CMS criteria for charting: Difference between revisions

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This page was created to assist EM providers with meeting Medicaid and Medicare standards. The object is to distill down the CMS guidelines into easy to follow steps to meet standards for proper billing.  
This page was created to assist EM providers with meeting Medicaid and Medicare standards. The object is to distill down the CMS guidelines into easy to follow steps to meet standards for proper billing.  
(
 


Background
Background
CMS recognizes 5 levels of care including "critical care".  
CMS recognizes 5 levels of care including "critical care".  


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Every chart requires a HPI w/ 4 of the eight descriptors listed here.  
Every chart requires a HPI w/ 4 of the eight descriptors listed here.  
-Location.
-Location.
-Quality.
-Quality.
-Severity.
-Severity.
-Duration.
-Duration.
-Timing.
-Timing.
-Context.
-Context.
-Modifying factors (alleviating vs aggravating).
-Modifying factors (alleviating vs aggravating).
-Associated signs and symptoms.  
-Associated signs and symptoms.  


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14 systems are recognized by CMS  
14 systems are recognized by CMS  
Const.                       Integument (skin and/or breasts).
 
Eyes.                       Neuro.
Const.
Ears,nose, mouth, throat.    Psych.
 
CV.                         Endo.
Eyes.  
Respiratory.                 Hematological/Lymphatic.
 
GI.                         Allergic/Immunological.
Ears,nose, mouth, throat.  
    
CV.
                     
Respiratory.  
             
GI.
                       
GU.
GU.
MSK.  
MSK.  
Integument (skin and/or breasts).
Neuro.
Psych.
Endo.
Hematological/Lymphatic.
Allergic/Immunological.


Lv 1-3 problem focused. Systems on pertinent to the complaint. 1-2 system review with one question per system.  
Lv 1-3 problem focused. Systems on pertinent to the complaint. 1-2 system review with one question per system.  
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''"All other systems reviewed and were negative"'' is permissible. Concerns about this statement;
''"All other systems reviewed and were negative"'' is permissible. Concerns about this statement;
-Assumes a full 14 system review.
-Assumes a full 14 system review.
-Questionable if defendable in court.
-Questionable if defendable in court.
-Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior, Berdahl, C., et al, ''JAMA'' Open, September 18, 2019
-Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior, Berdahl, C., et al, ''JAMA'' Open, September 18, 2019


Past, Family, Social History (PFSH).  
Past, Family, Social History (PFSH).  
Lv 1-4; at least one statement is required in order for CMS to consider the item documented.  
 
Lv 1-4; at least one statement is required in order for CMS to consider the item documented.
Lv5; requires two of the three mentioned to be documented.  
Lv5; requires two of the three mentioned to be documented.  


Physical Examination
Physical Examination
CMS recognizes 12 systems:
CMS recognizes 12 systems:
Const.                       Integument (skin and/or breasts).
 
Eyes.                       Neuro.
Const.  
Ears,nose, mouth, throat.   Psych.
                   
CV.                         Hematological/Lymphatic.
Eyes.
Respiratory.  
                     
GI.                       
Ears,nose, mouth, throat.
CV.
                     
Respiratory.
   
GI.  
                        
GU.
GU.
MSK.  
MSK.  
Integument (skin and/or breasts).
Neuro.
Psych.
Hematological/Lymphatic.


Requirements  
Requirements  
Lv1-3. problem focused exam.  
Lv1-3. problem focused exam.  
Lv4. 5-7 with a minimum of one element documented.
Lv4. 5-7 with a minimum of one element documented.
Lv5. 8 or more with minimum one element documented. (a medicolegally defensible chart would suggest a more comprehensive examination of relevant systems)
Lv5. 8 or more with minimum one element documented. (a medicolegally defensible chart would suggest a more comprehensive examination of relevant systems)


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Complexity matters.  
Complexity matters.  


4 types of medical decision making recognized.  
4 types of medical decision making recognized.
1. straightforward
1. straightforward
2. low complexity
2. low complexity
3. moderate complexity
3. moderate complexity
4. high complexity
4. high complexity


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For further guidance see MDM documentation and or Differential diagnosis documentation WikEM
For further guidance see MDM documentation and or Differential diagnosis documentation WikEM
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https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf


Special Thanks to The Center for Emergency Medical Education (CEME) EM Boot Camphttps://courses.ccme.org/course/embootcamp?gclid=Cj0KCQiAkNiMBhCxARIsAIDDKNVDk2xQgY-r8-28gaNGpRrhsd6QI3V3Np0AfEGLejLakpNtqfxY-z8aAvoTEALw_wcB
Special Thanks to The Center for Emergency Medical Education (CEME) EM Boot.
https://courses.ccme.org/course/embootcamp?gclid=Cj0KCQiAkNiMBhCxARIsAIDDKNVDk2xQgY-r8-28gaNGpRrhsd6QI3V3Np0AfEGLejLakpNtqfxY-z8aAvoTEALw_wcB

Revision as of 04:56, 19 November 2021

This page was created to assist EM providers with meeting Medicaid and Medicare standards. The object is to distill down the CMS guidelines into easy to follow steps to meet standards for proper billing.


Background

CMS recognizes 5 levels of care including "critical care".

Levels 1-3 are routine charting (ie CC, HPI, ROS, PE, MDM.) typically levels 1-3 do not or require minimal testing/imaging or resuscitation efforts. Medical decision making tends to be straightforward or low complexity.

Levels 4-5 and critical care require more complex medical decision making (ie moderate-complex),imaging studies, serial labs and resuscitation.

Charting requirements.

Every chart requires a chief complaint.

Every chart requires a HPI w/ 4 of the eight descriptors listed here. -Location.

-Quality.

-Severity.

-Duration.

-Timing.

-Context.

-Modifying factors (alleviating vs aggravating).

-Associated signs and symptoms.

ROS

14 systems are recognized by CMS

Const.

Eyes.

Ears,nose, mouth, throat.

CV.

Respiratory.

GI.

GU.

MSK.

Integument (skin and/or breasts).

Neuro.

Psych.

Endo.

Hematological/Lymphatic.

Allergic/Immunological.

Lv 1-3 problem focused. Systems on pertinent to the complaint. 1-2 system review with one question per system.

Lv 4 2-9 systems with one question per system.

Lv5 10 or more systems with one or more question per system listed

"All other systems reviewed and were negative" is permissible. Concerns about this statement;

-Assumes a full 14 system review.

-Questionable if defendable in court.

-Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior, Berdahl, C., et al, JAMA Open, September 18, 2019

Past, Family, Social History (PFSH).

Lv 1-4; at least one statement is required in order for CMS to consider the item documented.

Lv5; requires two of the three mentioned to be documented.

Physical Examination

CMS recognizes 12 systems:

Const.

Eyes.

Ears,nose, mouth, throat.

CV.

Respiratory.

GI.

GU.

MSK.

Integument (skin and/or breasts).

Neuro.

Psych.

Hematological/Lymphatic.

Requirements

Lv1-3. problem focused exam.

Lv4. 5-7 with a minimum of one element documented.

Lv5. 8 or more with minimum one element documented. (a medicolegally defensible chart would suggest a more comprehensive examination of relevant systems)

Medical decision making. Complexity matters.

4 types of medical decision making recognized.

1. straightforward

2. low complexity

3. moderate complexity

4. high complexity




For further guidance see MDM documentation and or Differential diagnosis documentation WikEM

References

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

Special Thanks to The Center for Emergency Medical Education (CEME) EM Boot. https://courses.ccme.org/course/embootcamp?gclid=Cj0KCQiAkNiMBhCxARIsAIDDKNVDk2xQgY-r8-28gaNGpRrhsd6QI3V3Np0AfEGLejLakpNtqfxY-z8aAvoTEALw_wcB

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