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Coding Drop Down

Different coding documentation requirements can seem convoluted. This resource details coding documentation requirements and gives you nephrology specific examples and codes.


Chief Complaint

Chief Complaint

  • Chief Complaint is a concise statement describing the symptom, problem, condition or other factor that is the reason for the encounter
  • The medical Record should always clearly reflect the chief complaint

History of Present Illness Documentation Requirements

History (4+ documented = Comprehensive)
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History Levels



Complete HPI = 4 or more elements
or documentation of the following


Status of 3 Chronic Conditions
You have to specifically document what chronic conditions the patient has and the current status of each
Communication Caveat
If you are unable to obtain the history from the patient you need to document why

History of Present Illness (HPI)
Brief
1-3 Elements
Brief
1-3 Elements
Extended
4 or more Elements
Extended
4 or more elements
(location, severity, timing, modifying factors, quality, duration, context, associated signs & Symptoms)


 

Review of Systems Documentation Requirements

Review of Systems



Complete ROS = 10 or more systems
or documentation of the following


"All other systems reviewed and Negative"

Communication Caveat = Complete
If you are unable to obtain the ROS from the patient you need to document why

Review of Systems (ROS)
N/A
Problem Pertinent
System directly related to the HPI
Extended
System directly related to problem in HPI and 1 – 8 additional
Complete
At least 10 systems reviewed


 

Inventory of body systems by asking patient what symptoms they are experiencing

Body Systems
Constitutional       Musculoskeletal
Eyes Integumentary
Ears, Nose, Mouth, Throat Neurological
Cardiovascular Psychiatric
Respiratory Endocrine
Gastrointestinal Hematologic/Lymphatic
Genitourinary Allergic/Immunologic

Past, Family and Social History Documentation Requirements

Past, Family and Social History



  • Review of:
    • Past History – patient's past experience with illness
    • Family History – review of medical events in the patient’s family
    • Social History – age appropriate review of past or current activities


Noncontributory is not recognized by CMS for PFSH



Examination Documentation

Examination Elements



  • Constitutional
  • Eyes
  • Ears, Nose, Mouth & Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurological
  • Psychiatric
  • Hematologic/lymphatic /immunologic
 


Examination Levels
To qualify for a given level of examination, the following content and documentation requirements must be met:



Examination Level Documentation must include Examination of
Problem Focused Exam 1 body area or system
(relevant affected area)
Expanded Problem Focused Exam 2-4 body areas or systems
(including affected area)
Detailed Exam 5-7 body areas or systems
(including affected area)
Comprehensive Exam 8 or more body areas or systems

Medical Decision Making

Medical Decision Making



MDM refers to the complexity of establishing a diagnosis and/or selecting management option as measured by the following:

  • Number of possible diagnoses and/or the number of management options to be considered
  • The amount of data and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed or obtained
  • The risk of significant complications, morbidity, and/or mortality as well as co-morbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.


How to calculate the level of medical decision making



You must have 2 of 3 components in the same column. You may go lower than your highest selected if you don’t have 2 in the same category.


Final Result for Complexity 2 of 3

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New Patient Office & Outpatient Hospital Documentation Requirements

New Patient Office & Outpatient Hospital



Need to Meet 2 out of 3 Requirements

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Observation Hospital Visits

Observation Hospital Visits



The Admitting physician

is the only provider who bills Observation Codes.

If an ESRD patient Observation visits count towards MCP

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Initial Inpatient Hospital Visit

Inpatient Hospital – Initial Visit



Need to Meet 3 out of 3 Requirements

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Subsequent Inpatient Hospital Visit

Inpatient Hospital – Subsequent Visit



Need to Meet 2 out of 3 Requirements

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Time Based Billing

Time Based Visit



Time can be a component:
  • For visits in which counseling and/or coordination of care by a provider is greater than 50% of the time spent with the patient and/or family
  • Medical record - total time and time spent in face to face counseling or coordination of care.


New Patient Office Visit Time Established Patient Office Visit Time
99201
10 minutes
99211
5 minutes
99202
20 minutes
99212
10 minutes
99203
30 minutes
99213
15 minutes
99204
45 minutes
99214
25 minutes
99205
60 minutes
99215
40 minutes
Initial Hospital Care Time Subsequent Hospital Care Time
99221
30 minutes
99231
15 minutes
99222
50 minutes
99232
25 minutes
99223
70 minutes
99233
35 minutes

Inpatient/Outpatient Dialysis Service

Inpatient/Outpatient Dialysis Service



  • 90935: Single Evaluation of Hemodialysis Procedure by a physician or other qualified healthcare professional
  • 90937: Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription (use this when patient has an adverse event during dialysis)

Comprehensive Assessment Documentation

Comprehensive Assessment Documentation



  • Comprehensive assessment should be performed at least once per month and include:
    • Patient’s current status and complaints
    • Physical exam
    • Assessment of adequacy of ESRD treatment including dialysis
    • Status of vascular access
    • Assessment and treatment of other conditions associated with ESRD (e.g., anemia, electrolyte management and bone density)
    • Plan of treatment and any changes to the patient’s management

Excluded Services of Monthly Capitation Payment

Monthly Capitation Payment Excluded Services



Excluded Services:

  • Comprehensive evaluation for transplant
  • Evaluation of potential living donor
  • Self-dialysis training
  • Non-renal related physician visits
  • Hospital inpatient services
  • Physician services that initiate outpatient dialysis


At NPS, we are committed to providing resources and solutions that deliver economic growth, practice stability and operational efficiencies to our physician partners. NPS offers coding review services to help guide your practice in accurate coding. Click here to learn more about our coding review or feel free to email or call us to speak directly to a member of the NPS team.

This guide is provided for informational purposes only, not as advice for your specific practice, and it should not be solely relied upon for appropriate coding.