Urgent care documentation

In healthcare provision, the meticulous documentation of patient interactions is the cornerstone for healthcare providers. Achieving a seamless Revenue Cycle Management (RCM) commences with the precise documentation of patient visits, encompassing every facet from the initial consultation to post-operative care. Thoroughly recording patient data, medical history, and treatment specifics lays the foundation for accurate coding, ensuring compliance with established guidelines, and optimizing reimbursement. Proper documentation serves as a linchpin, not only enhancing patient care but also facilitating audits, and compliance reviews and offering legal protection. It not only supports the precise coding of services but also underscores the medical necessity of the care provided. Furthermore, precise clinical documentation of Evaluation and Management (E/M) care and, subsequently, inpatient acuity is paramount. These details are pivotal in determining quality metrics, serving as vital indicators of overall hospital quality, especially in the context of CMS value-based payments and rankings.
However, patient care is the utmost priority that demands particular focus and time; therefore, spending proper time on documentation is a challenging task for healthcare providers. In this hustle to maintain a balance between fulfilling accurate documentation requirements and rendering full-time patient care, urgent care practitioners may make mistakes, leading to decreased reimbursement and penalties. To soothe this concern, MedsIT Nexus is there to shake hands with you in performing your documentation requirements flawlessly.

Urgent Care Documentation: Navigating Requirements & CMS Guidelines |Meeting 3 Critical Components for New and Established Patients

Two categories are there to document and code urgent care services.
New patients: Patients who have not received service in the last three years. Key components must meet or exceed the documentation guidelines in all three areas to appropriately assign the E/M code.
Established patients: Patients who have received medical services within the last three years. Two of the three components must meet or exceed documentation requirements.
So, what are the three key components you should know to document services in urgent care properly?

Component # 1: History

The first component, history, is vital in comprehending the patient's condition thoroughly. It encompasses several elements, including:

Chief complaint:

A detailed description of the reason for the patient's visit sets the stage for further evaluation and diagnosis.

History of present illness:

History of the present illness describes the development of the patient's condition from the initial sign and symptom to the current condition/state. A brief history necessitates documentation of 1-3 elements, while an extended history includes four or more.
Listed below is the detail of each factor that must be documented.

Location	Place on the patient body where the patient is experiencing signs and symptoms
Quality	Adjective describing the nature of the chief complaint or symptoms, such as throbbing, dull, or sharp
Severity	Description/statement of the intensity or severity of the symptoms experienced by the patient.
Duration	Duration of time during which the patient has been experiencing the signs and symptoms, for instance, over the past two years.
Timing	Timing of when the symptoms occur, such as in the morning, during physical activity, or at night.
Context	Details about the patient's activity or location when the symptoms first appeared, such as climbing stairs or cutting fruit.
Modifying factors	Factors that alleviate or exacerbate the symptoms indicating what makes the condition better or worse.
Associated signs and symptoms	Other signs and symptoms the patient is experiencing

Review of system (ROS):

For the review system, documenting one system is problem pertinent (99202, 99213), 2-9 system is extended (99203, 99214), and the above ten systems is Complete (99215, 99204, 99205).
All 14 systems that can be reviewed and documented are listed below.

Eyes	Integumentary
Constitutional	Musculoskeletal
Cardiovascular	Neurological
ENT	Immunologic
Respiratory	Lymphatic/hematological
Genitourinary	Endocrine
Gastrointestinal	Psychiatric

Documentation tips-ROS

• The "all-inclusive" statement for ROS is being overused, especially in cases where it is not medically necessary. For example, it would not be required to document a comprehensive ROS for most established care visits.
• Keep in mind that the lower levels of service require only 2-9 systems.
• For a system review of 13 or less, each system must be listed individually to include at least 10 when necessary. Let’s consider how a ROS should be documented when listed separately.

Eyes	No discharge
Constitutional	No fever
ENT	No sore throat, no nasal congestion, no dental pain, no hearing changes
Respiratory	No cough
CVS	No chest pain
MSK	No joint pain
Genitourinary	No dysuria
Neurologic	No headache, no speech problems

• Review and document 14 systems when medically necessary.
• Be sure to use consistent notation, which allows the specific number of systems reviewed to be identified.
• All-inclusive statements could be created as macros or phrases in the HER. Here are a couple of examples of acceptable statements and a couple of examples of unacceptable statements.

Acceptable

Statement # 1: “Pertinent positives and negatives as per HPI. All other systems have been reviewed and reported as negative."

Statement # 2: “Patient complains of chest pain and tingling in the right arm. He denies abdominal or back pain. Reviewed seven other systems; all findings are negative.”

Unacceptable statements
All systems reviewed are negative, except for those mentioned in the HPI.
Other systems reviewed are negative
ROS non-contributory
ROS is otherwise unremarkable.
Five systems were reviewed, and the remainder are negative.

Past, Family, and Social History:

Past medical history	A review of the patient’s past experiences with illnesses, injuries, and treatments. For instance: Prior illness, injuries, hospitalization, surgeries, age appropriateness, immunization status
Family history	A review of medical events in the patient’s family. For instance, Health status, cause of death, and specific diseases related to the chief complaint.
Social history	An age-appropriate review of past and current activities. For instance: Marital status, occupation, use of alcohol and drugs, lifestyle.

Documentation considerations for PFSH
Past, family, and social history documentation require 1-3 elements for pertinent history, and for an established patient, 2 of 3 elements must be met. However, a complete history for a new patient requires 3 of 3 to be included in the document.
The statements that must be avoided when documenting a patient’s family history are:

• Deceased at age (e.g., age 40) or age unknown
• Deceased
• Both parents deceased
• Alive
• Other
• Family history “not on file”

Component # 2: Physical exam

For physical exams, most levels of services require documentation of either body areas or organ systems.

Body areas	Organ system
Head including face	Eyes
Neck	CVS
Chest including Axilla and breast	GI
Abdomen	Respiratory
Genitalia, groin, buttocks	ENT
Back	Skin
Each extremity	Neurologic
	Psychiatric
	MSK
	Hematologic, lymphatic, immunologic

• The comprehensive level of service (99204, 99205, 99215) requires eight or more organ systems only.
• A detailed level of service (99203, 99214) requires 2-7 body areas or organ systems.
• 2-4 boy areas or organ systems are required for expanded problem-focused services.
• One body area or organ system is required for problem-focused services.

Physical exam documentation tips & guidelines (Body areas vs. Organ system)

Differentiating between body areas and organ systems within HEENT is crucial.

1. When HEENT is documented as "head is atraumatic," it refers to the body area only, specifically the head. However, if the documentation includes details such as "PERLA (pupil, equal, round, and reactive to light and accommodation)" and "pharynx is clear," it encompasses two organ systems: Eyes and ENT (ears, nose, and throat).
2. In the context of documentation, the neck can be perceived as a body area. When described as "non-tender," it signifies a single body system, specifically the musculoskeletal (MSK) system. However, if the documentation includes additional details such as "no lesion (skin)," "good pulses (cardio)," "full range of motion (musc or neuro)," and "no lymphadenopathy (lymph)," it expands to cover four organ systems: Skin, Cardiovascular (heart and blood vessels), Musculoskeletal, and Lymphatic.

According to CMS guidelines, it is crucial to provide specific details when documenting abnormal or relevant negative findings during a patient's examination. Simply stating "abnormal" without further explanation is not enough. Similarly, phrases like "within normal limits" or "normal" are insufficient. The documentation should indicate what is abnormal and how it deviates from the norm. Additionally, if unexpected findings are discovered in body areas or organ systems unrelated to the patient's symptoms, these findings must be described in detail. For instance, if a patient presents with a headache and an examination reveals abnormal respiratory issues, merely stating "abnormal" is inadequate. The documentation should specify the nature of the abnormality and provide a comprehensive description of the findings.

Component # 3: Medical decision making: New vs. Established patients

Keeping a close eye on the decision-making level is necessary while documenting urgent care services. There are four levels of medical decision-making in urgent care: Straightforward complexity (99201, 99202, 99212), Low complexity (99203, 99213), Moderate complexity (99204, 99214), and High complexity (99205, 99215)
Here are the levels of service and the number of components from each area that need to be documented to meet the expected level for a new patient.

Urgent care level of services for new patients (3 of 3 components must meet or exceed documentation requirements)

Level of service	MDM	History	Exam
99201	Straightforward	Chief complaint History of present illness: 1-3 elements ROS: N/A Past, family, and social history: N/A	One body area or organ system
99202	Straightforward	Chief complaint HPI: 1-3 elements ROS: 1 system Past, family, and social history: N/A	2-4 body areas or organ systems
99203	Low	Chief complaint HPI: 4+ elements ROS: 2-9 elements Past, family & social history: 1-3 areas	5-7 body areas or organ systems
99204	Moderate	Chief complaint HPI: 4+ elements ROS: 10+ systems Past, family & social history: 3/3 areas	Eight or more organ systems only
99205	High	Chief complaint HPI: 4+ elements ROS: 10+ elements Past, family & social history: 3 of 3 areas	Eight or more organ systems only

Here are the levels of service and the number of components from each area that need to be documented to meet the expected level for an established patient.

Urgent care levels of services for Established patients (2 of 3 components must meet or exceed the documentation requirements)

Level	MDM	HPI	Exam
99211	N/A	Chief complaint ROS: N/A HPI: N/A Past, family & social history: N/A	N/A
99212	Straightforward	Chief complaint ROS: N/A HPI: 1-3 elements PFSH: N/A	One body area or organ system
99213	Low	Chief complaint ROS: 1 system HPI: 1-3 elements PFSH: N/A	2-4 body areas or organ systems
99214	Moderate	Chief complaint ROS: 2-9 systems HPI: 4+ elements PFSH: 1 of 3 areas	5-7 body areas or organ systems
99215	High	Chief complaint ROS: 10+ systems HPI: 4+ elements PFSH: 2 of 3 areas	Eight or more organ systems only

Describing the nature of the presenting problem is crucial as it is the primary factor in determining the level of service. For instance, if the presenting problem is of high or comprehensive severity, even if the healthcare practitioner's documentation suggests a lower complexity level, the encounter will still be classified and coded as a high complexity level.
Besides these three critical components, other common but crucial documentation required
Patient Information: One of the fundamental aspects of urgent care documentation is the collection and recording of patient information. This includes demographic details, contact information, medical history, and insurance details.
Diagnostic Tests and Procedures: Documenting the results of diagnostic tests, such as laboratory tests, X-rays, or electrocardiograms, is vital for tracking the patient's progress and ensuring timely interventions. Providers must accurately record the tests performed, their results, and the interpretation of these results, providing a basis for treatment decisions.
Diagnosis and Treatment Plan: A precise diagnosis and a well-defined treatment plan are the cornerstones of urgent care documentation. Providers must clearly state the diagnosis, supported by the patient's symptoms, physical examination findings, and test results. The treatment plan should include prescribed medications, procedures performed, follow-up instructions, and referrals, if necessary. Documenting the rationale behind the chosen treatment options adds clarity to the medical record.
Informed Consent: Informed consent is a legal and ethical requirement in healthcare. Providers must document the process of obtaining the patient's informed consent for treatments, procedures, or surgeries. The documentation should include a description of the treatment, potential risks and benefits, alternatives, and the patient's agreement to proceed. Informed consent forms should be signed and dated by the patient or their legal guardian.
Time: In cases where time plays a crucial role during the patient encounter, it is imperative to document the duration of time spent with the patient accurately.

Best urgent care documentation services with MedsIT Nexus: A comprehensive billing platform

MedsIT Nexus is a premier provider of urgent care documentation services, offering unparalleled expertise and a comprehensive billing platform that ensures seamless operations for healthcare facilities. With years of experience in the field, MedsIT Nexus boasts a team of certified coders with a deep knowledge of the specifications of urgent care documentation, coding, and billing. The platform strictly adheres to the guidelines set forth by the Health Insurance Portability and Accountability Act (HIPAA), ensuring the confidentiality and security of PHI. What sets MedsIT Nexus apart is its exceptional ability to capture accurate documentation, allowing healthcare providers to focus on delivering high-quality patient care. The professionalism exhibited by our team is evident in their attention to detail and commitment to providing top-notch services. Moreover, MedsIT Nexus prides itself on offering round-the-clock support, providing healthcare facilities with the assurance of continuous assistance whenever needed. Contact us today, and let us help you take your urgent care facility to the heights of success.