Guide to clinical documentation, third edition

xiContents Part 1: Foundations of Documentation Medical Considerations of Documentation 2 Legal Considerations of Documentation 2 Health Insurance Portability and Accountability... Me

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Debra o · ull1van 5 GUIDE TO

THIRD EDITION

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GUIDE TO

Clinical

Documentation

T H I R D E D I T I O N

Debra D Sullivan, PhD, RN, PA-C

Lead Advanced Practice Provider Academic Urology and Urogynecology of Arizona Litchfield Park, AZ

Owner, Sullivan Consulting Services Medicolegal Consulting

Glendale, AZ

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Philadelphia, PA 19103

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As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo

changes The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted

standards at the time of publication The author(s), editors, and publisher are not responsible for errors or omissions or for consequences

from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book Any practice described in

this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that

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Library of Congress Cataloging-in-Publication Data

Names: Sullivan, Debra D., author.

Title: Guide to clinical documentation/Debra D Sullivan.

Description: Third edition | Philadelphia: F.A Davis Company, [2019] |

Includes bibliographical references and index.

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Dedication

When I think back to 2004, when the first edition of this book

was published, I think of a wonderful group of friends who

were there to celebrate with me As I anticipate the publication

of the third edition, almost all of those same wonderful friends

are still here, encouraging and supporting me, and cheering me

on to the finish line Sadly, my dear friend Candy left us much

too soon, and I miss her sweet presence more than words can

say The essence of her heart and soul is with me always For

the remaining STUB-C friends (Kent, Donna, Paige, Jeff,

John, Brianna, Justin, Tim, Carla, and Jeff), thanks for your

friendship, your love, and your constancy in my life through

the past two decades I couldn’t ask for a better group of people

to share life with! I hope there are many more decades to come!

Not only have I been blessed with these incredible friends, but

I am fortunate to have the most loving, caring, and supportive

husband any woman could hope for Greg is an unwavering

source of encouragement and inspires and challenges me to be

the best I can be He has stood beside me without complaint

through the days of writer’s block, looming deadlines,

malfunctioning computers, and the often-self-imposed frenzy

of my world He has the insight to know when to cheer me on,

when to make me take a break, and when to give me space I

am so grateful for his calming influence, his ability to make

me laugh and not take myself too seriously, and all he does

to keep things running smoothly in the Sullivan household

Thanks, Greg, for all this, and so much more And I promise

no fourth edition!

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Reviewers

Gilbert Boissonneault, PhD, PA-C, DFAAPA

Professor

Division of Physician Assistant Studies

Medical University of South Carolina

Charleston, SC

Elizabeth Brownlee, MPAS, PA-C

Physician Assistant, Assistant Professor

School of Physician Assistant Studies, College

Pat Kenney-Moore, EdD, PA-C

Associate Director/Academic Coordinator/Associate

Sara Haddow Liebel, MSA, PA-C

Education Director/Associate Professor

Physician Assistant Department, College

of Allied Health SciencesAugusta University

Augusta, GANicole Schmitz, DNP, APRN, PNP, CHSE

Assistant Professor

NursingMinnesota State University – MankatoMankato, MN

Emily K Sheff, CMSRN, FNP, BC

Assistant Professor

School of NursingMGH Institute of Health ProfessionsBoston, MA

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Acknowledgments

It is interesting to me how each edition of this book

has its own uniqueness I have worked at a different

place during the writing of each edition, and I hope

that has resulted in a deep layering of experience and

knowledge that makes each edition better I certainly

feel like each job change has enhanced my professional

practice and has enriched me as a person I have met

and worked with some extraordinary health-care

providers, and I have had valuable contributions from

so many of them

First, I would like to say thank you to my colleagues

at Academic Urology and Urogynecology of Arizona

I have had such encouragement and support from this

great group of people I am grateful to have learned from

so many outstanding health-care providers throughout

my more than 27 years in medicine I have benefitted

from the expertise of Jamie Bair, NP (cardiology);

Jennifer Nelson, PA-C (psychiatry); Steve Turner,

RN (hospice); Dr Richard Guthrie (palliative care);

and several outstanding hospitalists who wished to

remain nameless I’m thankful for a group of dedicated

Information Technology people who have helped me

navigate electronic medical records and who’ve answered

my questions with enthusiasm

I must take this opportunity to acknowledge

two incredible women who added so much to the

Document Library that we included in this edition

of the book: Madison Palmer, MMS, PA-C, not only

contributed the prenatal records, but she also provided

valuable assistance with content in the prenatal chapter

Larissa J. Bech, MSN, RN, FNP-C contributed the

pediatric records Without their contributions, the

prenatal and pediatric visit notes would not exist They

bring real-world knowledge and hands-on patient care experience where I would only have been able to read and write about what others do

There is a tremendous team of people at F A Davis who have been part of this project Even though he retired before this edition was published, my dear friend Andy McPhee was the driving (cajoling? bullying?) force behind the third edition I hope he is enjoying his much-deserved retirement and getting to write what he wants, when he wants, if he wants When Andy approached me about a third edition, one of the most anxiety-producing aspects of considering it was who would be the developmental editor because I had less-than-wonderful experiences on the two previous editions I need not have worried at all, as I have had the very good fortune to work with Stephanie Kelly, developmental editor extraordinaire! Stephanie’s knowledge of the process, her organizational skills, her sense of humor, and her hard work have made the journey so enjoyable, and she has my deepest gratitude

I’m also grateful for the guidance of and contributions from Melissa Duffield, Senior Acquisitions Editor;

George Lang, Director of Content Development;

Amelia Blevins, Developmental Editor for Digital Products; Megan Suermann, Content Project Manager;

Lori Bradshaw, Developmental Production Editor at S4Carlisle Publishing; and Robert Butler, Production Manager There’s probably not another publishing com-pany around that would have supported this project as

F A Davis has done, and I’m humbled and honored they chose to champion this book

—Debbie Sullivan

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Brief Contents

Part 1: Foundations of Documentation

Part II: Documentation Related to Outpatient Care

Part III: Documentation Related to Inpatient Care

Appendices

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Contents

Part 1: Foundations of Documentation

Medical Considerations of Documentation 2

Legal Considerations of Documentation 2

Health Insurance Portability and Accountability

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Chapter 2 The Comprehensive History and Physical Examination 23

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Contents | xiii

Part II: Documentation Related to Outpatient Care

Documentation of Perinatal and Postpartum Care 83

Pediatric Sports Preparticipation Physical Examination 106

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Documenting Preventive Care 126

Pre-operative Evaluation of Older Adults 162

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Noncompliance With Medical Treatment 179

Documenting Communications With Patients 183

Federal and State Regulations and Prescribing Authority 196

Controlled and Noncontrolled Substances 199

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Writing Prescriptions for Controlled Medications 201

Common Errors in Prescription Writing 202

Part III: Documentation Related to Inpatient Care

Admission History

Medical Admission History

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Contents | xvii

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Consult Note 266

Full Operative Report and Operative Note 271

Admitting and Discharge Diagnosis

Attending Physician, Primary Provider, and Consulting

Brief History, Pertinent Physical Examination Findings,

Disposition, Discharge Medications, Discharge Instructions,

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Appendices

Contents | xix

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Introduction

It’s no secret that medicine is constantly changing and

evolving, but I guess I didn’t realize that there have been

so many changes and evolutions in documentation until

I started working on the third edition Since the second

edition was published in 2011, there have been

signif-icant changes in coding, billing, reimbursable services,

federal requirements for documentation, platforms for

documentation, and so on And, thanks to the feedback

from users of this text and thoughtful reviews by

edu-cators and practitioners, the “wish list” of content for

this text has changed as well So, here you have it, the

third—and by far, the best—edition One thing that

has not changed is the basic principle of the book—this

is an instructional work on documentation and is not

meant to be an instructional work on the practice of

medicine Documentation and the practice of medicine

are interrelated, and it is sometimes a challenge to keep

them separate However, they are two distinctly

differ-ent practices As an educator, I teach As a Physician

Assistant, I practice medicine As an author, sometimes

I want to do both, but that has never been the goal

The goal is to provide a solid foundation of principles

of documentation that will preserve important aspects

of the health-care provider–patient encounter while

meeting the requirements for reimbursement and other

regulations There are many examples of

documenta-tion of various encounters throughout this book, and

each is just one example of how an encounter may be

documented There is not just one way to document

any encounter but many different ways; and different

doesn’t mean “good” and “bad”—just different I’m of

the opinion that the more examples you see, the more

you will learn and the more prepared you will be when

it comes time for you to document your way

Revisions started with the Table of Contents, which

has been expanded to highlight sections within the

chapters and to provide much more detail about the content New content includes Chapter 4, Documenting Prenatal Care and Perinatal Events, and Chapter 7, Older Adult Preventive Care Visits Some chapters were relocated within the text to present a more chronological sequence Every chapter was revised; some revisions were fairly minor, whereas others were extensive Medicolegal Alerts are included in each chapter to help highlight important concepts New to this edition are images of electronic medical record (EMR) entries, or screen shots

There are multiple EMR systems available, so what is presented may look different from what you’ve seen before, but I think it is helpful to see sample entries from different systems

Sometimes Appendices don’t get a lot of attention, but I hope you’ll check out Appendix A, the Document Library In the library, you’ll find documents that per-tain to a particular patient grouped together in a way that captures the patient’s care chronologically This provides a different perspective than seeing them as

“stand-alone” documents in multiple chapters

Many educators mentioned that they would like the worksheet answers moved out of the book so that they could be used more effectively as an educational tool,

so this was done You can find them in the Instructor’s Guide, at DavisPlus on the F.A Davis website, which will allow you to provide them to the students as you see fit—you can simply provide the answers so students can check their own work, or you can use the worksheets

as graded assignments

Whether you are a student, a novice practitioner, or an experienced provider, I hope this book will be a valuable resource in your journey of professional development

—Debbie Sullivan

Phoenix, Arizona

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Medicolegal Principles

of Documentation

LEARNING OUTCOMES

• Discuss medical and legal considerations of documentation

• Identify groups of people who may access medical records

• Identify general principles of documentation

• Discuss medical coding and billing

• Define the terms electronic medical records, meaningful use, and interoperability.

• Identify benefits of using electronic medical records

• Identify challenges and barriers to using electronic medical records

• Identify components of the Health Insurance Portability and Accountability Act

• Discuss principles of confidentiality

Introduction

You might be asking, “Why a book on documentation?”

Documentation is one of the most important skills a

health-care provider can learn You might feel tempted

to focus considerably more time and energy on learning

other skills, such as physical examination, suturing, or

pharmacotherapeutics These are essential skills, but

documentation is likewise extremely important State

licensure laws and regulations, accrediting bodies,

professional organizations, and federal reimbursement

programs all require that health-care providers maintain

a record for each of their patients

Documentation used to be mostly a memory aid

for the provider—a quick note of his or her thoughts

about a patient’s presentation, a likely diagnosis, maybe

a few words about the treatment plan Over the past

few decades, however, documentation has become a

more complex task due to changes in medicine and

with patients themselves Increased complexity in the

medical field is evident by the ever-increasing number

of medications and treatment modalities available to

health-care providers In addition, patients live longer

with a greater number of comorbid conditions, adding

to the complexity of caring for them and requiring that

complexity in the medical records The fact that our

so-ciety is so litigious certainly adds more weight to clinical

documentation and puts a greater burden on providers

to capture their thoughts and actions for others to read and interpret years after an episode of care took place

Dr Mitchell Cohen wrote about this evolution of

documentation in an article that appeared in Family Practice Management.* Dr Cohen explains:

From time to time I’ll stumble upon an old chart in my office that goes back 40 years My predecessors charted office visits on sheets of lined manila card stock, which would suffice for at least 15 to 20 visits Clearly, these charts were only intended for the physicians as a way to refresh their memory of what happened from one visit to the next For example, the documentation for one visit read simply, “1/20/67: pharyngitis >> penicillin.” These days chart notes are primarily not for the physician or patient, but for all the others who aren’t in the exam room and yet feel they have a stake in what takes place

in this once confidential arena To satisfy coders and insurers, my documentation for a 99213 sore throat visit must contain one to three elements of the history

of present illness, a pertinent review of systems, six to

11 elements of the physical exam, and low-complexity medical decision-making My malpractice carrier and

my future defense attorney would also like me to explain

my clinical rationale for why the patient has strep throat and not a retropharyngeal abscess or meningitis A table with a McIsaac score calculating the likelihood that this

PART I Foundations of Documentation

Chapter 1

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patient does indeed have strep throat might be nice as

well If I prescribe a weak narcotic for a really nasty

case of strep, the state medical board would be pleased

if I addressed what other medications have been tried

and whether the patient has any history of addiction

I’ll also need to document that I explained the proper

use of the medications and the need for follow up if the

patient doesn’t get better When I’m finally done with

my note, it looks like this:

CC: sore throat x 2d

HPI: 17 y/o F with 2d h/o sore throat Has an

asso-ciated headache and fever to 1018F No significant cough Patient has noticed some swollen lumps in neck Having significant pain despite use of Tylenol, ibuprofen and salt water gargles.

Social Hx: no h/o substance abuse or addiction.

ROS: denies neck stiffness or back pain, no rash No

difficulty speaking.

PE: VS: AF, VSS

Gen: alert, pleasant female in NAD

HEENT: NC/AT, PERRLA, EOMI, TM clear b/l,

OP notable for tonsillar enlargement with exudates

No asymmetry or uvular deviation present.

Neck: + tender anterior cervical adenopathy, no nuchal

rigidity or meningismus.

CV: RRR S1/S2 without murmurs.

C/L: CTAB

Abd: soft, nondistended, nontender, no hepatosplenomegaly.

McIsaac’s score = 4; Rapid strep +

A: streptococcal pharyngitis

P: 1) Pen VK 500 mg po TID x 10 days Discussed

risks of medication including allergic reaction and complications of not taking full course of antibiotics including rheumatic fever and valvular heart disease.

2) hydrocodone elixir q HS to help relieve pain

par-ticularly when trying to rest Has already tried acetaminophen and NSAID and will continue salt water gargles Follow up if no improvement in one week Have discussed other potential diagnoses and reviewed warning signs of retropharyngeal abscess and meningitis Patient agrees and understands plan.

Like I said, “pharyngitis >> penicillin.”

(*Used with permission of the American Academy of

Family Physicians)

Medical Considerations

As illustrated in the example, the medical record serves

to document the details of the patient’s complaint and

the medical evaluation and treatment The medical

record also serves other purposes and has audiences other than the patient and the health-care provider; it is

both a medical and a legal document The medical record

establishes your credibility as a health-care provider It

is important to remember that you are creating a record that other professionals will read; therefore, you should use professional language and include appropriate content Other readers will assume, rightly or wrongly, that you practice medicine in much the same way that you document If your documentation is sloppy, full

of errors, or incomplete, others will assume that is the way you practice Conversely, thorough, legible, and complete documentation will infer that you provide care in the same way, thus establishing your credibility

Some excellent providers simply do not have good umentation skills However, this is the exception rather than the rule It is very difficult to persuade those who read sloppy documentation that the person who wrote that way can, and did, provide good care

doc-Up-to-date and complete documentation is an essential component of quality patient care The medical record

is the primary means of communication between bers of the health-care team and facilitates continuity

mem-of care and communication among the prmem-ofessionals involved in a patient’s care Although many patients will have a primary care provider who provides most of their care, patients also may see specialists for specific problems Medical records are the vehicle for com-munication among members of the health-care team, and the medical record is the common storehouse for all information about the patient’s care and condition regardless of who is providing that care

Legal Considerations

As mentioned previously, all medical records are legal documents and are important for both the health-care provider and the patient, regardless of where the patient care takes place The most important legal functions of medical records are to provide evidence that appropriate care was given and to document the patient’s response to that care An often-quoted principle of documentation, which every health-care provider has probably heard, is that if it is not doc-umented, it was not done This is a fallacy because it

is impossible to capture with documentation every nuance of a patient–provider encounter, and it is im-possible to create a perfect record of every encounter

However, the principle behind the quote is important

in a legal context; there is a considerable time lapse between when events occur (and are documented) and when litigation occurs It may be anywhere from

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Chapter 1 Medicolegal Principles of Documentation | 3

2 to 7 years from the occurrence of an event until you

are called to give a sworn account of the event The

medical record is usually the only detailed record of

what actually occurred, and only what is written is

considered to have occurred You will not remember

the details of an event that happened 6 years ago; your

only memory aid will be the medical record As a legal

document, the medical record that you authored will be

made available to plaintiff attorneys, defense attorneys,

malpractice carriers, jurors, judges, and, most likely,

the patient You should keep this in mind at all times

when documenting

The record should be objective Personal, subjective

opinions regarding the patient, the patient’s family, or

other providers do not belong in the medical record It

is human nature to make value judgments about others,

but it is asking for trouble to note in a record those

irrelevant judgments about the patient Document facts;

not opinions All providers should strive for accuracy

in documentation Correcting a medical record is not

only encouraged, but it is necessary in order to avoid

potentially harmful mistakes or misrepresentations

Altering a record should never be done Alteration

con-notes an improper change, concealment, or omission of

portions of records that were written inappropriately

Correction implies the act of making something right

Record alterations have rendered many defensible cases

indefensible Most jurors will suspect that a provider

who alters records has done so to cover up a mistake

The opposing attorney will argue that alteration shows

consciousness of guilt Alterations in medical records

may give rise to a claim for punitive damages against a

provider Intentionally altering or destroying a patient’s

chart is considered unprofessional conduct Most states

will consider a practitioner who alters or destroys a

patient’s chart to have violated the applicable licensing

statute and will sanction or suspend the practitioner’s

license to practice medicine

Other Purposes

Reviewers from various organizations can obtain

access to a medical record for a variety of purposes

Health-care payers require reasonable documentation

for a number of reasons:

• To ensure that a service is consistent with the

pa-tient’s insurance coverage

• To validate the site of service, medical necessity,

and appropriateness of the diagnostic and/or

therapeutic services provided

• To confirm that services furnished were accurately

Researchers often obtain access to medical records for purposes of conducting scientific studies Although it

is important to remember that these audiences may have access to your records, you should keep in mind that the primary audience of the medical records will

be medical professionals involved in direct patient care

Throughout this book, you will analyze examples of documentation You may also complete the worksheets, which will help you apply the information as you read

it The purpose of this book is to teach documentation skills and critical analysis of medical records, not to instruct on the practice of medicine or to teach medical decision-making The content of a medical record—or

learning what to document—varies greatly, depending

on the patient’s presenting problem or condition The

principles of how to document and why documentation

is important do not vary as much and, thus, are the focus throughout this book

General Principles

The Centers for Medicare and Medicaid Services (CMS)

is one agency of the U.S Department of Health and Human Services (HHS) As one of the nation’s largest payers for health-care services, CMS has established specific guidelines for documentation that are referenced several times throughout this book There are two sets of documentation guidelines currently in use: the 1995 and the 1997 guidelines CMS published an evaluation and management guide in 2015; however, it was offered as a reference tool and did not replace the content found in the 1995 and 1997 guidelines There are minor differences between the two guidelines, and it is recommended that health-care providers refer to the guidelines to identify those differences Additional information may

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systems create a “digital footprint” every time a record

is accessed This digital footprint includes the date and time and the identity (typically name and title and/or role) of the person accessing the record The system also will indicate the time and date of any updates or changes made to the record You should never document

in a patient’s record in advance of seeing the patient In addition, you can correct or amend a patient’s medical record, but you should never alter it At times, it will

be necessary to make corrections to a record When making a correction in a paper record, you should draw

a single line through the text that is erroneous, initial and date the entry, and label it as an error If there is room, you may enter the correct text in the same area

of the note You should not write in the margins of a page; if there is no room to enter the correct text, use

an addendum to record the information You should never obliterate an original note, nor should you use correction fluid or tape In the EMR, once a document

is submitted, it is still possible to modify or correct the record If an entire entry is incorrect (for exam-ple, charting on the wrong patient), there is a process

to identify the entry as an erroneous document The process will vary with different EMR systems, and institutions will have their own policy for identifying erroneous entries

Based on your reading, complete the application exercise that follows

• Assessment, clinical impression, or diagnosis

• Plan for care

• Date and legible identity of the health-care

provider

3 If not documented, the rationale for ordering

diagnostic and other ancillary services should be

easily inferred

4 Past and present diagnoses should be accessible

to the treating and consulting providers

5 Appropriate health risk factors should be

identified

6 The patient’s progress, response to and changes

in treatment, and revision of diagnoses should be

documented

7 The diagnosis and treatment codes reported on

the health insurance claim form or billing

state-ment should be supported by the docustate-mentation

in the medical records (More discussion of

bill-ing and codbill-ing is included later in this chapter.)

There are other generally accepted principles of

documentation, such as that each entry should include

the date and time the record was created and should

identify the person creating the record In settings in

which care is provided around the clock, military time

is often used to avoid confusion between a.m and p.m

One o’clock in the afternoon is 1300, 10:30 at night is

2230, and so forth Electronic medical record (EMR)

Application Exercise 1.1

After seeing patient E H and documenting the encounter, you realize that you previously entered medications

and allergies for another patient in E H.’s chart Correct the record to show the correct medications as follows:

Zocor 20 mg daily, metformin 500 mg daily, Synthroid 0.125 mg daily

PMH: E H has a history of type 2 diabetes (diagnosed at age 41), hypothyroidism (diagnosed at age 37), and

hyperlipidemia (diagnosed at age 39) Surgical history includes tonsillectomy as a child and cholecystectomy at

age 42 Medications include Lasix 20 mg daily, Diovan 80 mg daily, warfarin 5 mg daily, and vitamin D, 2 capsules

daily Allergic to sulfa drugs Family history is positive for diabetes in mother and maternal grandmother and

heart disease in paternal grandfather

Application Exercise 1.1 Answer

PMH: E H has a history of type 2 diabetes (diagnosed at age 41); hypothyroidism (diagnosed at age 37), and hyperlipidemia (diagnosed at age 39) Surgical history includes tonsillectomy as a child and cholecystectomy at age 42 Medications include Lasix 20 mg daily, Diovan 80 mg daily, Warfarin 5 mg daily, and vitamin D, 2 capsules daily Allergic to sulfa drugs.

Family history is positive for diabetes in mother and maternal grandmother, and heart disease in paternal grandfather.

HUURUGV=RFRUPJGDLO\PHWIRUPLQPJGDLO\6\QWKURLGPJGDLO\

If using a ruled sheet such as an order sheet or

progress note, be sure that there are no blank lines

If a record is dictated and then transcribed, read the

transcription before signing it, correcting any errors in

the process You should not stamp a record “signed but

not read” or “dictated but not reviewed” because doing

so will call attention to the fact that you did not verify the content of the record

When entering the medical field, you must learn the language in order to function Part of learning this language

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with a hyphen The third category of CPT codes responds to emerging medical technology There are approximately 7,800 CPT codes, and the codes are updated annually

cor-Evaluation and Management Services

When a patient presents for care, you as the health-care provider evaluate the patient and then proceed to manage the presenting complaint That encounter between you and the patient may vary from brief to comprehen-sive depending on the patient’s chief complaint For example, the time required for evaluation of a child who presents with a sore throat is typically brief, and the management options are fairly straightforward

Conversely, more time is required for evaluating an older adult who has several chronic conditions and a new complaint of chest pain, and the evaluation and management process is more complex

CPT codes assigned for E/M services are mined by several factors One factor is whether the patient is new, established, or seen for consultation services, and another is the setting where care is provided Complexity of service is another factor and is determined by three key elements: history (including history of present illness [HPI]; review of systems [ROS]; and past medical, family, and social history [PMFSH], which are explored in Chapter 2), physical examination, and medical decision-making

deter-The complexity considers the presenting complaint, co-existing medical problems, amount of data to be reviewed (i.e., tests and old records), amount of time that you spend with the patient, number of diagnoses and treatment options, and risk for significant com-plications Table 1-1 summarizes the requirements for each level of E/M based on history, physical exam-ination, and complexity of medical decision-making

In the case where counseling and/or coordination

of care constitutes more than 50% of the encounter, time is considered the key or controlling factor to qualify for a particular level of E/M services This includes time spent with parties who have assumed responsibility for the care of or decision-making for the patient If you elect to report the level of service based on counseling and/or coordination of care, then you would document the total length of time of the encounter, and you should describe in the record the counseling and/or activities performed to coordinate care Counseling includes discussion of diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management options; instructions for management and/or follow-up;

importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education An example of documentation

of time spent with a patient is shown in Example 1.1

is to learn the meaning of the abbreviations, acronyms,

and symbols in use; therefore, they are incorporated in

this text Abbreviations are a convenience, a time saver,

a space saver, and a way of avoiding the possibility of

misspelled words Incorporating abbreviations is not

an endorsement of their legitimacy, but it is intended

to assist individuals in reading and understanding

medically related documents Sometimes abbreviations

are not understood They can be misread or interpreted

incorrectly For example, the abbreviation “CP” could

mean “chest pain” or “cerebral palsy.” Of course, the rest

of the entry should make clear the term for which the

abbreviation is being used There are variations in how

an abbreviation can be expressed “Anterior-posterior”

has been written as AP, A.P., A/P Abbreviations may

appear as all uppercase or all lowercase, and they may

or may not have periods after each letter (for example,

PRN, prn, P.R.N., meaning “as needed”) Many inherent

problems associated with abbreviations contribute to

or cause errors Health-care organizations should

for-mulate a “Do Not Use” list of dangerous abbreviations,

and you as the health-care provider are responsible for

complying with your institution’s policies regarding

use of abbreviations

Medical Coding and Billing

Concise documentation of the medical encounter is

critical to providing patients with quality care and to

ensuring accurate and timely reimbursement

Medi-cal records are subject to review by payers to validate

that the services provided were medically necessary

and were consistent with the individual’s insurance

coverage Standard codes are assigned to reflect the

health-care diagnosis, procedures, and medical

ser-vices provided and to create a uniform vocabulary

for claims processing, medical care review, medical

education, and research Two important code sets are

the Current Procedure Terminology (CPT) and the

International Classification of Diseases (ICD) codes

CPT codes are used to document many of the

med-ical procedures performed in a physician’s office This

code set is published and maintained by the American

Medical Association (AMA) CPT codes are five-digit

numeric codes that are divided into three categories

The first category is used most often, and it is divided

into six ranges that correspond to six major medical

fields: Evaluation and Management (E/M; discussed

in more detail next), Anesthesia, Surgery, Radiology,

Pathology and Laboratory, and Medicine The second

category of CPT codes corresponds to performance

measurement and, in some cases, laboratory or radiology

test results Typically, these five-digit, alphanumeric

codes are added to the end of a Category I CPT code

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Level of History HPI ROS PMFSH

Problem focused Brief (one to three elements) None None

Expanded problem

focused Brief (one to three elements) One system None

Detailed Extended (four or more

elements) Two to nine systems One pertinent PMFSH (one from any of the three)Comprehensive Extended (four or more

elements) 10 or more systems Complete PMFSH

Type of Physical

Examination Examination Description 1995 Guidelines 1997 Guidelines

Problem focused Limited to affected body area or

organ system One body area or organ system One to five bulleted itemsExpanded problem

focused Affected body area/organ system and other symptomatic or

related organ system(s)

Two to seven body areas

or organ systems Six to 11 bulleted itemsDetailed Affected body area/organ system

and other symptomatic or related organ system(s)

Two to seven body areas

or organ systems 12 to 17 bulleted items for two or more systemsComprehensive General multisystem Greater than eight body

areas or organ systems 18 or more for nine or more systems

Medical

Decision-Making Number of Treatment Options

Amount of Data (Diagnostic Studies, Prior Records)

Risk for Complications, Morbidity and/or Mortality

Straightforward One or less One or less Minimal

Moderate Three Three Moderate

High Four or more Four or more High

and Complexity of Medical Decision-Making

EXAMPLE 1.1

J.K is a 62-year-old established patient who comes

in to discuss use of cholesterol lowering medication

More than half of the time of the encounter was spent

providing patient education and counseling, and you

document the following:

A total of 15 minutes was spent face-to-face with the patient

during this encounter, and over half of that time was spent

on counseling We discussed in-depth the results of his most

recent labs, specifically high cholesterol and triglyceride levels,

his risk factors for coronar y disease (smoking, high cholesterol,

and family histor y), and the importance of primar y prevention

of coronar y disease with aggressive treatment of high

choles-terol I also educated the patient about lifestyle modifications

that may improve blood pressure and help lower cholesterol.

International Classification of Diseases

Coding

Whereas CPT codes indicate what services and procedures

were provided, the ICD codes explain the reason for the

services The ICD code is a diagnostic coding system

that classifies diseases and injuries and is used to track

mortality and morbidity statistics These standardized codes are used by national and international agencies and organizations to forecast health-care needs, evaluate facilities and services, review costs, and conduct studies

of trends in diseases over the years ICD was established

by the World Health Organization in the late 1940s and has been updated several times in the years since its inception The number following “ICD” represents which revision of the code is in use; therefore, “ICD-10”

represents the 10th revision ICD-10 has more than 155,000 codes and has the capacity to accommodate new diagnoses and procedures, expand descriptions of some diagnoses, and allow more detailed tracking of mortality and morbidity The ICD codes are updated every October; therefore, health-care providers and coding and billing personnel must ensure that they are using the most up-to-date code set

An ICD code is assigned to identify the diagnosis, symptom, condition, problem, complaint, or other reason for the encounter When assigning a diagnosis and code, you should be as descriptive as the data allow and use medical terminology rather than lay terminology For example, instead of documenting “runny nose,” you should use “rhinorrhea.” This does not work in every situation;

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The primary code would be abdominal pain (R10.10 if upper abdominal pain or R10.30 if lower abdominal pain)

4 Secondary codes are listed after the primary code and expand on the primary code or define the need for a higher level of service

• In the previous example, if the patient with abdominal pain has bloody vomitus, then hematemesis (K.92) would be coded as a secondary diagnosis

5 Code a chronic condition as often as applicable

to the patient’s condition

• Using example 3, the patient’s history of pression may not be pertinent to the complaint

de-of abdominal pain, so it would not be coded;

however, diabetes would be coded

6 Code co-existing conditions that may have an influence on the outcome

• In example 3, depression is a co-existing condition that may alter a patient’s percep-tion of abdominal pain The patient may take antidepressant medication, which could cause the pain Coding both the chronic condition ( diabetes) and co-existing condition (depres-sion) demonstrates the higher level of care needed to manage the patient

7 Do not use “rule out ” as a diagnosis

• There is no code for this Instead, use a diagnosis, symptom, condition, or problem

You may use “rule out” when documenting the assessment to guide you in your plan of care, although it is not necessary

8 Signs and symptoms that are routinely ated with a disease process should not be coded separately

associ-• An upper respiratory infection (URI) is ically associated with pharyngitis, rhinitis, and cough Pharyngitis, rhinitis, and cough each have a distinct ICD-10 code (J02.9, J00, and R05, respectively), but the code for URI (J06.9) is used because it encompasses these symptoms

typ-9 When the same condition is described as both acute and chronic, code both and use the acute code first

• A patient may have an acute exacerbation (J01.90) of chronic sinusitis (J32.9)

Accurate billing and coding is necessary to capture as much revenue as possible The information presented here is meant to be illustrative in nature and is by no means adequate treatment of the subject and should not

be relied on as authoritative Many excellent resources are readily available to assist those who desire more information on this topic

there is no medical term for “chest pain” when used as

a diagnosis, unless you know what is causing the chest

pain When claims are submitted for payment, both CPT

and ICD codes are provided, and your documentation

must support the level of service billed CPT codes work

in tandem with ICD codes to create a full picture of

the medical process for the payer; “this patient arrived

with these symptoms (as represented by ICD codes)

and these procedures were performed” (represented by

CPT codes) Downcoding is the process by which an

insurance company reduces the value of a procedure or

encounter and resulting reimbursement because either

(1) there is a mismatch of CPT code and description,

or (2) the ICD code does not justify the procedure or

level of service The quality and accuracy of the medical

record are vital to the reimbursement process, which, in

turn, is vital to the delivery of health care

Although getting paid is a very important issue for

health-care providers, you should never code for

re-imbursement purposes only This can be construed as

fraud Remember, your documentation must support the

level of service and the diagnoses reported

Good documentation is absolutely essential to support

the level of E/M services and facilitate assignment of

correct CPT and ICD codes Here are some key

con-cepts showing the interrelatedness of documentation

and codes and an illustrative example of each concept:

1 Any tests ordered must correlate with an ICD

code assigned to the visit

• If a urine pregnancy test is performed, a

rea-son for obtaining that test must be associated with a diagnosis, such as secondary amenor-rhea (N91.1), menometrorrhagia (N92.0), or abdominal pain (R10.10 if upper abdominal pain or R10.30 if lower abdominal pain)

2 Assign an ICD code that reflects the most

specific diagnosis that is known at the time

• A patient’s diagnosis is gastroenteritis (K52.9)

If it is reasonably certain that it is viral, use the code for viral gastroenteritis, A08.4 Suppose that the patient’s original complaint was di-arrhea (R19.7) The result of a stool culture is positive for shigella When the patient returns for a follow-up visit, then the diagnosis would

be enteritis, shigella (A03.9)

3 The primary code should reflect the patient’s

chief complaint or the reason for the encounter

• A patient with a history of depression and

diabetes presents with acute abdominal pain

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an electronic medical records system should be capable

A closer look at the intended functionality in each

of these eight areas identifies some of the perceived benefits of EMRs An electronic system would provide immediate access to key information, such as diagnoses, allergies, laboratory test results, and medications, that would improve the provider’s ability to make sound clinical decisions in a timely manner Result manage-ment would ensure that all providers participating in the care of a patient would have quick access to new and past test results, regardless of who ordered the tests, the geographic location of the ordering provider,

or when the tests were ordered or performed Order management would include the ability to enter and store orders for prescriptions, tests, and other services

in a computer-based system that would enhance ibility, reduce duplication, reduce fragmentation, and improve the speed with which orders are executed

leg-Using reminders, prompts, and alerts, computerized decision-support systems would improve compliance with best clinical practices, ensure regular screen-ings and other preventive practices, identify possible drug–drug or drug –disease interactions, and facilitate diagnoses and treatments Electronic communication and connectivity would provide efficient and secure communication among providers and patients that would improve the continuity of care, increase the timeliness

of diagnoses and treatments, and reduce the frequency

of adverse events Patients would be provided tools that give them access to their health records and interactive patient education and that would help them carry out home-monitoring and self-testing to improve control of chronic conditions Computerized administrative tools, such as scheduling systems, would improve hospitals’

and clinics’ efficiency and provide more timely service to patients Electronic data storage that employs uniform data standards will enable health-care providers and organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and epidemiological and disease surveillance Such data could be readily analyzed for medical audit, research, and quality assurance and could provide support for continuing medical education

Electronic prescribing, or e-prescribing, is a specialized function within a computerized medical record system

Electronic Medical Records

In just a decade, medical documentation has

transi-tioned from mostly paper records to mostly electronic

records Much of the stimulus for adoption of EMRs

is the increasing evidence that current systems are not

delivering sufficiently safe, high-quality, efficient, and

cost-effective health care According to HHS, 78%

of office-based physicians and 59% of hospitals use

a basic EMR system EMR lies at the center of any

computerized health system The EMR is a longitudinal

electronic record of patient health information

gen-erated by one or more encounters in any care delivery

setting Several interchangeable terms may be used for

EMR, such as electronic health record (EHR), electronic

patient record (EPR), and computer-based patient record

(CPR) A more comprehensive definition of EMR is

provided by the 1997 Institute of Medicine report, The

Computer-Based Patient Record: An Essential Technology

for Health Care:

A patient record system is a type of clinical information

system, which is dedicated to collecting, storing,

ma-nipulating, and making available clinical information

important to the delivery of patient care The central

focus of such systems is clinical data and not financial

or billing information Such systems may be limited in

their scope to a single area of clinical information (e.g.,

dedicated to laboratory data), or they may be comprehensive

and cover virtually every facet of clinical information

pertinent to patient care (e.g., computer-based patient

records systems).

The electronic storage of clinical information will create

the potential for computer-based tools to help providers

significantly enhance the quality of medical care and

increase the efficiency of medical practice These tools

may include reminder systems that identify patients

who are due for preventive care interventions, alerting

systems that detect contraindications among prescribed

medications, and coding systems that facilitate the

selection of correct codes for patient encounters The

potential of such tools will not be realized, however, if

the EMR is just a set of textual documents stored in

a computer, that is, a “word- processed” patient chart

To support intelligent and useful tools, the EMR must

have a systematic internal model of the information

it contains and must support the efficient capture of

clinical information in a manner consistent with this

model

Benefits of Electronic Medical Records

A 2003 report by the Institute of Medicine, Key

Capa-bilities of an Electronic Health Record System, identified

a set of eight core health-care delivery functions that

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such as patient records, cannot easily be shared across and sometimes within enterprises There are signifi-cant barriers to achieving interoperability Incredibly, there are over 1,000 EMR platforms on the market

Most of these systems are highly proprietary and may not communicate well with each other This lack of interoperability presents a barrier to the transparent communication of health information, preventing adequate coordination of care on the small scale and obstructing population health management on a larger scale There is no standard technical language shared between systems; hence, there is little or no integra-tion with other applications, nor is there the ability

of different systems to communicate in a meaningful way with one another Information technologies were not initially designed with interoperability in mind, so rarely are structures in place to support it Currently used data storage systems are often proprietary, and access to these systems is difficult Implementation of interoperable health information systems may require a high degree of technical expertise not readily available

to individual providers or smaller health-care tions Standards of interoperability are only just being developed—after many health information technology systems have already been installed and implemented

organiza-Meeting standards of operability will be an important criterion for the certification of EMR systems that are being developed at this time

of EMR and for regional health information exchange

The Health Information Technology portion of ARRA contains information related to the Health Information Technology for Economic and Clinical Health Act ( HITECH); the HITECH Act offers financial incen-tives for health-care providers and hospitals that comply with the standards of “meaningful use.” To receive an incentive payment, providers have to show that they are

“meaningfully using” their certified EMR technology

by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records The HITECH Act imposes requirements for notification of a data breach related to unauthorized uses and disclosures of “unsecured protected health information” (PHI) These notification requirements are similar to many data breach laws at the state level related to personally identifiable financial information (e.g., banking and credit card data) Under

the HITECH Act, unsecured PHI essentially means

“unencrypted PHI.” In general, the Act requires that patients be notified of any unsecured breach If a breach

Specific legislation and regulations exist that dictate

the use of electronic prescribing This is discussed in

detail in Chapter 9

Barriers to Electronic Medical Records

Many perceived barriers have hampered widespread

implementation of EMRs Although numerous studies

have shown that most health-care providers believe that

use of EMRs will improve quality of care, reduce errors,

improve quality of practice, and increase practice

produc-tivity, there is resistance to adopting EMRs A number

of factors contribute to this, including well-publicized

EMR failures; limited computer literacy on the part of

providers; concerns over security, productivity, patient

satisfaction, and unreliable technology; and the

ab-sence of reputable research substantiating the benefits

of EMR Market and economic factors are a concern

Apart from the costs of hardware and software, there

is a tremendous cost in staff time and revenue when

switching from paper to electronic charts Ethical

and legal issues abound with concerns about safety

and security of systems and the ability to protect and

keep private confidential health information There is

even disagreement over who “owns” the data entered

into any system as well as debate about accessibility to

the data Technical matters, such as functionality, ease

of use, and customer support from vendors are other

barriers It is challenging enough to find an EMR

system that works for a single-provider ambulatory

care–based practice; it is another challenge altogether

to find a system that will work for large institutions

and serve the needs of diverse departments Providers

often complain that EMRs interfere with clinical

care, making interactions more impersonal and less

face-to-face while also degrading clinical documentation

Despite the huge investments that have been made in

new technology, there are conflicting opinions about

the value of EMRs and whether or not they will truly

help improve quality of care while decreasing costs A

recent study by Medical Economics indicated that 67%

of physicians are displeased with their EMR systems

Interoperability

Perhaps the biggest barrier to widespread adoption of

EMR is lack of interoperability A basic definition for

interoperability is the ability of two or more systems or

their components to exchange information and to use

the information that has been exchanged As it relates

specifically to EMRs, the Healthcare Information

and Management Systems Society (HIMSS) defines

interoperability as “the ability of health information

systems to work together within and across organizational

boundaries in order to advance the effective delivery of

health care for individuals and communities.” Without

interoperability, fundamental data and information,

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may be excluded for 18 months If a person had health insurance coverage before enrolling in a new health plan, the exclusion period may be reduced by the number

of months a person was insured, as long as there were

no significant breaks of 63 or more days of coverage

Title I has additional important provisions Pre-existing conditions do not apply to pregnancy or to a child en-rolled within 30 days of birth or adoption Insurers are required to renew coverage to all groups regardless of the health status of any group member Insurers may not establish any rule that discriminates based on the health status of an individual or his or her dependent, nor may they charge higher premiums or alter the level

of benefits For those individuals with their own vate health insurance plan, renewability is guaranteed

pri-Coverage cannot be terminated unless the premiums are not paid, fraud is committed against an insurer, the policy is terminated by the insured, the insured person moves outside the service area of a network plan, or the insurance is available only to members of that association and membership in the association is ended If the insur-ance company stops selling the policy, it must offer the insured another policy it sells in the same state Further details may be found at http://healthcare.findlaw.com/

patient-rights/hipaa-the-health-insurance-portability- and-accountability-act.html

Electronic Health-Care Transactions

Prior to implementation of HIPAA, it was estimated that about 400 different formats were being used to process health claims online Billing and other adminis-trative procedures were inconsistent and varied among health insurers, the government, and other entities This made it difficult for providers, hospitals, health plans, and health-care clearinghouses to process claims and perform other transactions electronically In an effort

to lower costs and improve efficiency, standards were developed to simplify the administration of health in-surance claims by requiring common formats adopted

as national standards under HIPAA The standards require that the same format is used to transmit the following health-related information:

• Claims and equivalent encounter information

• Claim status

• Payment and remittance advice

• Enrollment and disenrollment in a plan

• Eligibility for a plan

• Premium payment

• Referral certification and authorization

• Coordination of benefits

The Privacy Rule

Providers have an ethical and legal obligation to guard patients’ privacy Because of the requirements of

safe-impacts 500 patients or more, then HHS also must be

notified Notification will trigger posting the breaching

entity’s name on HHS’ website Under certain conditions,

local media also will need to be notified Furthermore,

notification is triggered whether the unsecured breach

occurred externally or internally

Health Insurance Portability

and Accountability Act

(HIPAA)

Confidentiality of medical records has always been a

concern for health-care providers Regardless of the

medium of storage, confidentiality of data contained in

the records will continue to be of utmost importance

With the emphasis on interoperability and the criteria

that define how EMR systems must be able to exchange

confidential medical information securely, a discussion

of the Health Insurance Portability and Accountability

Act (HIPAA, or the Act) is warranted

Enacted by Congress in 1996 to address a number

of issues affecting national health care, HIPAA is a

large and complex law continually subject to

revi-sions and amendments by legislative actions The Act

establishes standards, and timetables for adoption of

the standards, for electronic transfers of health data,

addressing growing public concern about privacy and

security of personal health data The primary goals of

the standards are (1) to combat fraud and abuse; (2) to

make health insurance more affordable and accessible;

(3) to simplify administration of health insurance claims

by requiring all entities to bill electronically using one

format; (4) to give patients more control of and access

to their health-care information; and (5) to protect

medical records and individually identifiable medical

information from unauthorized use or disclosure,

es-pecially in the burgeoning electronic age

Health Insurance Portability

The Health Insurance Portability provision of the Act

(Title I) improves the portability and continuity of

health insurance coverage for workers and their families

when they change or lose their jobs by limiting the

re-strictions that a group health plan can place on benefits

pertaining to a pre-existing condition A pre-existing

condition is a condition for which medical advice,

diag-nosis, care, or treatment was recommended or received

within the 6 months before the enrollment date for a

new health insurance plan Pre-existing conditions can

be excluded from health benefits for only 12 months

A person who did not enroll during the initial or open

enrollment period is considered a late enrollee, and

benefits for late enrollees with pre-existing conditions

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business associate, there must be an agreement that the PHI will be handled according to federal and state privacy laws Additionally, a CE may disclose PHI as required by law, such as reporting child abuse to state child welfare agencies Treatment covers a wide array of patient-related activities, including providing health care, coordinating services, referring patients, and consulting among providers Communication between CEs may take place using any method, including oral, written, electronic mail, or facsimile, as long as “reasonable and appropriate safeguards” are used to protect the information

Payment includes activities relating to financial aspects

of health care PHI can be used for billing and claim processing to obtain reimbursement and for utilization review Health-care operations include a wide range of administrative and management activities in which CEs engage These include case management and patient care, risk management, legal services, credentialing, quality assessments and outcomes development, guidelines and

protocol development, and training students Sensitive PHI includes information about certain conditions or

their associated treatment, such as HIV status, substance

abuse, or mental health conditions Use of PHI refers to internal use by the CE; disclosure refers to sharing of PHI

for external purposes Sensitive PHI may not be disclosed without a patient’s written authorization, except in certain circumstances, such as to a consultant who needs this information to assist in the patient’s health care

Consent Versus Authorization

Consent must be obtained from the patient at the first visit before any services are provided Patients must sign

a consent form stating that they have been notified

of the practice’s privacy policy, which explains that the practice may use and disclose PHI for treatment, payment, and health-care operations Consent needs to

be obtained only once and is valid until revoked by the patient in writing In an emergency situation, treatment may be rendered without consent, but consent should

be obtained as soon as possible afterward

For all other uses and disclosures, unless required

by law, specific authorization must be obtained from the patient detailing what PHI may be disclosed, to whom it may be disclosed, and an expiration date An authorization is needed to release PHI to life insurance companies and patients’ legal counsel A CE may not give or sell patients’ names for commercial or marketing purposes For example, a CE may not give or sell names

of allergy sufferers to pharmaceutical companies that market allergy products

Individual Rights

Patients have the right to review and obtain a copy of their medical records, except in certain circumstances

Exceptions to the rule are psychotherapy notes, information

transmitting sensitive health information electronically,

the Privacy Rule was written to protect the

confidenti-ality of individually identifiable health information The

rule limits the use and disclosure of certain individually

identifiable health information; gives patients the right

to access their medical records; restricts most disclosures

of health information to the minimum needed for

the intended purpose; and establishes safeguards and

restrictions regarding the use and disclosure of records

for certain public responsibilities such as public health,

research, and law enforcement Under the rule, improper

uses or disclosures may be subject to criminal or civil

sanctions prescribed in HIPAA Federal HIPAA

regu-lations do not pre-empt any state laws that are stronger

or more protective of consumers’ security and privacy

Protected Health Information

and Covered Entities

PHI relates to the past, present, or future physical or

mental health or condition of an individual; the provision

of health care to an individual; past, present, or future

payment for the provision of health care to an individual;

and information that identifies or could reasonably be

used to identify a protected individual This information

may be oral, electronic, paper, or any other form

Individ-ually identifiable health information includes such data

as name, Social Security number, patient identification

number (such as a medical record number), address,

demographic data, or any other information that could

reasonably allow a person to be identified

The Privacy Rule applies only to covered entities

(CEs) that transmit medical information electronically

There are three categories of CEs: (1) health-care

pro-viders, such as doctors, clinics, psychologists, dentists,

chiropractors, nursing homes, and pharmacies; (2) health

plans, including health maintenance organizations

(HMOs), health insurance companies, and government

programs that pay for health care, such as Medicare,

Medicaid, and the military and veterans’ health-care

programs; and (3) clearinghouses that electronically

transmit medical information, such as billing, claims,

enrollment, or eligibility verification

Use and Disclosure of Protected

Health Information

HIPAA has very prescriptive language for the use and

disclosure of PHI A CE may use or disclose PHI

without patient authorization for purposes of treatment,

payment, or its health-care operations This includes

dis-closures to its agents or to another CE, such as another

health-care provider Agents are business associates who

perform a function for the CE, such as dictation, legal

services, billing, and accounting, and are not subject

to the Privacy Rule When a CE discloses PHI to a

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health-care provider judges it to be in the patient’s best interest and as long as the patient has not restricted the release of information to that person.

however, the Privacy Rule specifies three circumstances when certain minors may obtain specified health care without parental consent:

• When state or other law does not require the consent of a parent before a minor can obtain a particular health-care service, and when the mi-nor consents to the health-care service Example:

A state law provides an adolescent the right to obtain mental health treatment without the con-sent of the parent, and the adolescent agrees to such treatment without the parent’s consent

• When a court determines, or other law rizes, someone other than the parent to make treatment decisions for a minor Example: A court may grant authority to an adult other than the parent to make health-care decisions for the mi-nor, such as a stepparent or guardian

autho-• When a parent agrees to a confidential ship between the minor and the physician Exam-ple: A physician asks the parent of a 16-year-old if the physician can talk with the child confidentially about a medical condition and the parent agrees

relation-Even in these circumstances, the Privacy Rule defers

to state or other laws that require, permit, or prohibit the CE to disclose to a parent, or provide the parent access to, a minor child’s PHI When the laws are un-clear, a licensed health-care professional may exercise professional judgment on whether to provide or deny parental access

When a health-care provider reasonably believes that disclosure of PHI to the personal representative who is authorized to make health-care decisions for

an individual may not be in the patient’s best interest, the provider may choose not to disclose, especially in situations in which abuse, neglect, and endangerment are suspected For example, if a physician reasonably believes that disclosing information about an incompetent older individual to the individual’s personal representative would endanger the patient, the Privacy Rule permits the physician to decline to make such disclosures

Notice of Privacy Practices

Covered entities are required to develop a privacy gram detailing how their practice complies with the

pro-compiled for lawsuits, and information that, in the

opin-ion of the health-care provider, may cause harm to the

patient or another individual A reasonable, cost-based

fee may be charged to cover expenses for copying and

postage If a medical summary of the record is requested,

the fee should be agreed on beforehand Patients also

have the right to request an amendment or correction

if they feel the record is inaccurate or incomplete and

may submit a written supplement to be included in their

record If the health-care provider declines the request,

the provider must do so in writing and allow the patient

to submit a statement of disagreement for inclusion

in the record However, the health-care provider must

allow the patient to submit a correction to be placed in

the medical record The CE also may include its own

rebuttal A health-care provider may require a patient

to come into the office during normal business hours

to access and inspect the record The provider also may

arrange to have someone present who can answer any

patient questions or concerns

Patients have a right to an accounting of certain PHI

disclosures by a CE The CE must be able to report who

the recipient was, when the disclosure was made, and

for what purpose the disclosure was made The maximal

accounting disclosure period is the 6 years preceding

the request Exceptions to this rule include disclosures

for treatment, payment, or health-care operations; to

the individual or their representative; pursuant to an

authorization; and for national security purposes

CEs must take reasonable steps to ensure the

con-fidentiality of communications with the patient The

record should demonstrate how the patient would

prefer to be contacted regarding PHI, including test

results, appointment reminders, or discussions regarding

his or her medical care The patient may request to be

contacted at an alternative address or telephone number

A health-care provider may share relevant information

with family, friends, or caregivers involved in a patient’s

health care as long as the patient does not object and

the provider feels it is in the patient’s best interest

In-formation may not be disclosed to a person not involved

in the patient’s health care, if disclosure is judged to be

inappropriate by the provider, or if the patient requests

nondisclosure When disclosing PHI, only the minimal

information needed by that particular person should

be disclosed; for example, a caregiver needs to know

which medications are to be taken, what activity and

dietary instructions are prescribed, and what changes in

condition to report Details about the patient’s diagnosis

and prognosis may not be necessary and should not be

disclosed unless requested by the patient or the patient’s

personal representative A family member or friend

who is not involved in the patient’s care may be told of

the patient’s condition—stable, guarded, critical—but

additional information may not be disclosed unless the

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on the Privacy Rule, to termination If an employee does not report observed or suspected violations to a supervisor or HIPAA officer, that employee may be subject to disciplinary action for failure to report

Although an individual may not sue anyone over a HIPAA violation, a CE may be liable for civil penalties

at the state level A CE’s failure to follow the rules and standards of the HIPAA regulations can result in civil penalties of up to $100 per violation with a cap of

$25,000 per year Criminal penalties for violations by individuals or CEs range from a $50,000 fine and up

to 1 year of imprisonment for knowingly obtaining or disclosing PHI to a $250,000 fine and up to 10 years of imprisonment if the offense is committed with intent

to sell, transfer, or use PHI for commercial purposes, personal gain, or malicious harm

Security Rule

Security standards were promulgated to protect tronic health information systems from improper access or alteration The confidentiality, integrity, and availability of electronic PHI must be protected when it is stored, maintained, or transmitted CEs are required to develop and implement administrative, physical, and technical safeguards to protect against reasonably anticipated threats of loss or disclosure by implementing appropriate policies and procedures

elec-Periodic security awareness and training of workforce members is required Administrative safeguards must

be in place to ensure the following:

• Properly authorized personnel have access only to the PHI they need to perform their job

• Prevention, detection, containment, and tion of security violations are undertaken, includ-ing sanctions against an employee who violates the privacy and security of PHI

correc-• A disaster recovery plan is outlined

• A process is in place to develop contracts with business associates that ensure they will safeguard PHI appropriately

Physical safeguards include measures that accomplish the following:

• Limiting physical access to PHI systems while ensuring properly authorized access, such as keeping computers, printers, and fax machines out of patient and high-traffic areas and installing locking doors and alarm systems

• Providing secure access to workstations, including guidelines on use of home systems, laptops, cell phones, and other portable or handheld electronic devices

• Establishing procedures for receipt and removal

of hardware and electronic media containing PHI

Privacy Rule The notice must be provided to patients

at or before their first encounter, or as soon as feasibly

possible in an emergency situation It must be posted in

a clear and prominent location at the practice site and

on its website, and a written copy should be furnished

to patients at their request Written acknowledgment of

receipt of the Notice of Privacy Practices by the patient is

desirable; however, a patient may refuse to sign it (often

in the mistaken belief that signing it means the patient

agrees with it), in which case the CE must document

the reason for failure to obtain acknowledgment by the

patient Each practice should have a HIPAA privacy

officer or a designated person who is knowledgeable

in the standards and rules A HIPAA attorney may be

consulted in questionable matters when disclosure is a

concern Table 1-2 shows the elements that should be

included in a privacy policy

Privacy Violations and Penalties

CEs should have policies and procedures in place

that describe sanctions for employees who commit

violations, such as accessing a medical record for any

purpose outside of treatment, payment, or health-care

operations; discussing PHI in public; failing to log off

or leaving a computer monitor on and unsecured; or

copying or compiling PHI with the intent to sell or

use it for personal or financial gain Depending on the

violation, disciplinary actions may range from a letter

in the employee’s file, to requiring additional training

The policy should outline the following:

1 Describe how PHI is used and disclosed

2 State the CE’s duty to protect PHI, to provide a

notice of its privacy practices, and to abide by the

terms in its notices

3 Describe patients’ rights to:

• Inspect and copy their PHI

• Request a restriction of their PHI by stating the

specific restriction and to whom it applies

• Request confidential communications from the

CE by alternative means or at an alternative location

• Request an amendment to their PHI

• Receive an accounting of certain disclosures

the CE has made

• Obtain a paper copy of the Notice of Patient

Privacy on their request

• Complain to the CE or to the secretary of

HHS if they believe their privacy rights have been violated

4 Provide a point of contact for further information

and for submitting complaints to:

• A practice’s designated HIPAA officer

• The secretary of HHS

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Practices may be audited for HIPAA compliance with

or without notice New rules and policies are frequently written, and CEs must be aware of and comply with these HHS and CMS websites should be monitored regularly for updates

Summary

The requirements for documentation of health-care vices have evolved over the past few decades Health-care records are both medical and legal documents and serve many purposes The complexity of documentation reflects the requirements of payers and regulatory agencies as well as the need for clear and concise communication among members of the health-care team Just as the practice of medicine is both an art and a science, the practice of documentation is as well Whether on paper or electronic based, records created by health-care providers must be timely and accurate and reflect good patient care, support coding and billing, and meet regulatory requirements Completing the worksheets that follow will allow you to reinforce the content of this chapter

ser-And be sure to review Appendix A, the Document Library, for full case examples of patient documentation

Technical safeguards must be in place that protect and

control access to PHI, such as the following:

• Verifying identity of a person or entity

• Allowing access only to people or software

pro-grams that have access rights (e.g., using

pass-words, electronic signatures)

• Auditing records and examining activity in

infor-mation systems that contain or use PHI

• Protecting PHI from improper modification or

destruction

• Preventing unauthorized access to PHI being

transmitted over an electronic communications

network (e.g., the Internet)

• Installing and regularly updating antivirus,

anti-spyware, and firewall software

Summary of the Act

A CE has the responsibility to develop and track a wide

variety of privacy and security processes and establish

policies and procedures to address all of the HIPAA

standards Employees must undergo periodic training

in privacy and security rules Risk analysis, monitoring,

and testing of information systems’ security are

essen-tial to ensure the confidenessen-tiality and integrity of data

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Worksheet 1.1

Name

General and Medicolegal Principles

1 In addition to other health-care providers, list five different types or groups of people who could read

medical records you create

2 List at least five general principles of documentation that are based on CMS guidelines.

3 Describe how to make a correction in a paper medical record.

4 Beside each of the following, indicate whether the statement is acceptable (A) or unacceptable (U)

according to generally accepted documentation guidelines

_ Use of either the 1995 or 1997 CMS guidelines _ Making a late entry in a chart or medical record _ Using correction fluid or tape to obliterate an entry in a record _ Making an entry in a record before seeing a patient

_ Altering an entry in a medical record _ Stamping a record “signed but not read”

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1 Indicate whether the following statements are true (T) or false (F).

_ CPT codes reflect the level of evaluation and management services provided

_ The three key elements of determining the level of service are history, review of systems, and physical examination

_ Time spent counseling the patient and the nature of the presenting problem are two factors that affect the level of service provided

_ ICD codes indicate the reason for patient services

_ The ICD-10 code set has more than 155,000 codes, but it does not have the capacity to accommodate new diagnoses and procedures

_ The medical record must include documentation that supports the assessment

_ Assignment of appropriate CPT and ICD codes that support the level of E/M services provided is dependent only on adequate documentation of the history and physical examination

_ An ICD code should be as broad and encompassing as possible

_ There is no code for “rule out.”

_ The complexity of medical decision-making takes into account the number of treatment options

2 ICD codes are used to identify which of the following? Underline all that apply.

Reason for office visit Level of service Conditions

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Electronic Medical Records

1 List at least five functions that an EMR system should be able to perform.

2 Identify at least five perceived benefits of an EMR system.

3 Identify at least five potential barriers to implementing an EMR system.

4 List at least two criteria required to meet “meaningful use” standards.

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Guide to clinical documentation, third edition

INSTRUCTED REGARDING BASIC NUTRITION/HYDRATION FOR THE TERMINALLY