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Progress Note with Chart Mechanics Progress note with chart mechanics Medicare Advantage Documentation guidance Progress note (example) Ensure patient name, date of service (DOS) and date of birth (DOB) are identified on every Patient: Name DOS: 01/08/21 DOB: 12/05/48 page.1,2 Chief complaint (CC): “Follow-up” alone is not a Reason for visit: Follow-up for complicated diabetes following left great toe amputation. valid CC. The documentation must describe why CC: Patient notes progressive loss of sensation in her feet. the patient is presenting for follow-up.3 Medication list: Glyburide 10 mg PO q.d.; Pregabalin 50 mg PO t.i.d. S: States she is able to get around, including bathroom and kitchen, with the aid of her History: History of present illness (HPI), driven by walker. She tries to follow her diet, but does not check her fingerstick blood sugars. She has the CC and review of systems (ROS).3 not been taking her blood pressure medications regularly because she said it makes her feel dizzy. Exam: Exam driven by the patient history, O: Morbidly obese describing in detail any pertinent positive findings Vital signs: T 98.2; BP 154/95; HR 63; Wt. 238 lbs.; Ht. 64”; BMI 40.8; Fingerstick blood glucose and any chronic findings that affect the care and 275 treatment of the patient.3,4 Neck: Supple. Carotid pulses 2+. No bruits. No jugular venous distention. Thyroid normal and palpable. Trachea in midline. No masses or lymphadenopathy noted. Medical decision-making Skin: Warm, dry, intact, no rashes, no abnormal lesions, no cyanosis or diaphoresis. Chest: Lungs clear to auscultation. No rales, rhonchi or crepitation. No shortness of breath or Assessment that documents the diagnosis, its cough. status and any causal relationships (for example, Cardiovascular: RRR, normal S1 and S2, no extra heart sounds, no murmur, gallop, rub or diabetic, due to diabetes). Assessment that extrasystole. 1+ nonpitting peripheral edema. Peripheral pulses barely palpable, unchanged documents not only conditions being treated, but from prior exam. No clubbing or cyanosis. any chronic conditions that affect the care and GI/GU: Round, soft. Nontender. Bowel sounds normoactive in all 4 quad. No guarding, treatment of the patient.3,4 rigidity or rebound tenderness. Spleen, liver and kidneys are not palpable. No ascites present. No hernias noted. Colostomy intact with surrounding pink red stoma, liquid brown feces. No Plan that specifies treatment for each condition CVA tenderness. listed in the assessment, including, but not Neurological: Cranial nerves II-XII grossly intact. She is alert, oriented to place, person, time limited to, diet, medications, referrals, laboratory and purpose. Able to follow commands. Able to move all four extremities. No gross motor, 5 orders, patient education and return visits. fine motor or sensory deficits noted except for diminished vibratory sensation at right great Document and report coexisting diagnoses — toe DIP (5 seconds). DTRs 2+ and equal. Sharp and dull sensations noted normally bilaterally any that require or affect the care, treatment or in both upper but diminished in lower extremities with diabetic neuropathy. management of the patient that day.5 Musculoskeletal System: Strength 5/5 bilaterally both upper and lower extremities. No muscle asymmetry, atrophy or involuntary movements. No structural deformity, effusion, periarticular • Do not document “history of” for an active swelling or tenderness of any joint except as noted with left great toe amputation, healing incision condition, and do not assign an active code and no drainage. when the condition no longer exists. A: 1. Great left toe amputation: healing (Z89.412) • Use only standard abbreviations (acronyms 2. Diabetes type 2 with hyperglycemia (E11.65) and symbols). a. Worsening diabetic neuropathy (E11.40) • It is not appropriate to code a condition that b. Worsening diabetic peripheral vascular disease (E11.51) is represented only by an up or down arrow 3. Morbid obesity, BMI 40.8 (E66.01, Z68.41) in combination with a chemical symbol á 4. Functioning colostomy (Z93.3) or lab abbreviation, such as “ chol” for 5. Hypertension (I10) “hypercholesterolemia”. 6. Medical noncompliance (Z91.14, Z91.19) • Proper documentation should show monitoring, evaluation, assessment or P: 1. Great left toe amputation: Continue to monitor. Patient instructed to return to clinic for treatment (M.E.A.T.) of the conditions any signs of infection. documented. 2. Diabetes type 2 with chronic complications a. Patient advised on dietary changes. Authentication b. Continue current dose of Glyburide for now and check fingerstick BID and report Paper record: Authentication by the provider back results. author of the progress note, which includes c. Diabetic peripheral neuropathy: Increase Pregabalin to 100 mg by mouth three a legible name and credential, a handwritten times daily. signature and the date signed. EMR: d. CMP and HbA1c ordered for prior to next visit. Authentication by the provider author of the e. Diabetic eye examination and education class referrals ordered. progress note, password-protected to that provider only, at the end of the note (for example, Authenticated by: Joseph A. Williams, MD, 01/08/21 authenticated by, approved by), including typed name and credential and the date authenticated.2 Please note that CMS requires that the date of the electronic signature must be within 180 days of the date of service.2 - continued on other side - Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2021: “A dash (-) at the end of an alphabetic index entry indicates that additional characters are required. Even if a dash is not included at the alphabetic index entry, it is necessary to refer to the tabular list to verify that no 7th character is required.” The bolding of the ICD-10-CM codes represents categories, subcategories or codes that map to the CMS-HCC risk adjustment model for payment year 2021. PerThe thefollowing ICD-10-CM references Official were Guidelines used in thefor creationCoding andof this Reporting document FY at2020: time “A of dashpublication: (-) at the end of an alphabetic index entry indicates that additional characters are required. Even if a dash is not included at the alphabetic index entry, it is necessary to refer to the tabular list to verify that no 7th character is required.”Optum360 ICD-10-CM:The bolding Professional of the ICD-10-CM for Physicians codes 2021. represents Salt Lake City, categories, UT: 2020. subcategories or codes that map to the CMS-HCC risk adjustment model for payment year1. Centers 2020. for Medicare & Medicaid Services. 2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide. Palmetto GBA; 2008. https://www.csscoperations.com/Internet/Cssc3.Nsf/files/participant-guide-publish_052909.pdf/$File/participant-guide-publish_052909.pdf. Accessed October 24, 2019. Optum3602. Centers ICD-10-CM:for Medicare Professional & Medicaid for Services. Physicians Risk 2020.Adjustment Salt Lake Data City, Validation, UT: 2019. Medical Record Reviewer Guidance. cms.gov/Research-Statistics-Data-and-Systems/Monitoring- 1. CentersPrograms/Medicare-Risk-Adjustment-Data-Validation-Program/Resources for Medicare & Medicaid Services. 2008 Risk Adjustment Data Technical. Published Assistance January For10, Medicare 2020. Accessed Advantage March Organizations 15, 2021. Participant Guide. Palmetto GBA. https:// 3. www.csscoperations.com/Internet/Cssc3.Nsf/files/participant-guide-publish_052909.pdf/$File/participant-guide-publish_052909.pdf.Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. cms.org. https://www.cms.gov/Outreach-and-Education/ Accessed October 24, 2019. 2. Chassin,Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. et al. Ambulatory Health Care: 2017 National Patient Safety Goals . The Joint Commission.Published 1999. https://www.jointcommission.org/assets/1/6/2017_NPSG_AHC_ER.pdf. Accessed October 24, 2019. 4. PublishedDHHS. ICD-10-CM December Official 2, 2016. Guidelines Accessed for October Coding 24, and 2019. Reporting FY 2020. Centers for Disease Control and Prevention. cdc.gov/nchs/data/icd/10cmguidelines-FY2021.pdf October 3. Centers1, 2020. for Accessed Medicare March & Medicaid 15, 2021. Services. 1995 Documentation Guidelines for Evaluation & Management Services. https://www.cms.gov/Outreach-and-Education/Medicare- 5. Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf.Centers for Medicare & Medicaid Services. Evaluation and Management Services Published Guide. 1999. cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Accessed October 24, 2019. 4. DHHS.Downloads/eval-mgmt-serv-guide-ICN006764.pdf. ICD-10-CM Official Guidelines for Coding and Published Reporting February FY 2020. 2021. Centers Accessed for MarchDisease 1,Control 2021. and Prevention. https://www.cdc.gov/nchs/data/icd/10cmguidelines- FY2020_final.pdf. Published October 1, 2019. optum.com 11000 Optum Circle, Eden Prairie, MN 55344 This guidance is to be used for easy reference; however, the current ICD-10-CM code classification and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. The information presented herein is for general informational purposes only. Neither Optum nor its affiliates warrant or represent that the information contained herein is complete, accurate or free from defects. Specific documentation is reflective of the “thought process”
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