36C24219R0014-153.pdf

VA WESTERN NEW YORK HEALTHCARE SYSTEM

February 21, 2018 CENTER MEMORANDUM NO. 136-05

HEALTH INFORMATION MANAGEMENT

1. PURPOSE: To state VA Western New York Healthcare System (VAWNYHS) policy with regard to the adoption of the Center Medicare & Medicaid Management Services (CMS) 1997 Coding Guidelines. To ensure standard data collection for medical coding policy and procedures in the performance of both inpatient and outpatient services rendered. This memorandum applies to all Department/Services.

2. POLICY: It is the policy of the VAWNYHS to properly code pertinent diagnoses and procedures documented within each of Veteran’s medical record. Authoritative sources such as a the VHA Coding Guidelines Handbook/Coding Counsel, American Hospital Association (AHA), American Health Information Management Association (AHIMA), the American Association of professional coders (AAPC), the Centers for Medicare and Medicaid services (CMS), the National Center for Health Statistics, and the International Classification Of Diseases (ICD)/Coding Clinic and CPT manuals for guidance are referenced and utilized in code selection and assignment.

3. SCOPE: Clinical coding plays a vital role in the revenue cycle including Third Party and VERA, research, patient safety initiatives, healthcare quality measures, disease management, workload tracking and reporting. The level of E&M code reported will be supported by the clinical documentation in the patient's medical record. All providers and staff will follow current Common Procedural Terminology (CPT) coding conventions and current CMS and 1997 E&M Coding Guidelines.

4. RESPONSIBILITIES:

A. Clinical staff to include, but not limited to, physicians, surgeons, mid-level providers, psychologists, nurses and social workers are responsible for are responsible for:

1) Accurate and complete documentation of services rendered, including conditions and/or symptoms addressed, physical examination findings, assessment of the patient, treatment plans, as well as referrals for ancillary tests/procedures, according to the established medical record documentation guidelines and facility bylaws.

2) Documenting confirmed diagnoses into CPRS upon receipt of supportive diagnostic tests/procedures.

3) When documentation is missing or ambiguous provders are responsible for

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CENTER MEMORANDUM NO. 136-05

responding to queries made by Coding and/or Documentation Improvement staff in a timely manner, with supportive documentation entered into the health record as appropriate timely, no later than within 30 days.

B. The primary provider is responsible for the selection of the appropriate procedure and diagnostic codes for each encounter. Diagnosis and procedure codes selected must be supported by the documentation in the medical record in order to satisfy medicolegal requirements and to determine medical necessity.

C. Within the Health Information Management Department, coders are responsible for reviewing medical records and assigning a code to each pertinent diagnosis and procedure(s). This process is accomplished by utilizing ICD-10 CM, Physician’s CPT, and the Healthcare Common Procedure Coding System (HCPCS) coding manuals within the Clintegrity software. Coders are responsible for referencing and adhering to the VHA coding guidelines. If a critical element is missing (i.e., chief complaint), from the provider’s documentation, it is accorded responsibility to initiate a Physician Query Form in order to have the provider complete the needed/necessary information/documentation.

D. The Manager, Health Information Department, is responsible for ensuring that the functions of a clinical coding program are established, maintained, and supported at the VAMC.

5. DEFINITIONS:

A. E&M Codes: A subsection of CPT codes used to report patient evaluation and management services, such as those provided during outpatient office visits, inpatient hospital visits and consultative visits. Codes are based on type of visit and level of service rendered (based on medical documentation).

B. Established Patient: A patient who has received professional services from the same physician, the same specialty group, or the same healthcare system within the past three years.

C. New Patient: A patient who has not received any professional services from the same physician, the same specialty group or the same healthcare system within the past three years.

E. Consultations: A type of service provided by a physician whose advice regarding evaluation and management of a specific problem is requested in writing by another physician or other appropriate source. The consultant may initiate diagnostic or therapeutic services. The opinion rendered and services ordered/performed must be documented in the patient's medical record and communicated back to the requesting entity or providers relative to the patient's care. When coordination of care dominates more than 50 percent of the total visit, time spent with the patient can be considered the key or controlling factor to qualify for a particular level of E&M service. The provider must document either the total face-to-face time spent with the patient or the total unit/floor time spent (if inpatient), in addition to the time spent in coordination of care activities and the specific issues addressed.

F. Counseling: Discussion between the physician and the patient or family regarding more than 50 percent of the total visit, time spent with the patient can be considered the key or controlling factor to qualify for a particular level of E&M service.

The provider must document the total time spent with the patient, the time spent in counseling, and the specific issues discussed.

G. Face-to-Face Time: Time that the physician spends face-to-face with the patient and/or family in the office or other outpatient setting. This includes the time the physician spends in obtaining a history, performing an examination, assessing the patient's condition, planning treatment options, and counseling. Pre- and post- encounter time (such as reviewing records, arranging for further services, telephonic communications) are not included in the time component of E&M code selection in the outpatient setting.

H. Unit/Floor Time: Time that the physician spends on the patient's hospital unit and at the bedside rendering services for that patient. This includes the time in which the physician establishes and/or reviews the patient's chart, examines the patient, writes notes and communicates with other professionals and the patient's family.

6. PROCEDURES: The goals of the guidelines are to assist in the standard documentation by providers contained within the clinical medical record:

A. Definitions and documentation guidelines for the three key components of

Evaluation and Management services and for the visits which consist predominately of counseling or coordination of care. [History, examination and medical decision making].

The documentation of each patient encounter should include; reason for the encounter and relevant history and physical examination findings and prior diagnostic test results;

assessment and clinical impression or diagnosis; plan of care and date and identity of the provider. If not documented, the rationale for ordering diagnostic and ancillary services should be inferred. Include past and present pertinent diagnoses, health risk factors, patient progress and response to treatment and revision of diagnosis. Health record should substantiate the CPT evaluation and management coding by the documentation in the medical record.

B. It is the policy of the VAWNYHS to follow official coding guidelines for clinical classification systems such as, but not limited to, current editions of International Classification of Diseases – Clinical Modification/Procedure Coding System (ICD CM/PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Diagnostic and Statistical Manual of Mental Disorders (DSM), Coding Clinic and CPT Assistant.

C. Evaluation and Management (E&M) guidelines. The VAWNYHS will utilize the 1997 Documentation Guidelines for Evaluation and Management (E&M) Services, along with the information from the CPT manual, and other CMS and the American Medical Association (AMA) references, and the VHA coding guidelines, for assignment of E&M professional codes.

Type of Care Database Deadline

Inpatient Patient Treatment File (PTF) No later than the 7th calendar day following the patient's discharge/transfer/death per National.

Surgical VistA Surgical Package As soon after the surgery as possible - no later than 1 week from the date of surgery

Outpatient Appointment Management No later than 7 calendar days after the date of assignment.

Data not received timely may not be included in the facility’s workload statistics.

7. REPORTING: Through auditing, the procedure of review to evaluate the accuracy of information.

A. Internal audits performed by designated facility staff, VISN 2 individuals and/or contracted coding vendor/consultants with results provided to the National HIMS Office, facility Compliance, and local Leadership.

B. All services provided must be monitored for quality including, but not limited to completeness, timeliness and accuracy as established by local Medical Center Bylaws and in accordance with VHA Handbook 1907.01 and 1907.03.

C. Evaluation and Management Reason for change audit to assure 95% coding accuracy rate of providers.

D. Reason not billed audit to assure provider documentation, resident supervision and student documentation is standard has been met.

8. REFERENCES:

A. American Medical Association, HCPCS, current edition B. Ingenix Coder’s Desk Reference for Procedures, current edition C. Ingenix HCPCS Level II, current edition D. VHA Reasonable Charge and Billing Procedures Guide, current edition E. VHA Handbook for Coding Guidelines, current edition

9. RESCISSION: Center Memorandum 136-05 dated July 28, 2014

10. AUTOMATIC REVIEW DATE: February 1, 2021

11. FOLLOW-UP RESPONSIBILITY: HIMS Manager

//s// Michael J. Swartz, MPA, FACHE Interim Healthcare System Director VA Western New York Healthcare System

DISTRIBUTION: 1 copy each (00, 00QM, HIMS)