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Copyright @ 2023 by the National Alliance of Medical Auditing Specialist, a division of DoctorsManagement, LLC Printed in the United States of America Additional copies of this book may be ordered by calling 877-418-5564 or visit the NAMAS store at namas.co No part of this publication may be reproduced, stored for mass use without licensure, transmitted, or used by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission of the publisher. All rights reserved. To request a license for distribution of this or any of the NAMAS products, please contact NAMAS at [email protected] or 877-418-5564 for more information. Sample

Preface Healthcare providers face many challenges. It seems that oftentimes a higher emphasis is placed on documentation and compliance than is placed on concerns related to medical malpractice and even patient care itself. We hope that we can help push through the tasks of documentation by streamlining efficiencies that allow compliance in revenue, while optimizing patient care. This manual is written NOT by a peer, a fellow clinician. Rather it is written by the auditor who is tasked with understanding how to “grade” the encounter, break it down, understand the components of it, and when components may be deficient, train for improvements. Clinical care is YOUR area of expertise… This is OUR area of expertise, OUR specialty, the area we should excel in the most. Coding and billing by virtue is always evolving as our rules shape and shift with changes in disease, technology, even politics, and sometimes it even seems with the wind; however, there are evergreen areas that are rarely changed. E&M has been one of those areas for some 25 years. However, that all changed in 2021. This training manual will take you through these changes. Our goal is to be a guide, and also to provide some handson skills development, if you›re up for the challenge. The focus of this manual is specifically office/clinic based E&M services focusing on the code set 99215-99202. This manual does, at times, discuss other code sets, but the core focus will be 99215-99202. Even more fundamentally, the key function of this manual is documentation. The purpose of this manual is to bridge the gap between the encounter and the documentation, and to assist the clinician in meeting our common goalCorrect Coding! Page | 01 Namas Provider Desk Reference Sample

Notice This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher and instructors are not engaged in rendering legal, accounting, or other professional services. If legal advice or other expert assistance is required, the services of a competent professional person should be sought. (From a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a Committee of Publishers). Unless otherwise noted, no part of this book or provided material may be reproduced, stored in a retrieval system, or transmitted, in part or in whole, in any form, or by any means, to include but not limited to: electronic, mechanical, photocopying, recording, or otherwise without prior written consent of the National Alliance of Medical Auditing Specialists, 10401 Kingston Pike Knoxville, TN 37922. NAMAS is a division of DoctorsManagement, LLC. This curriculum is designed to serve as training material produced and maintained by NAMAS. This curriculum should be used for the purpose intended only. Additional copies must be purchased from NAMAS. Neither the publisher nor any of the instructors of this program are under obligation to attendees to provide a free telephone consultation or free manual updates. If you have needs beyond the information communicated during the presentation, the publisher or the instructor may charge you for telephone consultation time or printed materials. The author and/or any instructor may not be held accountable for any advice given or work performed by any student of this course. The curriculum is designed to instruct the attendee on proper auditing, auditing technique, and documentation guidelines based on national standards. The authors and instructors cannot be held liable for how any attendee utilizes or self-interprets any material contained in the NAMAS curriculum. www.NAMAS.co All information contained in this manual is copyright and property of NAMAS, a division of DoctorsManagement, LLC. All rights reserved 2022. Page | 02 Namas Provider Desk Reference Sample

Page | 03 ABOUT THE AUTHOR Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA, Ms. DeConda is president and founder of the National Alliance of Medical Auditing Specialists (NAMAS), as well as Partner with DoctorsManagement, LLC. She has more than 20 years’ experience with auditing of all medical specialties, practice management, provider and employee education, marketing, leadership, consulting, credentialing, and managed care. She has spoken nationally on a myriad of health care topics- including, but not limited to: regulatory issues, evaluation and management services, coding compliance, and electronic health records. She is sought after as a consultant on a national scale, and as an advisor to several medical associations. Her articles have appeared in BC Advantage, Medical Notes, the Tennessee Medical Association’s Tennessee Medicine, and The Coding Institute’s Coding Alert newsletters. Ms. DeConda holds a Respiratory Therapist degree and is credentialed through the Professional Alliance of HealthCare Specialists as a CMCSC, and through AAPC as a Certified Professional Coder (CPC®), a PMCC instructor, a Certified Evaluation and Management Coder (CEMC™), and as a Certified Professional Medical Auditor (CPMA®). She is also credentialed through NAMAS as a Certified Evaluation and Management Auditor (CEMA) Ms. DeConda has the ability to take broad spectrum topics and complicated guidelines and teach them in a simplistic and easy to understand format. Namas Provider Desk Reference Sample

Page | 04 REFERENCES www.cms.gov www.cms.gov/FraudAbuseforProfs www.cms.gov/FraudAbuseforConsumers www.hhs.oig.gov www.hipaa.org http://starklaw.org www.jcrinc.com/Joint-Commision-Requirements www.emtla.com www.tricare.com http://oig.hhs.gov/organization/oas/ratstats.asp www.ama-assn.org/go/cpt http://pssc.aphanet.org/resources-glossary.htm oig.hhs.gov/fraud/cia/cia_list.asp www.health-care-compliance.com/corporate-integrity-agreement.htm www.decisionhealth.com Ferenc,D. (2005). Understanding Hospital Billing and Coding. USA: Saunders Elsevier. Grider, D. (2006). Coding with Modifiers. USA: American Medical Association. Grider, D. (2008). Medical Record Auditor. USA: American Medical Association. Ingenix. (2006). National Fee Analyzer. USA: Ingenix, Inc. Santana-Johnson, T., Giddens. J. (2001). Modifiers Made Easy. USA: Ingenix, Inc. Namas Provider Desk Reference Sample

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1. Chapter One The following chapter reviews the fundamentals of documentation. For providers the chapter addresses concerns that are often addressed through audits such as the use of templates and copy & paste. Additionally, in this chapter signing the note and the proper use of scribes will also be addressed. Medical Record Documentation Page 5 Documentation Techniques Page 6 Multiple Entries ‘Smart Documentation’ Page 7 Macros Page 8 Templates Page 9 Copy & Paste Page 10 Documentation Fundamentals page 11 Format Page 11 Generating Documentation Page 12 Late Entry Page 12 Signatures Page 13 Attestation Statements Page 13 Addendums & Corrections Page 14 Scribes in Practice page 15 Role Page 15 Scribe Attestation Page 16 Provider Attestation Page 16 The Medical Record: Guidance and Regulations Page | 05 Namas Provider Desk Reference Throughout this manual you will note that CMS is referenced as a “standard”. because they are. Most commercial carriers use them as such and have identified that they follow their guidance. Therefore, if your specialty is pediatrics and Medicare is not a carrier, or you have opted out of Medicare and only see commercial payors, these rules STILL APPLY as they are the standards of documentation practices. CMS as the Standard Sample

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While the focus of healthcare continues to push the electronic medical record through reduced reimbursement penalties, the provider still has the latitude to utilize the style of documentation they prefer. There are a variety of types of medical record documentation techniques, including: • Dictation or voice to text • Longhand • Handwritten templates • Electronic record via an EHR system All are acceptable forms of documentation; however, each must meet the appropriate medical documentation guidelines and support the medical necessity of all services billed. EMRs are prevalent in many healthcare organizations and settings across the country, but remember that not all practices have gone electronic. Medicare continues to add penalties for not using EHRs, but many practices nevertheless continue using paper charts. So, be prepared to audit any style of note. Dictation is a form of medical documentation that produces a typed note which may include templated or “canned” statements. Dictation in the modern era refers to the provider speaking aloud the content of the note, usually into a microphone, with the resulting speech transcribed into text by specially designed software. Dictation is also sometimes used within the electronic medical record, but in this instance, we are describing the use of dictation to create the entire note. Within dictated notes, templated statements are often used. Dictated templates are more patient and encounter-specific because the provider is dictating specifics for editing purposes. EHR templates are pre-populated and unfortunately are stand-alone templates that, if not edited, support very comprehensive exams. Templates are acceptable forms of documentation as long as they represent work the provider actually performed. One of the drawbacks of dictation is the timeliness of documentation for services performed. It is recommended that a brief summary of services rendered be documented as soon as possible in the patient’s Different Types of Medical Record Documentation Techniques Page | 06 Namas Provider Desk Reference AMA CPT states that the main purpose of documentation is to support care of the patient by current and future health care team(s). Yet ironically, the responsibility of AMA is also creating and maintaining a coding system that includes active descriptions of the work to be expressed by the code that are then translated into RVU assignments that impact claim payment. The mechanics of these codes can at times be used to the detriment of the provider as well. Therefore, we must work together to have a better understanding of how guidelines and reimbursement- while distinct, also parallel as they work together to demonstrate the complexities of the patient’s health history. Medical record documentation must be addressed on both criteria while keeping in mind the variances as well: • Chronicling the patient›s health history for continuity of care o Chronicling the coded work in the form of documentation to substantiate services rendered • Communication regarding the patient’s overall health to other providers o Communication of the complexity and/or acuity of the patient’s condition to validate the coded work Realistically, documentation should be created in mirroring efforts of coding/billing as it is to the patient and care providers. It is apparent that arduous interpretations of the documentation guidelines over the past twenty five years has created a mind set fixed on the volume of documentation as opposed to the quality of the documentation, or that the treatment provided defines the prevailing level of service. This unfortunate misinterpretation has led to recoupments for years, and if not addressed will continue to be a misrepresentation of 2021 Documentation Guidelines as well. At-Will Employment Statement Sample

At times a provider may find it necessary to refer to other areas of the chart for reference purposes. This practice was more relevant prior to the adaptation of electronic documentation, although it is still used today for things such as placing orders for diagnostic services relevant to the encounter. References separate from the current encounter documentation include a medication reference form, immunization forms, or master history sheet. Each of these records are separate, however the provider has the ability to link them together within the documentation of the encounter, thereby bridging them together. Linking can be effectively achieved by including a statement in the main medical record such as “please see the attached immunization record for vaccines administered today.” Such a statement effectively leads the reader of the encounter to the additional documentation for proper identification of the exact dosage, site of injection, etc. Without the supporting documentation, the main record is incomplete. WIthout the link to bridge these two records together, there is no connection for staff or any other reader of the note to expect to find additional information located elsewhere. If only the main medical record is sent a carrier may have no other choice than to down-code or deny the service. Multiple Medical Record Entries Smart Documentation is best defined as efficiencies in documentation. These shortcuts have always existed- just in varying forms. With dictation, our providers used verbal cues to the transcriptions to add-in blocks of “normals” into the encounter. Handwritten notes included check-mark templates, and at present, EMRs are riddled with savvy integrations to make the documentation process streamlined and efficient. There is nothing wrong with creating efficiencies to the task of documentation, provided the quality of the interaction is intact demonstrating the complexity of care provided. The use of smart documentation often leads to documentation that is erratic and disjointed which leads to an encounter with a lack of complexity of care. For this reason, CMS and OIG have consistently noted problematic concerns with EMR efficiencies. Unfortunately, their notations do not point out the misgivings as erroneous use, but rather they make a leap to the use of such tools and the ease these efficiencies allow to create erroneous and fraudulent documentation. This is noted in such excerpts as below: According to the OIG January 2014 OEI00571-11-01- Report, two types of EHR usage have been identified as problematic and that is “Copy-Pasting” (cloning) and “over documentation.” Here is what the report states: • “Copy-Pasting: Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians’ copy-paste information but fail to “Smart” Documentation Page | 07 Namas Provider Desk Reference record as a placeholder until the complete documentation is dictated or otherwise captured. This ensures that some “proof” of the encounter will remain in case of any error with the dictation. Handwritten notes, while becoming extinct, are still used by some providers. Handwritten notes can be very tedious to audit. Let’s face it, providers are often in a hurry and it’s hard to keep handwriting legible all the time. Unfortunately, illegible documentation may count as no documentation at all. This may result in a financial loss to the provider. CMS does allow providers to dictate for legibility in instances of illegible documentation; however, keep in mind the time delay that may result for the purposes of billing and processing these claims. Sample

update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copypasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims. • Over Documentation: Over Documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing high level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.” CMS and AMA, aware of concerns that efficient documentation could be prompting providers to document work not actually performed or work performed by a provider previously, have been some of the reasons for the revision of E&M Documentation Guideline changes in 2021 for 99215-99201. The relaxations in the office space are said to be spreading to the other places of services beginning in 2023 as well, but the focus of this manual is the use of the code set 99215 -99202. As we look to these changes, efficiencies are STILL ALLOWED to be used, however more commonly than not- they are not often required for the same reasons they once were. Below, let’s identify the efficiency, discuss why it was an invaluable tool prior to 2021, and address it’s functionality or lack thereof in current documentation practice. Definition: A command that generates a predefined statement/finding for documentation purposes. Efficiency Provided: Statements or phrases that are used frequently by a provider can be created into a MACRO for quick incorporation into the encounter. Published Guidance: CMS indicates that the use of a MACRO is allowed within documentation, in the “Program Integrity Issues in Electronic Health Records”: “Templates, Macros, and Population via Default Some EHR systems use templates that complete forms by checking a box, macros that fill in information by typing a key word, or functions that auto-populate un-entered text. Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient’s condition and services. These features may encourage over-documentation to meet reimbursement requirements even when services are not medically necessary or never delivered.” Macros Current Documentation Practice: The key to a compliant macro is ensuring that it is appropriate, applicable, and updated to be relevant to the patient encounter. Our providers must understand that they must always review and update a macro, and that macros should be created with this in mind. Below is an example and note the options in italics for the provider to select, along with a reminder to have the attending input additional information at their discretion. Page | 08 Namas Provider Desk Reference Sample

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Page | 17 CHAPTER 2 Documentation fundamentals would not be complete without a reviewing medical necessity. In this section we are not discussing the medical necessity in the care rendered or the selection of services ordered, but rather the complexity of care documented in each encounter. Medical Necessity Page 18 Overarching Criterion Page 18 MDM vs. Medical Necessity Page 19 Determining Medical Necessity Page 19 Acute Problem Chart Page 20 Chronic Problem Chart Page 21 Documentation Findings vs. Medical Necessity Page 21 Medical Necessity Namas Provider Desk Reference Sample

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Page | 18 Every service regardless of the site of the service or the category of CPT code used must be “medically necessary,” and the documentation must demonstrate the medical appropriateness through the complexity of care. Oftentimes as providers work with coders and auditors there becomes a division of difference when conversations around medical necessity begin. Medical necessity within documentation is different from that of a clinical setting which causes this division of difference. Medical necessity within documentation is the value required to demonstrate the complexity and/or acuity of the patient (or the lack thereof) to support the billed/reported services rendered by the provider on that day. This is different from the clinical determination of medical necessity. Medical Necessity Medical necessity represents the complexity of care for a specific patient on a specific date and can be easily portrayed by good documentation. How? Unfortunately for the provider this does require clear documentation of the thought process and analysis of the encounter that providers often think of as being part of the “physicianto-physician” allowance of the medical record. Such documentation must describe clinical complexities to non-clinical readers. This is not only necessary to meet the needs of a coder/ auditor, but also for other clinicians. For example, if a primary care physician (PCP) truly needs the opinion of a specialist for a patient, then it would be incumbent on the specialist to clearly explain some of the specialtyspecific issues of the case to the requesting PCP, with the understanding that a general practitioner would not have such specialized knowledge or training. After all, access to their specialized knowledge and training is the reason for the specialist’s involvement. Likewise, non-clinicians can absolutely grasp the medical necessity through the lens of the complexity of care. Coders and auditors evaluate each E&M note based heavily on the complexity of care as portrayed by the documentation of the encounter. This is why CMS specifically indicates that the provider should “paint a portrait” of the patient every single encounter. For our part, we as auditors must be keenly aware of the boundaries that exist here. Auditors are evaluating the documentation to determine the complexity of care and whether medical necessity is demonstrated, but they DO NOT evaluate the clinical care involved with the encounter unless the auditor happens to be clinically trained. Overarching Criterion Medicare Claims Processing Manual: 30.6.1 - Selection of Level of Evaluation and Management Service (Rev. 11288; Issued: -04-03 22; Effective: 22-01-01; Implementation: -15-02 22) Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. The claims processing manual reminds us that volume of documentation is easily compiled especially with the adoption of EMR systems and therefore it cannot be the only determining factor in choosing a level of service. Lengthy problem lists NOT addressed at the encounter, erroneous additional testing ordered, diagnostics auto imported without interpretation or relevance- these increases to the volume of documentation without medical necessity validation will not merit the increased level of service. Namas Provider Desk Reference Sample

Page | 19 It is often thought that medical decision making (MDM) and medical necessity are one and the same, and for this reason many thought that the implementation of the 2021 Documentation Guidelines, medical necessity was automatically considered. However, this is actually not correct. There are still instances in which the scoring mechanics of MDM can still rival over medical necessity in instances when data and complexity along with risk of management options out-score the nature of the presenting problem. The AMA addressed such concerns within the Technical Corrections edition of the guidelines by noting that condition risk is different in nature than management risk or those of data and complexity. This statement is again supporting the requirement of medical necessity. This statement is found on page and is noted below: The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management. MDM vs. Medical Necessity There is no complex formula on how to matriculate the medical necessity of the encounter, outside of matching the complexity of the patient encounter, as documented with overall complexity as relegated per CPT guidance. However, this is not based on merely the presenting problem, nor the history only, nor even the diagnosis or MDM of the encounter. Medical necessity is determined by the overall complexity as portrayed based on the entirety of the encounter. We begin with the presenting problem as the driver of the medical necessity of the encounter. The medical necessity begins to follow the patient at the inception of the note with the presenting problem just as the beginning of the encounter documentation begins at this point. However, it is not just the presenting problem as it relates to the chief complaint, but how the presenting problem affects the complexity through the history, the needed examination, ordering and/or review of diagnostic tests, and eventual plan of care. So, we are essentially following the impact of the presenting problem on each aspect of the encounter. Once this review is performed, a decision is made as to whether the patient is meeting acute or chronic problem presentation and at what level as referenced on the charts to follow. It is possible that there will be a discrepancy between the medical necessity and the documentation findings, which we will discuss later in this chapter. Determining Medical Necessity Namas Provider Desk Reference Sample

Page | 22 CHAPTER 3 Time Based Billing Page 23 Time Chart Page 24 Qualification Statement Page 25 Prolonged Services Page 27 History Page 29 Exam Page 30 Medical Decision Making Page 31 Documenting E&M Services The most commonly audited services for the physician practice is their Evaluation and Management (E&M) services, which always seem to be a troublesome area for many auditors. This chapter will go into detail on the different components of E&M services as well as the rationale of why these components are a necessary part of the encounter Namas Provider Desk Reference Sample

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Page | 23 There are now 3 sets of documentation guidelines- 1997 ,1995, and 2021 Documentation Guidelines. While “rumor has it” 1995 and 1997 will soon be extinct, they are still the appropriate choice for certain types and places of service E&M codes. However, This manual is dedicated to the code set 99215-99202, and for that purpose we will be discussing this use of 2021 Documentation Guidelines. Most providers still document their encounters utilizing the E&M components as they clinically work best to evaluate the patients needs. However, within the code set 99215-99202 we will no longer use all of the key components for the scoring process. The primary components are: • History: No longer used in determining the level of service • Examination: No longer used in determining the level of service • Medical Decision Making: Used in determining the level of service • Time: Used in determining the level of service As noted above, the 2021 AMA E&M changes shifted our key components to MDM - OR - Time. This chapter is dedicated to understanding the proper use of MDM and Time as well how history and exam should now be considered within the audit process. Evaluation and Management 99215-99202 Time for office based encounters can be counted regardless of whether the provider is face to face with the patient or non-face-to-face. The validating component of whether the service is counted is two fold- first, what was the provider doing during that time, second did the provider document the time in a way that justifies the service. The following section will explain the criteria for time-based billing. In addition, this section will also discuss prolonged services as it would apply to time-based add-on services as well. Let’s begin. Time-based E/M Documentation Each CPT code has a range of time assigned, and each subsequent CPT code connects to make a rolling time to prevent any gaps. Time varies from new and established patients and is not the same. Additionally, you will note as the level of service increases, the time spent for the encounter also increases. The previous chapter discussed the medical necessity and explained the complexity of care. As the complexity of care increases, so does the level of service. The same process with time holds true as well. With each rise in level of service, and complexity of care (alleged) the amount of time that is required to support that encounter increases as well. On the table below you will note that 99211 is NOT a time-based service. Keep in mind that this code is used to report services performed by ancillary staff in the office and therefore it is not a time reportable service. Time Ranges Namas Provider Desk Reference Sample

Refer to the chart below: Office and Other Outpatient E/M Time 2021 New Patient Office Visits Total Time on the Day of the Visit Established Patient Office Visits Total Time on the Day of the Visit 99201 Deleted in 2021 99211 Time removed 99202 29-15 minutes 99212 10-19 minutes 99203 44-30 minutes 99213 20 -24 minutes 99204 59-45 minutes 99214 30 -39 minutes 99205 74-60 minutes 99215 40 -54 minutes Notice there are different time ranges for new patients as opposed to established patients. This is interesting because as we will discuss later in this chapter, the MDM scoring between new/established patients is the same, but time is different. This is a pretty straight forward time selection process, especially as opposed to the previous time selection process using typical time. The AMA rules indicate these minutes are the total minutes on the date of the encounter, which we will expand upon in further below. However, the auditor should expect that the provider’s documentation would include the total time spent on the date of encounter ONLY. • Are minutes the only acceptable time unit used in documentation? There is no guideline that requires a specific unit. It is recommended that since the rules are established in minutes, that minutes would be the best option, however NOT required. • In instances when time was not a forethought so the exact amount of time is not-known, could the provider state it was a “lengthy encounter” as opposed to a specific amount of time? Unfortunately, a specific amount of time is required to meet time-based requirements and therefore MDM scoring would take precedence in that particular encounter. • Does the documentation have to specifically indicate whether the patient is new or established? There is no published guideline that states this is a requirement. However, the difference between a 99203 and a 99213 is one variant- new versus established and therefore the provider should be tasked with documenting this difference based on the description of the CPT code. • Since we are not using a stopwatch or timer, I prefer to use words such as approximately, around, greater than, or more or less in association with the total time. Is this acceptable? The inclusion of this wording on principle is valid, however, many carriers will deem such documentation inappropriate and invalid as the provider is not able to authenticate the specific time of the encounter. The expectation with time based billing is that providers are submitting a time estimation, and as opposed to using validation verbiage such as approximate or around the preference would be to round-down the time to an appropriate range in which the wording is Page | 24 Namas Provider Desk Reference Sample

Minimal Risk Minimal is on the top of the chart, but rarely used. 2021 AMA Guidelines do not realistically address this any further other than as follows: Minimal problem: A problem that may not require the presence of the physician or other qualified healthcare professional, but the service is provided under the physician’s or other qualified healthcare professional’s supervision (see 99211). While providers, at times will find a service may be down-coded due to lack of complexity in the documentation, a minimal risk scenario should be more of a rare occurrence, as noted this is compared to a nurse visit. Low, Moderate, and High Risk: Each of these areas include ascending areas of risk based on acute or chronic presenting problems of the patient. The following section will help differentiate the selection process of each category. AMA first segregates problems addressed by causation: • Chronic problems addressed • Acute illness/injury addressed • Undiagnosed new problem with uncertain outcomes Problems are then ranked in complexity of low, moderate and high severity, but of course it’s not quite that straightforward. Qualification Statements 2021 Documentation Guidelines has defined chronic problems most notably different than would most clinicians. The definition is located on page 4 of the guidelines and states that a chronic problem is a problem with an expected duration of at least a year or until the death of the patient. Most clinicians have challenged the acceptable nature of this definition, however, at present- this is the guideline. Therefore, as previously stated, documenting the duration of the patient’s problem is most useful in context, or the provider documenting the problem as being “chronic” clearly notes this intent. For a provider, whether a problem is acute or chronic may seem a trivial conversation, but as later discussed- it can often mean the difference between a level 3 or 4. With some conditions, arguments could be easily made that patients have previously recovered, or that not all patients have this problem for a year or until death, inadvertently changing the problem to acute status. This argument has benefit to a carrier toward lower claim reimbursement as it is more difficult to reach a moderate level of complexity with an acute presenting problem than it is for a chronic problem to identify as exacerbate. Therefore, when a provider notes a problem as chronic they should document the problem as chronic to omit errors of ambiguity. If the provider feels that the standard for “chronic” has not been met, then documenting the specific duration is strongly recommended. The following is a brief statement of intent and example type of each stage of chronic patient. Chronic Complexity Page | 33 Namas Provider Desk Reference Sample

Page | 34 Note the trending progression of complexity, along with using the chart to the right for comparison. • Chronic, Stable: A patient that has a long term problem (1 year or until death) who is currently at their treatment goals through a management process. Example: Hypertension patient on medication with well controlled blood pressure • Chronic, Not-Stable: A patient that is NOT stable due to progression, exacerbation, worsening, poorly controlled, side effects of treatment, OR stable but not at treatment goals. Example: Hypertension not currently controlled and stated as not at treatment goals • Chronic, Not- Stable- SEVERE: A patient with SEVERE exacerbation, progression, or side effects of treatment with significant risk of morbidity/need for hospital level care. Example: Hypertensive patient presenting with abnormally high blood pressure in severe exacerbation and chest pain. Below the variances within each category will be further defined according to 2021 Documentation Guidelines. Chronic, Stable- Low As noted above, chronic conditions are long term problems being managed by the provider, and in this particular category they are stable. Stable, per 2021 Documentation Guidelines, is to be interpreted as a condition that is not changing significantly as they are within “normal limits” at this time and they are unlikely to deteriorate at this time. 2021 AMA Guidelines provide examples of chronic stable as: well-controlled hypertension, non-insulin dependent diabetes, cataract, or benign prostatic hyperplasia. On the first column of the MDM table of risk, chronic stable patients have been categorized as low risk which would be scored, for this column only, as a level three (3). Later in this chapter we will discuss that in determining the overall level of service per patient encounter, we use 2 of the 3 columns of the MDM table. Each column must have an overall score assessed, and if this box were chosen for the problem addressed- this portion of the complexity would support a Low- Level Three. Namas Provider Desk Reference Sample

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Mamas Provider Desk Reference APPENDIX A 2023 Expansion of 2021 AMA GUIDELINES Page | 60 Namas Provider Desk Reference Sample

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