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Timothy Brundage

Documentation Tips: Teaching Interns and Residents

Posted on Mon, Mar 27, 2017
Documentation Tips: Teaching Interns and Residents

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

A countersignature by itself is insufficient for both documentation and billing purposes.

Acceptable Documentation

According to CMS, at minimum, the following documentation must be included when billing for services provided by the intern/resident with a teaching physician:
 

  • "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care."
  • "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
  • "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs.”

Unacceptable Documentation

Unacceptable documentation by a teaching physician includes the following examples with a countersignature:
 
  • “I saw and evaluated the patient”
  • “I reviewed the resident’s note and agree with the plan”
  • “Agree with the above...”
  • "Patient seen and evaluated...”
  • “Discussed with resident and agree with plan...”

Resources:
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Timothy Brundage, MD, CCDS, is a hospitalist at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: Vascular Intervention

Posted on Mon, Feb 13, 2017
Documentation Tip: Vascular Intervention

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

“Peripheral Vascular Disease” is a huge, non-specific bucket. Operative notes need specificity for coding purposes.

Vascular interventionalists need to document three things for coding specificity:

1. Specific vessel(s) involved.

a. Anatomical name and laterality (R/L)

  • Artery
  • Vein
  • Previous bypass graft

2. Type(s) of lesion(s) identified and addressed.

a. Stenosis/blockage due to arteriosclerosis, embolus or thrombus. Note: the same area of blockage may have more than one etiology or two different lesions with different etiologies that are corrected in the same operation.

b. Detailed operative note with specificity is necessary for coding.
  • Example #1: The surgeon first removed an embolus from an artery and then they stent the stenosis where the embolus lodged. The embolus and its removal should be documented as should the arteriosclerosis and its stenting.
  • Example #2: The surgeon first stents an arteriosclerotic lesion proximally and then removes a thrombus distally. The surgeon should document a detailed procedure note that would include the specificity listed above in order to capture the accurate code.

3. Consequences of the blockages:
  • Claudication
  • Ulcers
  • Gangrene, dry/ischemic

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Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: Heart Failure - Framingham Criteria

Posted on Wed, Aug 24, 2016
Documentation Tip: Heart Failure - Framingham Criteria

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

Reduce risk of denial for CHF admissions using the Framingham Criteria for CHF diagnosis.  

Document these each and every time along with the following:
 

  • Acute/Chronic (both)
  • Systolic/Diastolic (both)

Framingham Criteria:

Major
 
  • Acute pulmonary edema
  • Cardiomegaly
  • Hepatojugular reflex
  • Neck vein distension (JVD)
  • Paroxysmal nocturnal dyspnea or orthopnea
  • Rales
  • Third heart sound gallop

Minor
 
  • Ankle edema
  • Dyspnea on exertion (DOE)
  • Hepatomegaly
  • Nocturnal cough
  • Pleural effusion
  • Tachycardia (>120bpm)

* Heart failure is diagnosed when two major criteria or one major and two minor criteria are met.

Reference: http://www.aafp.org/



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: CMS Three-Day Rule

Posted on Mon, Jul 25, 2016
Documentation Tip: CMS Three-Day Rule

Our ongoing series of documentation tips for clinicians.

By Timothy Brundage, MD

The Centers for Medicare/Medicaid Services (CMS) 3 day rule necessitates that all outpatient diagnoses and treatments are pertinent to the inpatient admission for 72 hours prior to admission.

The 3 day rule allows for the inpatient diagnosis to be made using data gathered from EMS as well as the ER evaluation.

Case Example:
Patient has documentation to support worsening shortness of breath with respiratory distress and hypoxia (81% on room air) documented in the EMS and ER records. This data supports the pulmonologist’s diagnosis of acute respiratory failure that was documented on the pulmonary consultation, treated with nebs, steroids and oxygen.  
 

  • The diagnosis of acute respiratory failure can be made at the time of the admission using the information obtained up to 3 days prior to admission
  • This is a valid diagnosis and should be coded and included in the inpatient DRG assignment



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: The Verboten List

Posted on Mon, Jun 27, 2016

Our regular feature of documentation tips for clinicians.

By Timothy Brundage, MD

The following words should be removed from use when documenting in the medical record:
 

Remove Replace With
"Admit" Status is “inpatient” or “observation”
"Admission Orders" “Initial care orders”
“Delirium” - This term almost made the Hospital Acquired Conditions (HAC) list Consider if there is a causative reversible medical condition that would support the diagnosis of encephalopathy
“Urosepsis” “Sepsis due to UTI”
“Stable” condition Use “fair,” “guarded,” “serious,” “critical” to justify medical necessity
“VSS” or “AF” Must document ALL vital signs. This helps to justify medical necessity and also counts as a component of the PE for E&M coding
Symbols/Arrows ↓Na+ ≠ Hyponatremia
“Post-op” This may be misinterpreted as a complication
“CRI/CRF" “CKD stage 1-5”
“Closed head injury” or “CHI” NO codes exist for this, must be injury specific
“Sharp” debridement May not count as “excisional” depending on the rest of the documentation
“History of...” This is a V code with less severity of illness (SOI) and risk of mortality (ROM)
“Unresponsive” (no code) Unconscious codes to coma
“Altered Mental Status” or “AMS” “Encephalopathy” when clinically appropriate
 


Timothy Brundage

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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