5 - The Framework for SMARText Documentation

The Framework for SMARText Documentation

and

E & M Coder

 

The framework for new generation documentation is in the on-line library of SMARText Items and Docuplates. No E&M Coder license is necessary to be able to utilize these tools. Learning and incorporating this framework of organization within documentation promises to greatly increase the value of the information within medical records. It is the first step toward turning the typical gobbIlty-goop of words (to the computer) into real data that can significantly improve the quality of care, practice efficiency, information access, and practice income.

Docuplates with the SMARText items used within the framework (and E&M coding) can be downloaded from the on-line SOAPware library. Search in the docuplate library using “EMC” as the search term. There will be several types of docuplates in the list. It is often wise to sort the list by clicking on "Description" at the top of its column. In early 2008, dates are often added to the end of the description. Select ones that have more recent dates in time.

Introduction:

SOAPware users can chose to have assistance determining the level of service within its encounter note documentation. Using the optional E&M coder, a wizard continually reports the complexity of history, exam and decision-making. This may simplify the process of determining the adequacy of documentation. It is simply another tool to assist the clinician with an often onerous task.

In SOAPware, go to the Menu bar; Tools;     E&M Coder to bring up the wizard to the far left below...

Note: We advise that levels of service be primarily determined by the nature of the visit and not how much documentation can be created. For example, if a patient comes in with a simple rash and no other problems or issues, then that is most likely going to be a level 3 visit, even though it is very easy to have documentation to support a higher level. Let the reason/nature of the visit determine the level you submit.

In the initial release of E&M Coder, exam scoring is based solely on the General Multi-Systems Exam. Support for the single systems exams (e.g. Cardio, ENT, etc.) are still in development.

Evaluation and Management codes, as designed by CMS and the AMA, have 5 levels of service (or level of complexity) for each type of patient encounter (new patient, established patient, consultations, initial hospital visit, subsequent hospital visit, ER encounter, etc.). The level of service (or evaluation and management code, E&M code) for encounters is determined by 3 categories:I. History;II. Exam; III. Decision Making. Each of these three main categories is separated into subcategories:

I.    History                    =     1. HPI*;                     2. Review of Systems;           3. PFS*

II.    Exam                     =     15 main categories and 54 specific items

III.     Decision Making   =     1. Diagnosis complexity;      2. Data/studies complexity;      3. Risk

*HPI = History of present illness.

*PFS = Past, Family, and Social (histories).

In order to justify a level of service for any/all levels of service, there must always be a chief complaint and at least one diagnosis. Until there is a Chief Complaint, a warning will be displayed at the top of the E&M Coder.

Subsequently, if a diagnosis hasn’t been entered, another warning is displayed.

Only after there is both a Chief Complaint and at least one diagnosis will E&M Coder begin to suggest levels of service

.

Following, is an outline as to how to determine the level of service:

 

Chief Complaint:     Yes?

Diagnosis:             Yes?

 

I.  HISTORY:

                         Total HPI Score: _____
                         Total ROS Score: _____
                         Total PFS Score: _____
                         Total History Score: _____

II.  EXAM:
                             Total Exam Score: _____

III.  DECISION MAKING:

Total Number of

Problems/Diagnoses Score:____
                     Total Data Score:____
                     Total Risk Score:____

                             Total Decision-Making Score: _____

Specific SMARText items must be incorporated into documentation in order to get assistance in determining level of service. This assistance is a potential time saver. It greatly reduces the need to count up individual scores, etc which is very difficult for busy clinicians. Following, are explanations of the structure and logic SOAPware uses to calculate the E&M codes as defined by CMS and the AMA. In order to get started, go to the menu bar;     Docuplates. (Or just press F6)...

 

 ...and download a docuplate that has “EMC” as one of the keywords. Type “EMC” into the search box and click on the search icon. For this discussion, it is assumed that users are able to search and retrieve docuplates from the library.

Here is a screen shot of a typical docuplate with description of “E&M Coding Outline”. Insert one of these into an encounter note to get started with E&M Coding. To insert this docuplate into an encounter, have an empty encounter open. In Docuplate Manager (i.e. F6), once you have the desired docuplate in view, click on the Insert button. The result should be an encounter note looking very similar to the following…

 

I.History - E&M Coding Systems Organization

Most of the history components for E&M coding are placed in the Subjective area of an encounter note. For this demonstration, we have entered a simple “E&M Coding Outline” docuplate into an empty encounter. For the E&M coder to work properly, it is necessary to place certain combinations of SMARText items into the subjective field. Below, is a picture of the headers for all the subjective SMARText Items that can contribute to the history scoring.

Note: Rarely are all of these utilized within any single, specific patent encounter. Therefore, “Remove Unused Items” automatically removes all the empty ones (the ones you do not address).

Actually, what you are viewing are the SMARText “Headers” for specific types of ST items. These are examples of the types SW uses to calculate the level of service. The following table shows some of the headers of these ST items in the first column and then displays some of the ST item’s other relationships.

CMS Description – These items arethe specific elements as defined by CMS.

Shortcut – This is a code-word that can be used to insert the item into medical record documentation. Also, they can usually be used in the search box in the ST Manager in order to find the ST item.

SMARText Item Type - By using specific ST Item types, the scoring wizard does not care where they are located in the subjective field and it does not matter what the wording of the headers and actual documentation actually looks like. Users can change the wording (i.e. items in blue below) without affecting the ability to calculate history scores.

 

Subjective Items Table:

SOAPware “Header”	CMS Description	Shortcut	SMARText Item Type
		Sxx
CHIEF COMPLAINT:	CHIEF COMPLAINT (CC)	ChiX	Chief Complaint
HPI:	(HPI = 8 sub-items)		HPI Item
			HPI Findings
LOCATION:	location	LocX	Location
QUALITY/COURSE:	quality	QuaX	Quality/Course
INTENSITY/SEVERITY:	severity	IntX	Intensity/Severity
DURATION:	duration	DurX	Duration
ONSET/TIMING:	timing	OnsX	Onset/Timing
CONTEXT/WHEN	context	ConX	Context/When
MODIFIERS/TREATMENTS	modifying factors	ModX	Modifiers/Treatment
SYMPTOMS/RELATED	Assoc. signs & symptoms	SymX	Symptoms/Related
ROS:	(ROS = 14 sub-items)
GEN - Constitutional:	Constitutional symptoms	ROSGENCon	GEN/Constitutional
GEN - Endocrine	Endocrine	ROSGenE	GEN/Endocrine
GEN - Allergic-Immunologic	Allergic/Immunologic	ROSGenHL	GEN/Allergic-Immunologic
GEN - Hematologic-Lymphatic	Hematologic/Lymphatic	ROSAllImm	GEN/Hematologic-Lymphatic
ENT:	Ears/Nose/Mouth/Throat	ROSHENT	ENT
Eyes:	Eyes	ROSeyes	Eyes
LUNGS/Respiratory:	Respiratory	ROSLUNGS	LUNGS/Respiratory
HEART/Cardiovascular:	Cardiovascular	ROSHEART	HEART/Cardiovascular
ABD/Gastrointestinal:	Gastrointestinal	ROSABD	ABD/Gastrointestinal
GENT/Genitourinary:	Genitourinary	ROSGENT	GENT/Genitourinary
BJE/Musculoskeletal:	Musculoskeletal	ROSBJE	BJE/Musculoskeletal
NEURO/Neurological:	Neurological	ROSNEURO	NEURO
PSYCH/Psychiatric:	Psychiatric	ROSPSYCH	PSYCH
SKIN/Integumentary:	Integumentary (+ breast)	ROSSKIN	SKIN/Integumentary

***Later, add info on getting to ST item list, etc.

***Later, demo “Remove Unused”

***Later, demo double-click + delete

So, each of these SMARText Item types, here, are visually identified (by clinicians within the actual patient charts) by its blue header. The wording of all these headers can be changed to reflect preferences. For example, CHIEF COMPLAINT: could be changed to REASON FOR VISIT: if that is the preferred wording. Also note that when printing or storing permanent documentation, most prefer the headers to be black rather than blue. Printing as all black ink can be specified either within SOAPware or within most printer software at the time of printing. Of course, this is not even an issue if you are using a monochrome printer only containing black ink.

***Later, demo change of header name

***Later, include examples of final documentation

So, each of these SOAPware Headers represents an element defined in the documentation guidelines from CMS. Clicking on one of these blue headers in a chart brings up a pick list of items for selection.

 

 

The next E&M coding history section is the History of Present Illness (HPI). In general, again, each time one of these headers is associated with information (by selecting an item in its pick list or typing into its comments section), then a point is added to the HPI score. For example, click on ONSET/TIMING:  and then select “3 days ago.”

In the previous screen shot, notice there is one HPI item and the E&M Coder indicates the HPI score of the same. In another example…

 

… this has an HPI score of 9. This may be a little confusing because there are only 8 HPI headers. The ST item with the header “SYMPTOMS/RELATED:” is a special exception in that it has a unique capability to add up to 3 ROS points, by way of adding 3 separate ST items, up to 3 times. In this example, it contains 2 items and so it adds 2 points to the HPI. Hopefully, it will be apparent that the maximal possible HPI score is thus 10. The maximum is reached when all 8 HPI items have associated information, and the last line has at least 3 separate items. Another example of where the last line would add 3 points would be the following.

 

SYMPTOMS/RELATED:  Abdominal pain, Anxiety, Bloating, Constipation.

The line above in the subjective field will add 3 HPI points to the History score because 3 separate ST items have been selected as sub-items of the ST item with a header of “SYMPTOMS/RELATED:”

Note - A level 4 visit must contain at least 2 of the 8 elements (SMARText HPI items) in the HPI section. A level 3 visit only has to contain 1 of these HPI elements.

Again - Each of the 8 HPI elements (other than SYMPTOMS/RELATED)can score only one point for each element, even though you may include more than one item of information. For example,

ONSET/TIMING: 3 days ago. Nocturnal.

and

ONSET/TIMING: 3 days ago.

both of these, above, add just one point even though the first item actually contains 2 data items.

Once the documentation is completed, any of the 8 HPI elements in the subjective field left blank can be automatically removed via the “Remove Unused Items” commands in the Subjective menu. This menu is obtained by right clicking on either the “Subjective” header or within an empty area within the subjective section. For example, note the following subjective field text:

 

ONSET/TIMING: 3 days ago. Nocturnal.

DURATION:

QUALITY/COURSE: Worsening.

 

After selecting the option “Remove Unused Items” it appears as

ONSET/TIMING: 3 days ago. Nocturnal.
QUALITY/COURSE: Worsening.


The " REVIEW OF SYSTEMS: " or ROS section contains 14 sections as defined by CMS. A level 4 visit, for example, must have at least 2 of the categories addressed as below:

ROS:

GEN- Constitutional:     Fatigue.

GEN - Endocrine:

GEN - Hematologic-Lymphatic:

GEN - Allergic-Immunologic:

HENT:

EYES:

LUNGS/Respiratory:

HEART/Cardiovascular:

ABD/Gastrointestinal:

GENT/Genitourinary:

Musculoskeletal (BJE):

NEURO/Neurological:     Vertigo.

PSYCH/Psychiatric:

SKIN/Integumentary:

 

If any data elements (one or many) is associated with any one of these ROS ST items, (i.e.“Vertigo.” that is included after ”NEURO/Neurological:” ), then one point is added to the History score within the ROS category. The previous example will adds 2 points to the ROS score (i. e. Fatigue =1 and Vertigo = 1).

 

 

PAST – FAMILY - SOCIAL (histories)

The PFS history information comes from specific sections of the medical summary. Most users prefer a chart layout that displays the summary on the left side of the SOAPware chart. Specific sections in the summary need to contain data elements in order for the coder to be able to add PSF points to the History Score. E&M coder checks to see if any of 3 groups of sections within the summary contain any data items.

Group #1-Past History, includes any information within any one of five sections

Active Problems

Inactive Problems

Surgeries

Medications

Allergies

Group #2 - Social History - Any information within Social History section

Group #3 - Family History - Any information within the Family History section

As noted in the introduction, PAST – FAMILY - SOCIAL history (PSF) can add up to 3 points to the history score. One point is added for each of the 3 groups, above, for any data items within them. Understanding the role of Social History and/or Family History sections is easy because any data in either one adds a point to the history score. So, if both Social History and Family History have any information, a total of 2 points arises.

For some reason, there are 5 other summary fields that are lumped together with the 3^rd, available scoring point. A single point is added if any one of 5 sections of the summary contain any information (Active Problems, Inactive Problems, Surgeries, Medications, and/or Allergies). CMS lumps all five of these sections into a single item (point) called Past History.

The final encounter documentation, which is either printed or stored, must include at least some information from these “summary” sections to justify any level of service above level 3. If a level of service above level 3 is selected, the document design utilized to create the final documentation (either printed or stored) will need to include some of these summary sections in addition to the 6 fields in the SOAP encounter notes.

Again, specific sections in the summary need to contain data elements to justify higher levels of service (i.e. greater than level 3 such as 99214).

History - Outline SOAPware E&M coder utilizes for determining the history component:

CHIEF COMPLAINT(Must be present and within Subjective section)

1 – History of Present Illness:(Within Subjective)

HPI:

ONSET/TIMING:(e.g. 3 days ago, nocturnal)

DURATION:(e.g. continuous, intermittent)

QUALITY/COURSE:(e.g. sharp, dull, worsening)

LOCATION:(e.g. bilateral, right)

INTENSITY/SEVERITY:(e.g. mild, severe)

CONTEXT/WHEN:(e.g. activity, stress)

MODIFIERS/TREATMENTS:(e.g. analgesics, cough)

SYMPTOMS/RELATED: (e.g. diaphoresis with chest pain)

 

Total HPI Score: _____

 

2 - REVIEW OF SYSTEMS:

ROS:(Within Subjective)

GEN:

Associated/Constitutional:

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

ENT:

Eyes:

LUNGS/Respiratory:

HEART/Cardiovascular:

ABD/Gastrointestinal:

GENT/Genitourinary:

BJE/Musculoskeletal:

SKIN/Integumentary:

NEURO:

PSYCH:

Total ROS Score: _____

3 - PAST-FAMILY-SOCIAL(Within Summary)

 

P -Active Problems | Inactive Problems | Surgeries | Medications | Allergies

F -Social History

S -Family History

Total PFS Score: _____

II.      EXAM     E&M Coding Systems Organization:


The exam documentation is entered into the objective section in SOAPware. There are 14 exam systems listed in the CMS/AMA documentation guidelines as shown in the first column, below.

CMS Exam Systems	Legacy SOAPware Exam Systems
1.Constitutional: 2.Lymphatic: 3.Ears, Nose, Mouth, & Throat: 4.Eyes: 5.Neck: 6.Respiratory: 7.Chest: 8.Cardiovascular: 9.Gastrointestinal (Abdomen): 10.Genitourinary: 11.Musculoskeletal: 12.Neurologic: 13.Psychiatric: 14.Skin:	1.GEN: 2.LYMPH: 3.HEENT: 4.EYES: 5.NECK: 6.LUNGS: 7.(CHEST)BREASTS: 8.HEART: 9.ABD: 10.GENT: 11.BJE: 12.NEURO: 13.PSYCH: 14.SKIN:

E&M coding = #14 “Systems”