannot

be reported separately.

ACP time must be separate from time spent doing other

things, like taking the history or doing other E/M work

 ​ ​

ACP work cannot be reported with critical care.

Code

99497 ​99498

Total Time

16 minutes up to 30 minutes

Each additional 30 minutes (starting at 46

minutes)

Documentation Tips for HM

Advance Care Planning: Documentation Requirements

Documentation should include:

 ​

 ​



Who was present during the encounter, including the names of those present ​The content and medical necessity

oWhat was discussed and any follow up as appropriate

oWhy are they making the decision

oThe understanding of the illness, spiritual factors

If any forms were completed and the content of any advance directives

Any change in health status or health care wishes if the patient becomes ​unable to make their own decisions

The time spentdiscussing ACP during the face-to-face encounter

A statement like the following might adequately describe the Advance Care Planning service for ​reimbursement purposes:

“I spoke with the patient and her daughter, Amanda, today regarding advance directives and end of life planning. Due to the ​progression of the patient’s heart failure she wishes to be made DNR. I have updated the orders to change the patient to DNR. ​She concluded that she would like to complete ACP forms. I spent 20 minutes of face-to-face time discussing ACP.”

Documentation Tips for HM

Tobacco Cessation Counseling: Time based code

Code

99406 ​99407

Total Time

Greater than 3 minutes ​Greater than 10 minutes



Documentation in the medical record must clearly represent:

• ​• ​•

•

That the patient is alert and competent

The patient’s tobacco dependence (cigarettes, smokeless) ​Your counseling session with the patient, including the

Recommended and the Patient’s Responseto counseling

The Total Timein minutes spent performing the service (

range)

Treatment

not a



Suggested Tobacco Cessation Counseling Tips

• ​• ​• ​• ​• ​• ​•

Ask about tobacco use at every visit

Discuss health risks of continued tobacco use ​Advise tobacco users to quit

Discuss rewards/benefits of tobacco cessation ​Assess the willingness to attempt quitting ​Assist the patient with methods for quitting ​Arrange for follow-up contact as appropriate

Example: “Patient was counseled on smoking cessation for 6 minutes, RX for nicotine patch offered, patient refuses and statesdoes not want to quit.”

NP/PA ​Documentation ​Requirements

Attestations

Split Share-2024 Attestation Update



January 2024 CMS Updates:

of the E/M visit. For 2024, the substantive portion is defined as:

•Time Spent

OR

•Medical Decision Making

The substantive portion of the MDM requires the billing practitioner to:

The medical record should indicate which practitioner performed the substantive portion

: more than half of the total time spent by the physician and NP or PA performing the shared visit

: performing the substantive portion of the medical decision making





Make or approved the management plan for the number and complexity of problems addressed at the

encounter

Take responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient

management

Note:Any independent interpretation of tests and discussion of management plans must be personally

performed by the billing practitioner

For time-based codes, (such as critical care and discharges) the practitioner who performs more than half of the total

(non-duplicated) time spent on the visit will receive credit for the entire time-based service.

–Time spent by NP/PA and the physician needs to be separately documented.

–Critical Care Timeguidelines allow for critical care time to be shared between the providers to arrive at the

final critical care code.

Split Share –2024 Attestation Update

Evaluation and Management (E/M) Visits (excluding time services, i.e., critical care or HM discharges)–If the physician performs

the substantive portion of the MDM and documents the recommended information below, the E/M visit will be billed under the ​physician.

if you are collaborating with an NP/PA in direct patient care:

of the following by the physician:

and take responsibilityfor the patient management.

The following specific documentation is recommended

If performed, personal documentation of ONE

Statementthat you made/approved the management plan

OR

Medical Decision Making

–to include patient complaint, differential diagnoses, the work-up performed for differential

diagnoses and medical necessity by the physician

Document your review and whether you agree with NP/PA’s documentation, treatment plan, and medical decision making

A statement indicating whether you had face-to-face time with the patient

 ​

Examples of acceptable physician attestations during NP/PA collaboration:

" I personally made/approved the management plan for this patient and take responsibility for the patient ​management. I reviewed the NP/PA’s documentation, agree with the NP/PA’s assessment, and I had face to face ​time with the patient.”

Split Share –2024 Attestation Update

independent interpretationdiscussion of management plans

If any of tests or are performed by the physician, then the ​attestation should also include the physician’s independent interpretation and/or details of the discussion/consultation.

•

•

•

“I personally made/approved the management plan for this patient and take responsibility for the patient management. I reviewed ​the NP/PA’s documentation, agree with the NP/PA’s assessment, and I had face to face time with the patient. I independently ​interpretedthe EKG, shows NSR of 72, No ST segments, or T wave changes.”

“I personally made/approved the management plan for this patient and take responsibility for the patient management.I reviewed

the NP/PA’s documentation, agree with the NP/PA’s assessment, and I had face to face time with the patient.I discussedthe patient

with cardiology. They recommend cardioversion in the ED and follow-up with their office.”

“I reviewed the NP/PA’s documentation, agree with the NP/PA’s assessment, and I had face to face time with the patient. My MDM:”

64-year-old female with CP and vital signs, B/P 140/90. Old records indicate a history of coronary artery disease. ​DDX: ACS, pneumonia, and pneumothorax

EKG Interpreted by me -shows normal sinus rhythm of 72 no ST segments or T wave changes

Troponin normal, d-dimer elevated, glucose 210

CXR normal

CTA no evidence of pulmonary embolus

Impression: Chest pain unclear etiology

Discussed admission and plan of care with Emergency physician

Plan is to admit to Telemetry

Split Share –2024 Attestation Update

Time-based services (such as critical care and discharges) –the

practitioner who performs more than half of the total (non- ​duplicated) time spent on the visit will receive credit for the entire ​time-based service.

Critical Care Timespent by NP/PA and the physician

be separately documented. 2022 guidelines allow for critical

care time to be shared between the clinicians to arrive at the

final critical care code. Thus, it is critical that you document

your individually dedicated critical care time. Document your

time spent even if less than 30 minutes.

needs to

Example of acceptable ​during NP/PA collaboration:

critical care

physician attestation

“Patient developed hypotension and hypoxia; I spent 45 ​minutes of critical care time while the patient was in this ​condition, providing fluids, pressor drugs, and oxygen. I ​reviewed the NP/PA’s documentation and agree with the ​assessment and plan of care.”



The physician must still document a statement which ​states:



 ​

The total time the physician personally spent providing ​critical care.

How the patient was critically ill when the physician saw ​the patient.

What made the patient critically ill; and the nature of the ​treatment and management provided by the physician.

Example of acceptable ​during NP/PA collaboration:

discharge

physician attestation

“I reviewed the NP/PA’s documentation and agree with the ​NP/PA’s assessment and plan of care. I had face to face ​time with the patient. I spent 40 minutes discharging the ​patient.”

Split Share –2024 Attestation Update

Additional tips for Collaboration with NP/PA’s:

“co-signature” is not the same as an attestation

An important distinction to note is that a . Many EMRs have a ​process in place that requires all NP/PA charts to be co-signed by the physician. However, this does not mean that all ​charts will necessarily be attested. This simply means that the physician reviews NP/PA documentation and co-signs ​the chart without seeing the patient. Under this scenario, the chart would be billed under the NP/PA.

Facilities that have NP/PA’s working in the department may have facility-specific criteriathat is more stringent on

what is described above. Please coordinate with your Medical Director with any related questions.

You will continue to receive queries (Attestation and/or Service Category Query) via mySCP Care for those split/share

encounters without evidence of substantive portion of treatment documented.





Reference the link below for more information: ​•ACEP’s Shared Services FAQs

https://www.acep.org/administration/reimbursement/reimbursement-faqs/Shared-Services- ​FAQ#:~:text=Specifically%2C%20for%20CY%202024%2C%20for,making%20as%20defined%20by%20CPT

•

CMS –MPFS Final Rule 2024 –page 468

https://public-inspection.federalregister.gov/2023-24184.pdf

Documentation Tips for HM

Split-Shared vs Independent Visits

Split Shared

 ​

PHYSICIAN face-to-face AND attestation ​is required

In the absence of F2F attestations,

MD/DO co-signature may be required

Independent

 ​ ​

Billed under the NP/PA’s provider ​number

No PHYSICIAN face-to-face or attestation

is required

MD co-signature may be required

Note: Coding will adjust the billing provider at time of their secondary review to match the documentation submitted

Teaching Physician ​Services

Documentation Tips for HM

Teaching Physician Services –Documentation Scenarios

The teaching physician must document:

That he/she personally saw the patient

Personally performed critical or key portions of

the service

Participated in the management of the patient.

The teaching physician’s note should reference the

resident’s note.

For payment, the composite of the teaching

physician’s entry and the resident’s entry together

must support the medical necessity of the billed

service and the level of service billed by the

teaching physician.













Minimally acceptable documentation in this scenario:



Initial Visit:

“I saw and evaluated the patient. I reviewed the resident’s ​note and agree, except the clinical picture is more consistent ​with pericarditis than myocardial ischemia. Will begin ​NSAID’s.”



Initial or Subsequent Visit:

“I saw and evaluated the patient. Discussed with resident and ​agree with resident’s findings and plan as documented in the ​resident’s note.”

Subsequent Visit:

“See resident’s note for details. I saw and evaluated the ​patient and agree with the resident’s findings and plan as ​documented in the resident’s note.”

“I saw and evaluated the patient. Agree with resident’s note

but lower extremities are weaker, now 3/5; MRI of L/S spine

today.”

Documentation Tips for HM

Minor Procedures Performed by Residents

Procedures that take only a few minutes (five ​minutes or less) to complete, e.g. simple suture, ​and involve relatively little decision making once ​the need for the procedure is determined:

The teaching physician must be present for

the entire procedurein order to bill for the

procedure

Documentation Tips for HM

Teaching Physician Services –Unacceptable ​Documentation

“Agree with above.”, followed by legible countersignature or identity;



 ​ ​ ​ ​

“Rounded, Reviewed, Agree.” followed by legible countersignature or identity;

“Discussed with resident. Agree.” followed by legible countersignature or identity;

“Seen and agree.” followed by legible countersignature or identity;

“Patient seen and evaluated.”, followed by legible countersignature or identity;

A legible countersignature or identity alone.

Documentation Tips for HM

Medical Students

An individual who participates in an accredited educational program (e.g., a medical school) that is not an ​approved GME program.

CMS has approved the use of student documentation to decrease

the documentation burden on the NP, PA, or physician.

This applies to all students (medical, NP, and PA)

The physician, NP, or PA must personally perform (or re-

perform)the physical exam and medical decision-making

activities however, re-documentation is not required.

The student attestation below must be used as written.

•“I was physically present during the student’s evaluation

of the patient. I personally re-performed the physical

exam and medical decision-making activities. I reviewed

and agree with the student’s documentation and/or

findings including history (CC, HPI, ROS, PFSH), physical

exam, and medical decision making except as

documented below. “

Procedures and students from a billing perspective:

Billable

•

must be repeated by the supervising provider

to make the procedure billable

If a student does a procedure, the same procedure

Non-billable

•If the student does a procedure and it is not

repeated by the supervising provider, the

procedure is non-billable.

Merit Based Incentive ​Payment System

Documentation Tips for HM

Merit Based Incentive Payment System

Screening for Social Drivers of Health

Advance Care Plan or Surrogate Decision Makers

Documentation of Current Medications in Medical ​Record

Heart Failure:

ACE/ARB/ARNI Therapy for LVSD ≤ 40%

Beta Blocker Therapy for LVSD ≤ 40%

t-PA Utilization for Ischemic Stroke

Screening for Tobacco Use and Cessation

Screening for High Blood Pressure ​and Follow Up

Diabetes: Hemoglobin A1c Poor

Control

2024 Hospital Medicine MIPS

Documentation Tips for HM

Common MIPS Measures

Screening for Social ​Drivers: 18+

•

Documentation should ​acknowledgement that the ​screening was performed, and ​any areas identified

Sample phrase:

The patient was screened for social ​drivers of health including food ​insecurity, housing instability, ​transportation needs, utility

difficulties and interpersonal safety.

Areas identified for concern are:

<list area/circumstance>

None

Advance Care Plan or ​Surrogate Decision ​Makers: 65+

•

The patient’s advance care

plan and code status

should be documented

upon admission in the H&P

•Any subsequent clinicians

will acknowledge in mySCP

Care that it is present in the

EMR

Documentation of ​Current Medications: 18+

•

Within the EMR there should

be documentation of the

patient’s prior to arrival

medications. The list should ​include dose, frequency, and

route

•The clinician can attest to

documenting, updating or

reviewing a list of all known

prescriptions, over the counter

medications and supplements

Documentation for HM

Diagnosis Specific Measures

Heart Failure Therapy for LVSD ​≤ 40%

• ​•

• ​•

Applies to discharges

ACE/ARB/ARNI Therapy prescribed or

currently being taken

Beta Blocker Therapy prescribed or

currently being taken

If not prescribed document

contraindication

t-PA Utilization for Ischemic ​Stroke

•

•

IV Thrombolytic therapy initiated within 4.5 ​hours of time last known well

If not initiated documentation should include

rational for not administrating t-PA

Documentation Tips for HM

Observation/Outpatient Measures

Preventive Care and Screenings

Tobacco Use and Cessation

Diabetes: Hemoglobin A1C Poor ​Control

Documentation should include either:

•The patient was screened for tobacco use and

received cessation counseling

•The patient is non tobacco user

•Most recent HbA1C is documented

•A1c drawn within 1 year from admit can be

used if current A1c is not drawn

High Blood Pressure and Follow Up

Documentation should include:

•The patient was screened for high blood

pressure and recommended follow up plan

•Systolic BP 120-139 and Diastolic BP 80-89

require referral to alternate/primary care

•Systolic BP ≥ 140 and Diastolic BP ≥ 90 required

referral between 1 day and 4 weeks

Recap, Reminders, ​and Provider ​Feedback

Documentation Tips for HM

Recap & Reminders

All encounters must include documentation of a:

• ​•

•

Chief Complaint

Medically appropriate History (HPI, PFSH, ROS) and

Physical Exam

Descriptive medical decision making

Date of Service:

Include your date of service for every encounter to ​avoid confusion and potential missed billing.

o

It is sometimes confused with dictated date, transcribed date, ​typed date, authenticated date

Progress notes:

Total time MUST be documented for:

• ​• ​• ​• ​•

Critical Care

Prolonged Services ​Tobacco Cessation ​Advance Care Planning ​Discharge Activities

Make sure that each DOS is unique ​Update Dxstatus/plan as appropriate ​Avoid “cloning” of same information

Timeliness:

Documentation completion –same date ​Responsiveness to administrative requirements

Documentation Tips for HM

Provider Feedback

Provider performance reviewed on ​a monthly basis.

Facility Report Cards provided to ​HM leadership and Medical ​Directors/Facility Site Leads on a ​monthly basis.

Clinicians will receive

educational email notifications.

Provider Portal & ​mySCP Care

SCP Account Creation

To create your SCP account, access the ​website below:

https://www.myscphealth.com/login-

help/provider-access

Complete the information below:



 ​ ​

Your global ID was sent via email, or you ​can contact your SCP Documentation ​Specialist or Practice Manager

Last 4 of SSN

Mailing Zipcode

Phone Number

Provider Portal

www.myscphealth.com

Need help logging in? Navigate to

www.myscphealth.com/login-help

Provider Portal ​Quick Links

SCP University

Educational videos

mySCP Care/Connect/Practice

SCP Product Suite used for encounter entry, secure messaging, ​and scheduling

UpToDate

Evidence based resources to support your clinical decisions ​and inform your research

SCP University

Click the SCP University icon on ​your Provider Portal homepage to ​get started.

Click on the “Content Library” ​link

Search “HM Physician ​Orientation”

.

Other Resources

mySCP Care App

Capturing Encounters & Expectations

mySCP Care

Process Overview

Important:Clinician must complete all documentation and enter ​encounters prior to end of shift

mySCP Care

What happens if chart is incomplete?

Documentation Tips for HM

mySCP Care: Clinician

Expectations



Clinician is

responsible

for

entering all new patients

in mySCP Care

Clinician

shift.

must enter

in

all encounters

for each patient

prior to end of

Clinician is required enter all documentation, including the history, ​physical, and medical decision makingin the EMR at their facility.

If working with an NP/PA, the ​clinician who authored the ​original note will enter the ​patient in mySCP Care. The ​physician will be selected as ​supervising by the NP/PA and ​the physician will be sent those ​encounters to review.

Delay of

documentation may

result in the return of

an incomplete chart

due to timing of

process.

Documentation Tips for HM

mySCP Care: Queries

Timely ​Documentation

Complete ​Documentation

No ​Queries!

mySCP Care

Queries

Documentation Missing

 ​ ​ ​ ​

Diagnosis Missing

Physical Exam Missing

H&P Missing

Progress Note Missing ​Discharge Summary Missing

ICD10 Clarification

 ​

Displaced or non-displaced fracture ​Abdominal pain laterality

Date of Service Clarification

 ​

Documentation either does not contain a DOS or a ​DOS clarification is needed

DOS should be listed as the date the provider first saw

the patient for those visits that cross over midnight

Admit Order/Place of Service Clarification

 ​

Applied when the admit order is missing OR

Admit order is present, but does not match the place of

service indicated within your note

HM ObsStatement Needed





Observation orders must be placed by the admitting HM ​clinician, this applies to bridge orders from the ED.

“As clarification, the patient should be placed in ​observation services under my care.

mySCP Care

How to Get Started

mySCP Care can be accessed via a mobile app or a web browser. ​Please login using your SCP Health credentials.

mySCP Support

If you experience issues or have questions, ​please reach out to your facility



Hospital

Practice Manager (HPM) and/or Hospital ​Practice Specialist (HPS), for assistance.

additional support

If you need or have a feature

suggestion,please email

mySCPCareSupport@scp-health.com

Access issues: please go to

https://www.myscphealth.com/login-

help/provider-accessand reset your password.

Documentation Tips for HM

mySCPCare App Demonstration

mySCP Care

D em ons tr at ion

Reviewing NP/PA Shared ​Encounters in mySCP Care

Documentation Tips for HM

mySCP Care: How to Access Encounters Pending Review

2

3

1. ​2. ​3. ​4.

Under Patient census select Today’s pending review from the drop-down list ​Select the patient

Once side pane opens, select Episode of Care

Select encounter that is pending review

Documentation Tips for HM

mySCP Care: How to Access Encounters Pending Review