COC Chapter 6 - Documentation and Coding Standards

Pathology and Laboratory Services Each NCD outlines the requirements that must be met to submit a claim:

*A physician's order for the lab test *The medical condition for which a laboratory test is reasonable and necessary *The appropriate use of procedure codes in billing for a laboratory test. Do not unbundle the CPT® codes for laboratory services (Example: a basic metabolic panel includes seven individual tests. Do not report all seven tests separately, report the basic metabolic panel with one CPT® code.) *The medical documentation that is required by a Medicare contractor at the time a claim is submitted for a laboratory test *Record-keeping requirements in addition to any information required to be submitted with a claim, including all physician's documentation requirements as outlined in each NCD in Pub 100-03 National Coverage Determinations Manual *Limitations on frequency of coverage for the same services performed on the same individual

When coding operative reports, the following list is useful for understanding operative reports and choosing the correct CPT® code(s):

*Approach *Findings *Indication *Closure *Index/code range(s) *Correct CPT® codes *Applicable modifiers *Rationale for CPT® code choice *Revenue code choice *Status indicator for OPPS (discussed in Chapter 25) *Payment indicator for ASC (discussed in Chapter 25)

Education

*Assessment of learning needs in relation to cultural and religious beliefs, emotional and educational barriers, physical and cognitive limitation, and communication barriers *Basic health practices and safety *Patient is educated regarding: £ Safe and effective use of medications £ Understanding of plan of care, treatment, and services £ Nutritional interventions, diets, and oral health £ Safe and effective use of medical equipment or supplies provided by organization £ Rehabilitation techniques to help reach maximum independence £ Understand pain, risk for pain, importance, and effective pain management process £ Arrangement for services needed to meet patient's medical needs after discharge, if applicable £ Specific academic educational needs of children, if applicable

Assessment of Patients

*Assessment to include physical, psychological, social, nutrition, hydration status, and functional status *Medical history and physical within 24 hours of admission *Comprehensive pain assessment appropriate to patient's condition and scope of care, treatment, and service provided *Assessment or impression derived from history and examination *Initial nursing assessment of inpatient admission within 24 hours *Diagnosis, diagnostic impression, or condition *Sufficient information in the medical record to: *Identify patient *Support diagnosis/condition Justify care, treatment, and service *Document course and results of care, treatment, or services *Promote continuity of care among its providers *Identify nutritional screenings, if justified *Identify allergies to medicines and foods *Complete functional status screening, when warranted *Any specialized assessment and reassessment information for various populations *Discharge plan or transfer of care *Periodic reassessment of patient, as needed *Integrated information from staff members from various assessments to develop a plan for care, treatment, and services

The operative report should contain:

*Date and Time of Procedure *Names of surgeon, co-surgeon, assistant surgeon *Type of anesthesia (MAC, general, local), anesthetic and anesthesiologist *Medical necessity of the procedure for the treatment of the patient's condition (preoperative diagnosis) *Postoperative diagnosis *Title of procedure *Indication for surgery *Details of procedure(s) Patient preparation including cleansing, medications, enemas, anesthesia Medications used Summary of the procedures performed and techniques used *Instruments and/or equipment used *Length, depth, and extent of incisions *Clinical findings during the procedure *Nature, location, and depth of resections *Depth of instrument penetrations through body orifices or cavities *Foreign bodies observed or removed *Nature and amount of material drained *Location, number, and size (including length, width, and depth) of lesions excised, biopsied, curetted, frozen, exposed to laser, or otherwise removed *Nature, source, and size of specimens sent for pathological examination (Results of pathological examinations must be incorporated into the patient's medical record when they are received.) *Reference to any devices or implants left in patient (In the hospital setting, this may be a sticker placed in the medical record with the manufacturer, make, and model of the device.) *Complications and unusual services *Immediate postoperative condition *Estimate of blood loss and replacement, and urine output *Fluids given and invasive tubes, drains, and catheters used *Signature

The following format is suggested for documenting invasive radiology procedures:

*Date and time of report *Title of operation or procedure *Clinical indication or reason for procedure *Monitoring (optional) *Sedation *Detailed account of procedure *Radiology modality used for imaging (CT, MRI, Fluoroscopy, Ultrasound, etc.) *The procedure note must show performance of each procedure listed in the report heading *For vascular procedures, include the access route(s), each nonselective and selective vessel catheterized, and any deviation from normal anatomy *Injections (including type and amount of contrast material) *Findings *Complications *Post-procedure patient status *Impression or short description of the findings

Radiology The following list identifies the elements to document in support of medical necessity and complexity:

*Detailed description of imaging performed and interpreted *Number of views (when an exam does not meet the criteria of the code, it may have to be reported with an unlisted procedure code) *Unilateral or bilateral views (bilateral views performed for comparison are coded as a single procedure) *Limited or complete *Diagnostic or therapeutic (nuclear medicine) l 3-D rendering *With or without KUB (Kidney, Ureter, Bladder), a type of single abdominal view *With or without contrast material (type and amount) *With or without duplex scans (ultrasound studies) *Complete or limited follow up *Indication for procedure or service *Findings (if known)

To qualify for Medicare coverage of a bone mass measurement study, one of the following must apply:

*Determined by provider to be estrogen-deficient and at clinical risk for osteoporosis based on medical history and other findings *Vertebral abnormalities demonstrated by an X-ray to be indicative of osteoporosis, osteopenia, or vertebral fracture *Glucocorticoid therapy equivalent to 5.0 mg of prednisone, or greater, per day, for more than three months *Primary hyperparathyroidism *To assess response to, or efficacy of, a FDA-approved osteoporosis drug therapy

Therapy cannot start until the initial plan of care is established. A plan of care should be established for each type of therapy. The plan of care must contain:

*Diagnoses *Long term treatment goals *Type of rehabilitation therapy services (physical therapy, occupational therapy, or speech-language pathology) to be performed including specific intervention, procedure, or modality *Amount of therapy—number of treatment sessions in a day *Duration of therapy—number of weeks or number of treatment sessions *Frequency of therapy—number of treatment sessions in a week

Documentation requirements for therapy services include:

*Evaluation and plan of care *Certification and recertification *Progress reports *Treatment notes for each treatment day *Length of therapy session—The time spent by the therapist should be recorded in minutes for each treatment modality as CPT® codes are based on 15-minute intervals.

Documentation of Care

*Every medical record entry is dated, author identified, and authenticated *Signature either written, electronic, or rubber-stamped (based on state regulations and carrier requirements) *History and physical examination £ Consultations £ Operative reports £ Discharge summaries *When verbal orders are given, a date and identification of the individual who gave the order, who received it, and who implemented the order *Verbal orders authenticated within given timeframe (defined by state, federal law, or regulation *Goals of treatment and treatment plans documented *Relevant observations *Progress notes, documented and authenticated *Consultation reports documented, as applicable *All diagnostic tests, therapeutic procedures, and results documented *Hospital must have policies and procedures in place regarding £ Entry of information in patient's medical record £ Timeframe not to exceed 30 days in which the record must be completed after discharge *Hospital measurement of medical record delinquency, no less frequently than three months

Medical Necessity

*In accordance with standards of good medical practice *Consistent with the diagnosis *The most appropriate level of care provided in the most appropriate setting

Payers define medically necessary services or supplies as consisting of what three elements?

*In accordance with standards of good medical practice *Consistent with the diagnosis *The most appropriate level of care provided in the most appropriate setting

Operative report documentation must include:

*Indications for the procedure (supports medical necessity) *Findings *Procedure performed *Description of procedure *Specimen removed *Postoperative diagnosis *Primary surgeon and assistants identified *Complications *Unusual service *Estimated blood loss *Operative progress note dictated immediately after procedure *Postoperative documentation record including patient discharge from post-sedation or post-anesthesia care according to discharge criteria and name of responsible physician *Operative reports should be dictated or handwritten immediately or within 24 hours following procedure. *Immediate postoperative note required in the chart on the first eight elements

To meet the specific documentation requirements, the following general information must be documented:

*Patient demographics including name, address, sex, date of birth, etc. *Reason for care, treatment, or service *Evidence of informed consent including nature of proposed care, treatment, services, medications, interventions, procedures, potential benefits, risks, side effects, goals, alternative treatments, etc. *Evidence of known advance directives *Legal status of patients receiving behavioral healthcare services *Emergency care, treatment, services provided to the patient before arrival *Documentation of findings and assessments *Diagnostic and therapeutic orders *Reassessments and plan of care revisions, if indicated *Response to care, treatment, and services provided *Every dose of medication administered and any adverse drug reaction *Medications dispensed or prescribed at discharge *Relevant diagnoses/conditions established during care, treatment, and services

The lab report should contain the following elements:

*Patient name and identification number *Name of laboratory *Name of physician or practitioner ordering the test *Date and time of the collected specimen, and date and time of receipt *Reason for an unsatisfactory specimen, if applicable *Test or evaluation performed *Method of testing if applicable, such as, immunoassay, enzyme-linked immunoassay (ELISA), Gas chromatography (GC), GC-Mass Spec *Specimen source such as, blood, plasma, urine, saliva) *Result *Date and time of report

Documentation standards are classified into two categories:

*Patient-specific data and information. *Additional standards for specific patient populations, such as operative/invasive procedures, ambulatory care, emergency, clinical trials, addictions, emotional, or behavioral disorders.

Postoperative monitoring and documentation include:

*Physiological status l Mental status *Medications including IV fluids *Blood and blood components, if administered *Vital signs and level of consciousness *Pain level, pre- and post-administration of prescribed medication for pain *Complications, unusual events, and management of those events *Use of approved discharge criteria to determine patient's readiness for discharge appropriately documented *Operative report authenticated by surgeon and available in the medical record

Operative/Other Invasive Procedures

*Provisional diagnosis recorded prior to performance of procedure *Completed informed consent for procedure identifying benefits, risks, side effects, and potential difficulties related to recovery *Pre-anesthesia assessment prior to administration of moderate (conscious) sedation, or general anesthesia *Reevaluation of patient immediately before moderate (conscious) sedation or general anesthesia induction *Appropriate methods to continuously monitor oxygenation, ventilation, circulation during the procedure

Outpatient therapy services are covered when:

*Services were required because the individual needed therapy services *A plan of care has been established and is periodically reviewed *Services were furnished while under the care of a physician *The physician or nonphysician practitioner certifies the plan of care

Additional optional, but recommended elements for a plan of care include:

*Short-term goals *Long-term goals *Expected duration for current episode of care *Specific treatment interventions, procedures, modalities or techniques and the amount of each *Beginning date for the plan

Ambulatory care records should contain, at the minimum, the following documentation:

*Summary of all significant diagnoses, procedures, drug allergies, and medications *Known significant medical diagnoses and conditions *Documentation of significant operative and invasive procedures *Known adverse and allergic drug reactions *Documented medications, including over-the-counter drugs and herbal preparations *The documentation should be stored in the same location to assist the provider in quick access of the medical information

Emergency Treatment and Care Records of patients who have received emergency care, treatment, and services should contain the following detail:

*Time and means of arrival *Whether the patient left against medical advice *Final disposition, condition, and instructions for followup care, treatment, and services *Communication between organization or provider to which patient is transferred or discharged *Reason for transfer or discharge *Patient's physical and psychosocial status *Summary of care, treatment, and services provided, and progress toward goals *Community resources or referrals provided to the patient

Computed Tomography (CT)

*With or without contrast material (type and amount) *Multiplanar scanning and/or reconstruction

Magnetic Resonance Imaging (MRI)

*With or without contrast material (type and amount) *Number of sequences When radiological studies are performed for urgent, acute problems, the radiologist must convey results verbally to the physician as soon as they are available

Operative Report Coding Tips

1. Always use a copy of the operative report for coding. Never use the original report. 2. Diagnosis code reporting—Use the postoperative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the operative report. If a pathology report is available, use the findings from the pathology report for the diagnosis (outpatient services only). 3. Start with the procedures listed—For the coder who is new to coding a procedure, one way of quickly starting the research process is by focusing on the procedures listed in the title of the report. Read the note in its entirety to verify the procedures performed. Procedures listed in the title may not be listed correctly and procedures documented within the body of the report may not be listed in the title at all; however, it will give you a place to start 4. Look for key words—Key words may include locations and anatomical structures involved, surgical approach (open, laparoscopic, percutaneous), procedure method (debridement, drainage, incision, repair, etc.), procedure type (open, closed, simple, intermediate, etc.), size and number, and the surgical instruments used during the procedure. 5. Highlight unfamiliar words—Unfamiliar words should be highlighted and researched for understanding. 6. Read the body—All procedures reported should be documented within the body of the report. The body may indicate a procedure was abandoned or complicated, possibly indicating the need for a different procedure code or the reporting of a modifier.

The medical record chronologically documents patient care to:

1. Enable the physician and other healthcare professionals to plan and evaluate the patient's immediate treatment, and to monitor his or her healthcare. 2. Enhance communication and promote continuity of care among physicians and other healthcare professionals involved in the patient's care. 3. Facilitate claims review and payments. 4. Assist in utilization review and quality of care evaluations. 5. Reduce complicated medical reviews. 6. Provide clinical data for research and education. 7. Serve as a legal document to verify the services provided, for example, in defense of an alleged professional liability claim.

Documentation Standards Some of the most critical questions a coder should ask about the standards of documentation are:

1. Is the reason for the patient encounter documented in the medical record? 2. Are all services provided documented? 3. Does the medical record clearly explain why support services, procedures, and supplies were provided? 4. Is the assessment of the patient's condition apparent in the medical record? 5. Does the medical record contain information on the patient's progress and the results of treatment? 6. Does the medical record include the physician's plan of care? 7. Does the information in the medical record provide a reasonable medical rationale for the setting and services to support billing? 8. Does the information in the medical record support the care given when another healthcare professional must assume care or perform medical review?

Lesions When documenting procedures involving lesions, it is important to record the size of each lesion. If the actual size of the lesion is not documented, coders and payers must down-code to the smallest size available for reporting purposes. When measuring the size of a lesion, consider the following:

1. Lacerations and nerve grafts are measured by total length in centimeters. 2. Skin grafts and destruction codes are measured by area in square centimeters (sq. cm), calculated by multiplying length by width. For example, a wound 2 centimeters in length and 3 centimeters in width is 6 square centimeters. (2 cm x 3 cm wound = 6 sq. cm) 3. Neoplasms are measured across the greatest dimension, including the smallest margin for excision multiplied by two. 4. Tattooing is measured by square centimeters. 5. Sizes need to be recorded so that the person reviewing the claim has the correct information for proper code selection. This information may support a higher code, which will result in a higher payment. Recording the precise size involves a mathematical number (2 cm), not subjective terms such as small, medium, or large. 6. Correct coding is dependent on whether the lesion is benign or malignant. Refer to the pathology report if the physician did not document this in the note.

Operative Report Checklist Applying the following suggestions will help ensure accurate and correct reporting of procedures.

1. The dictation should match the seriousness of the circumstances and procedures. If there were extensive complications, the words extensive complications should be included in the report. The dictation should also indicate what aspects of the procedure were unusual or complicated. Was there abnormal anatomy? Were there extensive adhesions requiring surgery time longer than normal for lysis of adhesions? Words or phrases such as very difficult, complicated, unusual circumstances, extensive, and multiple, or ordinary, uncomplicated, and simple, help you verify the appropriate codes and modifiers to describe the service rendered. It is essential that the selected codes are validated by the operative report. 2. Make sure the modifiers used for outpatient hospital facilities are approved for use in the facility setting. Keep in mind not all CPT® modifiers are used in the hospital outpatient setting. 3. The length of time spent on each procedure should be specified, especially if the time spent is of unusual duration. 4. The length of all repairs should be specified. Note whether a repair is simple, intermediate, or complex. The layers of skin, subcutaneous tissue, down to the bone, that are involved in a procedure should be documented. In some cases, the depth of involvement will determine the code selected for the procedure. For lesion excisions, specify the diameter of the lesion plus the smallest margin multiplied by two. 5. Time spent in prolonged attendance should be documented. 6. Unusual circumstances and the use of special instruments or aids, such as an operating microscope or fluoroscopic guidance, should be recorded. There are several modifiers to describe specific circumstances, such as the use of a surgical team or an assistant surgeon. The time spent using an operating microscope, fluoroscopic or ultrasonic guidance, or other special aids should also be documented.

Documentation Criteria The following criteria apply to all documentation:

1. The medical record should be complete and legible to ensure accurate understanding of the patient's medical condition. Every page in the record should contain the patient's name or ID number. 2. The documentation of each patient encounter should include the date; the reason for the encounter; an appropriate history and physical exam; review of lab, X-ray data, and other ancillary services, if appropriate; assessment; care plan (including discharge plan, if appropriate); and legible identity of the observer. 3. Past and present diagnoses should be accessible to the treating and/or consulting physician. 4. The reasons for and results of X-rays, lab tests, and other ancillary services should be documented or included in the medical record. 5. Relevant health and risk factors should be identified. Medication, allergies, and adverse reactions should be prominently noted in the record. 6. The patient's progress, including response to treatment, change in treatment, change in diagnosis, and patient noncompliance should be documented. The documentation for each encounter needs to be complete to avoid relying on prior chart entries. 7. The written plan of care should include, when appropriate, treatments and medications, specifying frequency and dosage, referrals and consultations, patient/family education, and specific instructions for follow up. 8. The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making. 9. The CPT®, HCPCS Level II, and ICD-10-CM codes reported on the health insurance claim form or billing statement should reflect the documentation in the medical record for each date of service. 10. When a consultation is requested, there should be a confirmed note from the consultant in the medical record.

Reading and Coding Operative Reports The following points offer a methodical approach to deciphering and coding surgical records:

1. The original operative report should never be "marked up." A copy of the operative report may be printed for making notes. 2. A ruler and highlighter are invaluable when scanning an operative report. Use a ruler to read the operative report line by line. If there are any unfamiliar terms, highlight them. You should research and define them on the working copy. Major errors can occur when a coder is not familiar with the medical terms being used. The relatively small time investment will pay dividends in the long run as optimal reimbursement is achieved. 3. Verify what procedure or procedures were performed; there may be additional procedures listed. Before coding additional procedures separately, make sure that they were not part of the main procedure. Some procedures are inherent to others. For example, a surgeon may record in the operative note an exploratory laparotomy (a surgical opening into the abdominal wall). In the process, the appendix was removed. In this situation, the appendectomy is coded, but the exploratory laparotomy is not. In the CPT® code book, an exploratory laparotomy is designated as a separate procedure; therefore, it is not reported when a more extensive procedure is performed through the same incision. 4. You should code only the operations documented in the body of the operative report. If there is a discrepancy between the operative report and the procedure listed in the Procedure Title, the physician should be consulted. If additional procedures were performed, the physician can add an addendum to the operative report. 5. Take care when a referenced code is designated as a separate procedure. A separate procedure is a service that is performed as part of a larger procedure and it is not coded separately (see #3 above, for an example). If the separate procedure is the only surgical procedure performed, or is unrelated to the major procedure performed at the same time, it may be a reportable service. 6. Terms such as undermining (cutting in a horizontal fashion), take down (to take apart), or lysis of adhesions are part of major surgical procedures and should normally not be coded separately. 7. After the CPT® codes have been determined, the corresponding ICD-10-CM diagnosis code must be assigned. Usually, there is a preoperative and postoperative diagnosis stated at the beginning of the operative report. The report must be read to ensure all procedural and diagnostic codes have been identified. The postoperative diagnosis is the primary diagnosis and if any additional diagnostic statements are present, they should be reported as secondary diagnoses. If there are any further questions, check with the surgeon. Remember: the diagnoses listed on the postoperative diagnosis line must be supported in the body of the report. 8. Reference other parts of the patient's chart by examining the pathology report, history, etc., to ensure the correct diagnosis code for the procedure performed was chosen. For example, a pathology report will indicate if a biopsied lesion was benign or malignant, which affects the diagnosis. 9. Verify the CPT® codes to determine the procedure, or procedures, and to determine if the procedure is considered approved for outpatient services. The status indicator should also be verified to determine payment method. 10. Become familiar with certain surgical terms such as: Excision—The act of cutting out; the surgical removal of all or part of a structure or organ. Incision—A surgical cut made into skin. Resection—Surgical removal of a section or segment of an organ or body structure. Transection—A cutting or section made across the long axis of a structure. Bisection—Division by cutting into two parts. Blunt Dissection—Separating tissue with a finger or blunt instrument without cutting. Sharp Dissection—A separation of tissues using a sharp instrument for cutting, such as a scalpel. Anastomosis—Joining together, such as two hollow organs, two arteries, or two veins. 11. Note the position of the patient during surgery, especially for back procedures. The patient's position indicates different approaches that a surgeon may use to perform a procedure and will assist in selecting the correct CPT® code. 12. When reviewing operative notes, identify the surgical approach used. For example, code 58820 describes drainage of an ovarian abscess from a vaginal approach, whereas 58822 describes ovarian abscess drainage, abdominal approach. The selection of the correct code will depend on the surgical approach used. 13. Any unusual details should be noted, including special instruments or other aids. If multiple procedures are performed, they should be noted. Read all paragraphs of the operative report. Review modifier usage and guidelines. A good rule to follow: if one procedure is always included in the main procedure, the main procedure is usually the code selected. For example, all open abdominal surgical procedures will be closed by suturing, stapling, or another method. Do not code for the closure as it is included in the abdominal surgery

SAMPLE DOCUMENTATION #3

65-year-old male arrived at ASC for laparoscopic cholecystectomy. PERRLA, Lung sounds clear. Abdominal pain in RUQ. EKG WNL. Pt c/o nausea p.c. NPO after MN. Interpretation: 65-year-old male arrived at Ambulatory Surgery Center for laparoscopic cholecystectomy (lap chole). Pupils equal round, reactive to light and accommodation. Lungs sound clear. Abdominal pain in right upper quadrant. EKG within normal limits. Patient complains of nausea after meals. Patient has not had anything to eat or drink since midnight.

Transection

A cutting or section made across the long axis of a structure.

diagnostic mammogram

A diagnostic mammogram is performed in the presence of symptoms or signs of breast disease, such as lumps, nipple discharge or bleeding. A physician or qualified nonphysician practitioner must order the exam, which Medicare covers as often as is medically necessary. A rule out diagnosis is insufficient for determining medical necessity and documentation must include a physician's interpretation of the results. If there are no significant findings, the diagnosis code will be assigned for the signs and symptoms that led to the order for the diagnostic mammogram

Sharp Dissection

A separation of tissues using a sharp instrument for cutting, such as a scalpel.

Incision

A surgical cut made into skin

Which statement does NOT fall within CMS requirements for electronic signature in the hospital medical record?

A system in which a physician allows the nurse to review the documentation and signs off on the documentation with the provider's key code.

Surgeons

All surgeons involved with the procedure should be listed, including the primary surgeon, co-surgeons, and assistant surgeons. For surgical procedures with more than one surgeon, the primary surgeon is responsible for the procedural note. A resident, intern, or assistant can dictate the note, but the primary surgeon must indicate agreement by reading and signing it. Do not confuse co-surgeons with assistant surgeons. Co-surgeons, usually called in to handle an area of expertise, have shared responsibility in the procedure and must document their involvement. Co-surgeons must dictate their own operative note showing their specific involvement in the procedure(s). Assistant surgeons provide assistance when needed under the guidance of the surgeon. They do not dictate a separate note. When co-surgeons dictate a portion of the procedure, they should make clear at what point they became involved, such as, "I, Dr. A, performed an abdominal hysterectomy and then proceeded with a resection of the rectum and colon and performed a colostomy. After finishing, I turned it over to Dr. B, who removed the bladder and transplanted the ureters." Due to the complex nature of some surgeries that require the expertise of several co-surgeons, the dictation can become very complicated. The best way to handle such a situation is for one of the surgeons to be placed in charge of the overall dictation. That surgeon then gives an overview of the entire procedure describing each surgeon's role and how that role fits into the procedure. Each surgeon then dictates his or her involvement in the procedure in descriptive terms in a separate operative report.

AAAASF

American Association for Accreditation of Ambulatory Surgery Facilities

What is the term for two hollow organs joined together surgically?

Anastomosis

Unusual Services

Any time a procedure involves services that are unusual or unique, they should be documented in the patient record with an explanation of why the procedure was unusual. For instance, did the procedure involve dissecting extensive adhesions, or was unusual anatomy discovered? If the unusual circumstance involved a nonstandard approach or unique way of accomplishing the procedure, that information should be documented. When dictating unusual services, the physician should state the procedure was unusual and explain how it compares to the same procedure under normal circumstances. Usually this is documented in a separate paragraph in the body of the operative report, so that you or the payer can identify it.

Signature

As with other types of services, if dictation is the method used to document an operative report, the surgeon must read the transcription before signing it. The transcription may contain inaccuracies and spelling errors. To ensure this does not become part of the patient's permanent medical record, the physician must read the transcription completely before signing. The transcription is not official until signed; therefore, changes can be made prior to a signature. A copy should also go into the patient's clinic chart so that two separate copies are maintained; thus, making cross-referencing easier. Dictation should be completed as soon as possible after the procedure. The longer the time lapses, the greater the chance that details will be lost. Although it is preferable for the primary surgeon to dictate the report, an assistant or a resident may provide the dictation. When this occurs, the primary surgeon must be involved. The physician should carefully read the report to make sure nothing is missing and actively monitor it for statements about unusual procedures. The primary surgeon must sign the operative report.

Additional Studies

Based on findings from a routine X-ray exam, a radiologist may feel further studies are warranted. For example, a radiologist may elect to do a tomogram on a patient whose chest X-ray revealed a mass. The documentation must indicate that the existence of the mass establishes the medical necessity for further studies. In such a situation, the radiologist is usually not required to check with the ordering provider before proceeding with additional studies, except when Medicare is the primary payer; Medicare does require going back to the ordering/treating physician.

C

Celsius

CAMAC

Comprehensive Accreditation Manual for Ambulatory Care

CAMH

Comprehensive Accreditation Manual for Hospitals

CfC

Conditions for Coverage

CoP

Conditions of Participation

What step should you take if there is a discrepancy between the operative report and the procedure listed in the Procedure Title?

Consult with the physician who performed the service.

The physician or other person collecting the specimen should also note the following:

Dimension of specimen(s) Source of specimen(s) (where on body) Type of tissue(s) Color of specimen(s) Foreign body(ies) Drug(s) or antibiotic(s) used by patient

Discharge Information

Discharge summary providing information facilitating continuity of care with the following information documented: £ Reason for hospitalization or care £ Significant findings £ Procedure, care, and/or treatment provided £ Patient's condition at discharge £ Medications and/or the services prescribed £ Instructions to patient and/or family for immediate care when discharged and follow up care, when necessary

Bisection

Division by cutting into two parts.

Electronic Signatures

Electronic signature systems use a code or other means to uniquely identify each physician having access to the system. The physician signs an electronic record by entering his or her code into the system.

F

Fahrenheit

All payers employ the same rules concerning coding and reimbursement. A. True B. False

False

Rubber stamps for signature authentication are NEVER allowed for Medicare claims. A. True B. False

False

Which Act imposes civil liability on any person or entity who submits a false claim?

False Claims Act

Combined Services

If a combination of services is performed in the same session for the patient, each should be separately documented in the written report, either delineated in the same report or described in separate reports the radiologist generates from each of the services provided.

Invasive/Interventional Radiology Procedures—

Invasive or interventional radiology procedures are radiological studies accompanied by an invasive surgical procedure. Examples include venogram, angiogram, transcatheter abscess drainage, and X-ray guided biopsies.

Anastomosis

Joining together, such as two hollow organs, two arteries, or two veins.

Signatures

Medicare requires a legible identity for services ordered and provided.

CERT

Medicare's Comprehensive Error Rate Testing

Indications

Noting indications helps establish the medical necessity of the procedure and gives a good foundation for coding. Include a brief history or summary with the cause for the surgical intervention.

SAMPLE DOCUMENTATION #1

Patient presented to ER with ETOH on breath. T-98.1F, HR-76, R-16, Hx of DM, CAD, AAOx3, skin: warm, D&I. Pt c/o pain in LLE due to fall off barstool. Interpretation: Patient presented to the Emergency Room with alcohol on breath. Temperature - 98.1 degrees Fahrenheit, Heart Rate- 76, Respirations 16, history of diabetes mellitus and coronary artery disease. Patient is awake, alert, and oriented to person, place, and time. Skin is warm, dry and intact. Patient complains of pain in left lower extremity due to fall off barstool.

SAMPLE DOCUMENTATION #2

Patient presents to the ED by ALS c/LOC. IV line started LAC c/18 G needle. One L NS given by IV bolus. EKG shows abnormal arrhythmia. Patient admitted to CCU. Interpretation: Patient presents to the emergency department by advanced life support (level of ambulance service) with loss of consciousness. Intravenous line started at the left antecubital fossa (inner crease of elbow) with 18 gauge needle. One liter of normal saline given by IV bolus (one liter infused rapidly). Electrocardiogram shows abnormal heart rhythm. Patient admitted to coronary cardiac unit.

To monitor reimbursement and coding patterns by providers, what do payers conduct?

Prepayment reviews, post-payment reviews, and audits

Blunt Dissection

Separating tissue with a finger or blunt instrument without cutting

Skin Grafting

Skin grafting is reported in square centimeters, but burns are often documented by percentage of total body surface area (TBSA) affected.

How are skin grafts measured?

Square centimeters

Resection

Surgical removal of a section or segment of an organ or body structure.

Excision

The act of cutting out; the surgical removal of all or part of a structure or organ.

Postoperative Condition

The condition of the patient at the completion of the surgery, as well as the disposition (postoperative location of the patient), should be documented in the operative report such as, "The patient is stable in a recovery room," or "The patient is critical in the intensive care unit").

Date and Time

The date and time should accompany all entries. Including the time of service is important so that the events of a patient's medical treatment can be reconstructed later.

Additional Information

The following elements should be included in the documentation where applicable: estimated blood loss (compared to the normal range); type and quantity of intraoperative fluids given such as, blood, saline, catheters, tubes or drains left in the patient, such as, intravenous lines, urinary catheters, or drainage systems. Also, include any foreign bodies intentionally left in the operative site.

Complications

The nature of the complication should be reported, as well as the amount of time taken, in relation to the length of the surgery. If one hour of a nine-hour surgery was spent dissecting adhesions, it should be stated in the documentation. Any intraoperative misadventure should be summarized in the complications section of the operative report. Specific information about the complications and the steps taken to deal with them belong in the body of the report. Some physicians feel that documenting a complication, unusual situation, or misadventure that could result in an unfavorable outcome only increases the risk of a malpractice suit. Attorneys may agree; however, not reporting these problems raises suspicion in the event of litigation.

Title of Procedure

The operative report must include a listing of all procedures performed, usually in chronological order. If eponyms are used, add a technical description to ensure proper understanding for anyone who may see the chart. An eponym is a name given to a diagnosis or procedure based on the name of a person. An example of a procedure is a McBride procedure, which is a type of bunion repair. Procedures performed by the anesthesiologist are also listed here. Do not code from this section but use it as a guide when reading the body of the procedure.

Postoperative Diagnosis

The postoperative diagnosis is a more definitive diagnosis, based on intraoperative findings. This diagnosis is the basis for ICD-10-CM code selection and must be supported in the body of the report

Preoperative Diagnosis

The preoperative diagnosis is often a presumed diagnosis, as findings during and after surgery can lead to a different postoperative diagnosis

Procedure in Detail (Body of report)

The procedure in detail constitutes the ultimate source of documentation for the procedure, and payers consider it the final resource for payment decisions. It should read like a step-by-step report of the operation and be as descriptive as possible, using phrases that reflect CPT® terminology. Include the structures and layers of tissues involved, as well as the length of all incisions and the size of all pertinent normal or abnormal structures. Eponyms do not provide sufficient information about the procedure and how it is performed. The description should include a report of any abnormalities or special circumstances, and most importantly, any complications or differences in approach.

Alternative Therapies

The report must indicate the patient was given adequate information to sign an informed consent, including information on alternative therapies. The alternative therapies are individually named in the consent form and state the risks and benefits of each one, along with a statement outlining the risks and benefits of the current surgery. The physician should note the patient indicated an understanding of the discussion.

Anesthesia and Anesthesiologist

The type of anesthesia used should be reported with the name of the anesthesiologist or nurse anesthetist. It is often helpful to note the anesthesia time as well.

abd

abdomen

AK

above the knee

APTT

activated partial thromboplastin time

ABS

active bowel sounds

ALS

advanced life support (frequently designates type of ambulance service taking patient to emergency department)

p.c.

after meals

p

after, per

AMA

against medical advice

AKA

also known as

ADH

antidiuretic hormone

When reviewing operative notes and before selecting a CPT® code for a procedure, it is important to note the that was used by the surgeon.

approach

ABG

arterial blood gas

ASHD

arteriosclerotic heart disease/atherosclerotic heart disease

ad lib

as desired

p.r.n.

as needed

AAOx3

awake, alert, and oriented to person, place, and time

BRP

bathroom privileges

bpm

beats per minute

ā

before

#

before a digit, means "number"; after a digit or digits means "pounds"

a.c.

before meals

BK

below the knee

BPH

benign prostatic hypertrophy

Bx

biopsy

BP

blood pressure

BS

blood sugar

BUN

blood urea nitrogen

BSA

body surface area

AU

both ears

OU

both eyes

p.o., per os

by mouth

per

by or through

cap

capsule

CO

cardiac output

cm

centimeter

CXR

chest X-ray

CC

chief complaint

c/o

complains of

Documentation criteria require that the medical record should be ___________________ and __________________ .

complete, legible

CAD

coronary artery disease

CCU

coronary care unit

CPK

creatinine phosphokinase

cc

cubic centimeter ( = milliliter (ml or mL))

DOA

dead on arrival

DM

diabetes mellitus

Dx

diagnosis

Appropriate documentation of lesion destruction consists of the following:

diagnosis(es), anatomic diagram indicating the site(s), size and number of lesions treated, the method of destruction, and any extenuating circumstances.

DC or D/C

discharge, discontinue

DP

dorsalis pedis

dsg

dressing

gtt

drops

D&I

dry & intact

q

each, every

ECG or EKG

electrocardiogram

EPs

elements of performance

ECU

emergency care unit

ED

emergency department

ER

emergency room

ETOH

ethyl alcohol

qh

every hour

FHT

fetal heart tones

fl oz

fluid ounce

The HIPAA Standards Office within CMS is responsible

for transactions and code sets, security, and identifiers for providers, insurers, and employers for use in electronic transactions

q.i.d.

four times a day

fx or Fx

fracture

gr

grain

g or Gm

gram

≥

greater than or equal to

HOB

head of bed

HR

heart rate

Ht

height

Hct

hematocrit

H&H

hematocrit & hemoglobin

Hgb

hemoglobin

h. or hr

hour

h.s.

hour of sleep

s.o.s.

if needed

STAT

immediately

HHS Office of Civil Rights (OCR) is responsible for

implementation and oversight of privacy regulations

IS

incentive spirometry

I&O

intake & output

ICU

intensive care unit

ID

intradermally

IM

intramuscularly

IT

intrathecal

IV

intravenous

KO

keep open

KVO

keep vein open

kg

kilogram

LAC

left antecubital space (frequent site for IV) (crease on inside of elbow)

AS

left ear

OS

left eye

LLE

left lower extremity

LLL

left lower lobe, left lower leg

LLQ

left lower quadrant

LUE

left upper extremity

LUL

left upper lobe

LUQ

left upper quadrant

≤

less than or equal to

L

liter

LOC

loss/ level of consciousness

MPAP

mean pulmonary artery pressure

mcg

microgram

mEq

milliequivalent

mg

milligram

ml

milliliter

mm

millimeter

Each page of the medical record should contain the patient's _________________or ________________

name, patient ID number

N&V

nausea & vomiting

noc

night

NTG

nitroglycerine

NKA

no known allergies

NKDA

no known drug allergies

NS

normal saline

NPO

nothing by mouth

ung

ointment

q.d.

once a day

OR

operating room

OOB

out of bed

OP

outpatient

pt

patient

PCN

penicillin

PR

per rectum

lb

pound

A service is considered diagnostic if

procedure is performed to aid in the assessment of a disease or medical condition. Some diagnostic tests include laboratory services, diagnostic X-rays, EKGs, pulmonary function studies, psychological tests, thyroid function tests, and other tests, to diagnose an illness or injury.

P

pulse

PERRLA

pupils equally round & reactive to light & accommodation

ROM

range of motion

In regard to X-rays, lab tests, and other ancillary services, documentation should include the _______________________________ and ______________________ of those services in the medical record.

reasons for, results

Screening mammography

refers to a radiographic procedure for the early detection of breast cancer in an asymptomatic woman. The exam includes a physician's interpretation of the results of the procedure and Medicare covers mammography provided to a woman at her direct request, without a physician's order.

R

respirations

RTC

return to clinic

RTO

return to office

RAC

right antecubital space (frequent site for IV)

AD

right ear

OD

right eye

RLE

right lower extremity

RLL

right lower lobe or right lower leg

RML

right middle lobe

RUL

right upper lobe

RUQ

right upper quadrant

R/O

rule out

SOB

short of breath

According to Medicare guidelines, dictated notes must be ______________________ by the physician before they are placed in the patient's chart.

signed

SC/subq/s.q.

subcutaneous

tbsp

tablespoon

tsp

teaspoon

T

temperature

Rx

therapy, treatment, or prescription

t.i.d.

three times a day

TKO

to keep open

top

topical

Tx

treatment

TCDB

turn, cough, deep breath

b.i.d.

twice a day

US

ultrasound

UA

urinalysis

VS

vital signs

vd

void

w/d

warm & dry

wk

week

Wt

weight

WDWN

well developed, well nourished

c

with

WNL

within normal limits

s

without or w/o

y.o.

years old