The medical record of an individual patient serves numerous functions. Ideally, the record should provide a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities (such as hospitals). The medical record also serves as the basis for a variety of financial, legal, and administrative functions including the documentation for both professional and facility fee reimbursement, quality and safety assessments (including pay for performance), malpractice litigation and disability determinations, and community-based care and public health initiatives.

Currently, the medical record of an individual patient is fragmented, with various pieces shared only sometimes among numerous providers. Hospitalists typically care for a patient during a single episode of facility-based care. Fortunately, the proliferation, adoption, and increasing interoperability of electronic medical records (EMRs), and their evolution into personalized health records, holds promise for consolidation and availability of all relevant clinical information to each provider participating in the care of a single patient.

Some General Principles

This chapter focuses upon the documentation requirements incumbent upon hospitalists for professional fee billing of their clinical services. Some general principles of physician documentation warrant discussion despite this focus, and apply to both paper and electronic medical records.

The documentation of physician services should always comprise the essential components of a patient’s chief complaint, history, physical examination, and medical decision making. The concerns of both patient and provider should be clearly recorded, including expectations (realistic or not) and satisfaction (and dissatisfaction). All diagnostic test orders and results should reside in the chart, as well as documentation of various specific services (eg, physical, occupational, speech, or rehabilitation therapy; home health services, durable medical equipment needs, and social work evaluations).

Corrections

At some point in time, every medical record requires a correction. In a paper document, draw a single line through the inaccurate portion and write a correction nearby, dating and signing the revision. The original entry thereby remains legible for future reference. For example, consider misidentification of a right swollen knee joint, when actually it is on the left: when the physician recognizes the mistaken documentation, the right side should have a single line drawn through it (ie, overstrike text) and a note written nearby indicating that the left side is the accurate side. Sign and date these changes on the day of correction. Methods and appearances of corrections and amendments in electronic medical records continue to evolve, but all incorporate password-protected signatures with electronic date- and time-stamped entries.

Late-Entry Documentation

Like corrections, addenda or late entries can be made at any time and labeled as such, with a dated and timed signature. Also, explain why the entry was made late and not contemporaneously. For example, following a hospital visit, a hospitalist responds to a rapid response call and neglects to document the visit in the hospital medical record. When recognized the next day, document the hospital visit as a late entry and specify that the care was delivered the previous day.

An Overview of Hospital Payment Systems

As the most prominent payer in the United States, Medicare payment systems are of paramount importance to understand. Fortunately, Medicare policies are established by the Centers for Medicare and Medicaid Services (CMS) and available online through the CMS On-Line Manual System, so that everyone can in principle understand how claims are processed and payments are made. Medicare policies are largely consistent across the United States, and many private payers follow CMS’s lead to a greater or lesser extent. However, remember that regional Medicare contractors develop local coverage determinations from CMS payment policy, and can create idiosyncratic interpretations of the documentation guidelines for evaluation and management (E/M) services. One such example would be the nuanced medical decision making (see below) evaluations implemented by Trailblazer Medicare. Similarly, various third party payers have the right, as allowable under their contract with physician groups, to create unique documentation mandates and payment policies. Facilities also generate requirements, such as a history and physical are required before a procedure, which do not comprise medically necessary, billable physician services.

Medicare pays hospitals for inpatient services using an inpatient prospective payment system (IPPS), which relies primarily on the diagnosis in order to group the services delivered to an inpatient into a Medicare severity-diagnosis related group (MS-DRG). Many diagnostic categories have two or three severity levels, differentiated by the presence or absence of a specified set of complications and comorbidities (CCs) or major complications and comorbidities (MCCs). Hospitals and other facilities frequently request hospitalists to clarify, expand, or specify their clinical documentation to ensure the assignment of a hospitalization to the proper MS-DRG. This single MS-DRG payment covers all facility services during the inpatient stay. Many payers have adopted a similar mechanism of providing a single, fixed payment for an entire hospitalization, often referred to as a case rate.

Some non-Medicare payers still reimburse hospitals and facilities with a fixed payment for each day, commonly described as a per diem rate. The daily payment potentially varies depending upon the types of services provided to the patient (eg, intensive care versus skilled nursing care). Other payment models are likely to emerge as a result of health care reform, including the evolution of accountable care organizations and the emergence of patient-centered medical homes.

An Overview of Physician Payment Systems

Physician services are typically reported using the American Medical Association (AMA) Current Procedural Terminology (CPT), fourth edition, which lists descriptive terms and identifying codes to report medical services and procedures. CPT provides a uniform language to accurately describe all medical, surgical, and diagnostic services and procedures. Even physicians receiving capitated payments still typically report CPT codes for their services.

Hospitalists predominantly report E/M codes (CPT 99201-99499), which for Medicare exceed $32 billion annually and account for more than 40% of the Medicare physician fee schedule allowed charges. Other bedside procedures and diagnostic testing, sometimes performed by hospitalists, are found in CPT. In selecting the proper E/M code, the site and nature of service determine the visit category; and the key components of history, physical examination, and medical decision making determine the specific level of CPT code within a visit category.

Many payers are now adopting Medicare’s recognition and regulation of nurse practitioners and physician assistants as nonphysician providers, independently able to provide, document, and bill for E/M services. The number of nonphysician providers performing hospitalist services is rapidly increasing. Therefore, when we refer to providers throughout this chapter, we include both physicians and these qualified nonphysician providers functioning in an independent billing role.

Diagnosis Coding

The International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9) codifies every disease, disorder, condition, symptom, and health care encounter. Payers initially determine the medical necessity of services and procedures based upon the ICD-9-CM code(s) that accompany every provider and hospital claim. Each entry into the medical record should clearly state the diagnoses considered and addressed in the service. The successor International Classification of Diseases, Tenth Revision (ICD-10), which has been available for more than 10 years, is slated for implementation in 2013.

Selecting an E/M level focuses upon the content of the three key components: history, physical examination (PE), and medical decision making (MDM). Time is considered a fourth key component, but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician’s total visit time (see below). When counseling and/or coordination of care involves less than 50% of the physician’s total visit time, both time and the nature of the presenting problem are only considered as contributory factors and do not determine the E/M level.

Two sets of documentation guidelines have been elaborated by Medicare and largely adopted by other payers. The earlier 1995 guidelines are the most widespread, and generally applicable to hospitalists along with most medical and surgical specialists. The later 1997 guidelines elaborate specialty-specific physical examinations, as well as clearly articulate detailed physical examination requirements lacking in the 1995 guidelines. Several nuanced differences also exist between the two guidelines in aspects of history. The 1995 guidelines will be described in detail throughout this section, and the 1997 guidelines are highlighted below in a separate section for completeness.

History

The elements of history include the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and the past, family, and social histories (PFSH). A chart note may not segregate these elements into unique subtitled areas, but rather the information may be interspersed amid the written, typed, or even dictated narrative.

Chief Complaint (CC)

Typically, the reason for the visit is often quoted from the patient’s own words as a sign or symptom, such as, “my belly hurts.” Always document a CC in the progress note, even absent an acute complaint, such as, “pneumonia follow-up.” Avoid statements lacking a specific clinical reference (eg, “postop visit Day#3”).

History of Present Illness (HPI)

The HPI conveys information about the CC, from either the origin (at an initial encounter) or the interval between sequential patient encounters. This information is arbitrarily allocated into eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms. The HPI is then quantified as brief (one to three elements) or extended (four or more elements). For example, consider this extended HPI: “Patient complains of increased (severity) pedal (location) edema that began two days ago (duration). Less able to walk. No chest pain (associated signs/symptoms).”

Review of Systems (ROS)

The ROS refers to signs or symptoms experienced in conjunction with the CC. Fourteen systems are recognized: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (which includes the breast), neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. Medical necessity, as deemed by the treating provider in light of the patient’s current or previous conditions, determines the number of systems required for review.

An ROS may be problem pertinent, extended, or complete. A problem-pertinent ROS documents one system directly related to the CC. An extended ROS requires documentation of two to nine systems, that is, the system that is directly related to the CC, along with one or more additional systems. A complete ROS documents 10 or more individual systems. When obtaining a complete ROS, to decrease the amount of time spent listing each system individually, both the 1995 and 1997 (see below) E/M documentation guidelines allow the physician to comment on the positive and pertinent negative systems, with an additional comment that the “remainder is negative.” However, insurers may not accept alternative phrases, and even some Medicare contractors (eg, Trailblazers Medicare) require individual documentation of each system.

Past, Family, and Social Histories (PFSH)

The past history includes documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations. The family history provides information regarding potential hereditary illnesses. The social history may list details of the patient’s substance use (tobacco/alcohol/illicit drugs), sexual history, employment status, level of education, marital status, or living arrangements.

A pertinent PFSH includes a comment in any one of the three histories (ie, past, family, or social). Full credit for a complete PFSH requires a comment in each history (ie, past, family, and social). When reporting initial hospital, observation, or nursing facility care, consultations, and new office, home, and domiciliary visits, a complete PFSH comprises one comment documented in each of the three histories. In contradistinction, emergency department (ED) services or established patient visits in the home, domiciliary, office, or other outpatient area require one comment in two of the three histories for credit as a complete PFSH.

Providers may review and comment that the “family history is noncontributory” and still receive credit for the family history from most insurers. Certain Medicare contractors, such as Trailblazers Medicare and Wisconsin Physicians Service Insurance Corporation, prohibit this terminology and require specific documentation regardless of clinical relevance (eg, “family history negative for liver disease”). Also note that with subsequent services, both for hospital care and nursing facility visits, indicating an “interval history” does not require redocumentation of the PFSH unless it is clinically relevant.

Determination of History Level

The number of historical elements present in the chart note determines the level of history (Table 28-1). If all of the requirements are not met for a given level of history, select the level associated with the deficient element. For example, a comprehensive history requires documentation of the CC, ≥4 HPI elements, ≥10 ROS, and a complete PFSH. If the ROS only includes documentation for 9 systems, a comprehensive history cannot be selected; report a service that requires only a detailed history: CC, ≥4 HPI elements, 2-9 ROS, and a pertinent PFSH.

Other Circumstances

A PFSH obtained during an earlier encounter does not need to be rerecorded if the provider demonstrates review and updating of the previous information. Update the history by describing any new information or noting the absence of change, along with the date and location of the earlier PFSH; this earlier PFSH must be contained in the body of the medical record. CPT requires only an interval history for subsequent hospital or subsequent nursing facility visits, and it is usually unnecessary to record information about the PFSH, which is unlikely to change in these settings. For established outpatient encounters, documentation regarding the PFSH is unnecessary when PE and MDM are used as the basis for the level of the encounter, unless the patient provides the physician with updated information.

Most auditors disallow a single statement as both an HPI element and ROS element. The ROS and/or PFSH may be recorded by ancillary staff, or on a form completed by the patient. The provider must annotate, supplement, or confirm this information recorded by others, either by a reference to the history form in the progress note or by initialing and dating the form.

If unable to obtain history from the patient, the record should describe the patient’s condition or the circumstance that precludes obtaining a history. For example, ″… patient sedated and paralyzed, unable to obtain additional history.″ However, reviewers expect providers to incorporate historic information to the extent possible, from all reasonably available sources (eg, old records, Emergency Medical services documents, other provider documentation, or conversations).

Finally, although the physician may collect all of the information required for a complete ROS, the most common under-documentation error is failure to document at least 10 systems. The second most common mistake is a missing family history or social history.

Physical Examination (PE)

Individual PE elements will be assigned to body areas (head and face, neck, chest, abdomen, genitalia/groin/buttocks, back/spine, and each extremity) or organ systems (constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, and hematologic/lymphatic/immunologic). Providers may document specific findings (eg, “abdomen soft”) or make a generalized comment (eg, “HEENT normal”). Abnormal findings must be specifically documented, such as “S3”; however, a comment indicating “abnormal” without elaboration is insufficient.

The PE documented in the medical record is categorized as problem-focused, expanded problem-focused, detailed, or comprehensive. One comment in an area constitutes a problem-focused exam. The distinction between the expanded problem-focused and detailed examination under the 1995 Guidelines is the greatest ambiguity in physical examination documentation. Both the expanded problem-focused and detailed exams require documentation of two to seven systems. However, “detailed” is defined as an extended examination of the affected body area or organ system, in addition to other symptomatic or related organ systems. The number of required comments regarding the affected body area or organ system to consider the examination detailed has never been defined by either CPT or Medicare. Attempting to decrease ambiguity and variability among auditors, Highmark Medicare Services scores a detailed exam using the “4 × 4” rule: 4 elements examined in 4 body areas or 4 organ systems (totaling 16 documentation elements). In contrast, Trailblazers Medicare and some other contractors suggest using the 1997 guidelines (discussed later) for detailed exam requirements.

The comprehensive examination is a general multisystem examination or a complete examination of a single organ system. Medicare requires the minimum documentation for the general multisystem examination to include one comment in each of eight systems; of course, additional comments in each system and more than eight systems may be described, as clinically indicated. For example, a comprehensive examination may be documented as follows: “P=76, BP=120/80, RR=12 (constitutional); HEENT normal (eyes and ENMT); neck supple (musculoskeletal); regular rate and rhythm (cardiovascular); lungs clear (respiratory); soft abdomen (gastrointestinal); no icterus (integumentary), normal gait (neurological).” The requirements for a comprehensive single organ system still remain undefined for use with these 1995 guidelines.

Medical Decision Making (MDM)

The complexity of MDM drives selection of a level of service. MDM is categorized as straightforward, low, moderate, or high. Three categories must be considered to determine the level of MDM complexity: the number of diagnoses, the amount and complexity of data, and the risk to the patient.

Number of Diagnoses Considered

This first category identifies the number of diagnoses and/or management options considered in the encounter, based upon the documentation. Up to four points are assigned to each problem, with more points assigned for new problems than for established problems, and a new problem requiring additional workup (ie, diagnostic testing) given the maximum four points. Established problems identified as worsening receive a higher value than stable or improving problems. A self-limited or minor problem (eg, sunburn) receives minimal credit as these issues typically do not warrant a defined plan of care (Table 28-2).

New problems require initiation of a care plan, while established problems may require modification or continuation of a care plan. An established problem has been previously considered by the physician or provider group (to allow for cross coverage and handoffs between same specialty providers in the same group). Note that credit is given for a problem considered, although not primarily under treatment by the physician. For example, in a patient receiving steroids for an inflammatory disease, the hospitalist receives credit for noting the potential adverse consequence upon serum lipids, even if a cardiologist is primarily treating the dyslipidemia. Similarly, a chronic condition such as diabetes, cared for by an endocrinologist, is categorized as a new problem to the hospitalist newly treating the patient during an admission for ketoacidosis.

Established patients may also have new problems. For example, an asthmatic with a resolving flare may experience heartburn. This additional new complaint of heartburn may be considered new if commented upon in the progress note and no prior care plan for gastroesophageal reflux exists.

Physicians receive credit only for issues considered in the care plan. Diagnoses merely listed in the assessment and plan without elaboration of the care, or simply ascribing the care to others (eg, “diabetes – per endocrinologist”) are considered part of the patient’s problem list in the PFSH. Additionally, new hospitalizations warrant new care plan development, and physicians can receive new problem credit even if the patient has been previously hospitalized by the same group. This is a nuance of inpatient and observation care only.

Data Considered

The second category of determining the MDM complexity is the amount and/or complexity of data reviewed or ordered by the provider during the patient encounter. Both the type and source of information considered are valued (Table 28-3).

Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit. Irrespective of the test volume in each category, only one point is allocated per category (ie, pathology/laboratory, radiology, or medicine) for the encounter. For example, the provider ordering a dozen serologic collagen vascular studies in the morning may also review the three results received in the afternoon; nonetheless, only one point is granted for this care. A single, separate point may be assigned each to pathology/laboratory, radiology, and medicine data, respectively, are cumulative in nature, and the chart note should refer to all the data reviewed or ordered to capture all of the provider work. In other words, if the chart note comments upon a radiology result (one point) and an echocardiogram order (one point), two points may be awarded for the amount of data in that encounter. Independently visualizing images, tracings, or specimens is considered separately, and additional to reviewing the formal interpretation, as long as the chart note clearly documents this occurrence (ie, ″…films and report reveal…″). Without such specific reference distinguishing personal review of the images and of the formal interpretation, an auditor only provides minimal credit for merely reviewing the report.

Providers also receive credit for the additional effort of obtaining information from sources other than the patient or old records, such as conversations with other health care professionals. The chart note should specifically mention the source, along with the information reviewed (eg, ″…spouse confirms loud snoring″).

Risk to the Patient

The third MDM category assesses the patient’s risk of complications, morbidity, or mortality, with respect to the presenting problem, diagnostic procedures ordered, or management options chosen. Four levels of patient risk exist (minimal, low, moderate, and high), with examples of each risk type included in Medicare’s “Table of Risk” (Table 28-4). The limited number of examples serves as illustrative references for common clinical scenarios, but not as a comprehensive list.