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 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 (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)
1-3 Elements
1-3 Elements
4 or more Elements
4 or more elements
(location, severity, timing, modifying factors, quality, duration, context, associated signs & Symptoms)

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)
Problem Pertinent
System directly related to the HPI
System directly related to problem in HPI and 1 – 8 additional
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

Review of:

  • Past Historypatient’s past experience with illness
  • Family Historyreview of medical events in the patient’s family
  • Social Historyage appropriate review of past or current activities

Noncontributory is not recognized by CMS for PFSH

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

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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Established Office

Need to Meet 2 out of 3 Requirements

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New Patient Office

Need to Meet 3 out of 3 Requirements

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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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Inpatient Hospital – Initial Visit

Need to Meet 3 out of 3 Requirements

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Inpatient Hospital – Subsequent Visit

Need to Meet 2 out of 3 Requirements

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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
10 minutes
5 minutes
20 minutes
10 minutes
30 minutes
15 minutes
45 minutes
25 minutes
60 minutes
40 minutes
Initial Hospital Care Time Subsequent Hospital Care Time
30 minutes
15 minutes
50 minutes
25 minutes
70 minutes
35 minutes

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 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

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.