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Coding Lecture 2013 Zesut for learning how to code
- 1. 🙢 � Must communicateto the payer your concerns and thought process � The payer does not have the following: � The chart � The patient’s perspective on the treatment received � The ability to talk to the treating physician � The payer (insurance or patient) receives a series of 5 digit codes representing your treatment � Your documentation must empower/allow the coder to accurately report the work performed Coding Basics
- 2. 🙢 � Medical DecisionMaking determines the highest possible code � Your Hx and PE documentation supports the level � Chest Pain could be a level 5 � Without appropriate documentation…down coded � Significant revenue loss � Compliance Issue � Can not over document an ankle sprain, bruise, suture removal, or abrasion to be a level 5 Coding Basics
- 3. 🙢 � HPI (totalof 8 items) � ROS (total of 14 items) � PMSF Hx (total of 3 items) � Physical Exam (total of 14 organ systems) � Medical Decision Making (4 levels*) � Coding Level (5 major and 2 additional) Anatomy of a Chart
- 4. 🙢 � 99281 � 99282 �99283 � 99284 � 99285 � Critical Care: 99291/99292 E/M Codes we use
- 5. 🙢 � HPI (totalof 8 items) � ROS (total of 14 items) � PMSF Hx (total of 3 items) � Physical Exam (total of 14 organ systems) � Medical Decision Making (4 levels*) � Coding Level (5 major and 2 additional) Anatomy of a Chart
- 6. 🙢 HPI � Location � Quality �Severity � Duration � Timing � Context � Modifying Factors � Associated Symptoms � Level 1-3 (1-3 items) � Level 4-5 (4-8 items)
- 7. 🙢 � HPI describesthe chief complaint in greater detail. � 99281‐99283: 1‐3 elements � 99284‐99285: 4 elements � Need 4 HPI elements for 99284 and 99285! HPI Breakdown
- 8. 🙢 Review of Systems �Allergic/Immunologic � Cardiovascular � Constitutional Symptoms � Ears, Nose, Mouth, Throat � Endocrine � Eye � Gastrointestinal � Genitourinary � Hematologic/Lymph � Integumentary � Musculoskeletal � Neurological � Psychiatric � Respiratory
- 9. 🙢 � 99282/99283 –1 system � 99284 : 2‐9 systems � 99285 ‐ 10 systems � Need 10 ROS for 99285! ROS Breakdown
- 10. 🙢 “Those systems withpositive and negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.” CMS 1995 Documentation Guidelines □ All systems negative except as marked ROS Blanket Statement
- 11. 🙢 � 99281‐99284 require1 PFSHx element � 99285 – requires 2 PFSHx elements � Incomplete PFSHx costs you 1.57 RVUs! Past, Family, Social History (PFSHx)
- 12. 🙢 � “The ROSand/or PFSHx may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.” CMS 1995 Documentation Guidelines Nursing Notes
- 13. 🙢 � “If thephysician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstances which precludes obtaining a history.” CMS 1995 Documentation Guidelines � You should document the reason history is unobtainable � Unconscious � Overdose � Patient with dementia � Postictal � Severe dyspnea (CHF or Asthma) EM Caveat
- 14. 🙢 Physical Exam � Constitutional �Eyes � Ears, Nose, Throat � Cardiovascular � Respiratory � Gastrointestinal � Genitourinary � Musculoskeletal � Skin � Neurologic � Psychiatric � Heme/Lymph/Immun.
- 15. 🙢 � 99281 –1 body system � 99282/99283 – 2‐4 body systems � 99284 – 5‐7 Body systems � 99285 – 8 systems Guidelines for PE
- 16. 🙢 Physical Exam � ProblemFocused � Limited to affected body area or organ system � Expanded Problem Focused � examines affected body organ or system � checks other symptomatic ore related organ systems •Detailed - Extended exam of the affected body area(s) and other symptomatic or related organs Concerned about learning as many details as possible ex. LBP radiating to the leg •Comprehensive - Perform a complete single system specialty examination or a complete multisystem examination - ex. Vasculitis
- 17. 🙢 � HPI (totalof 8 items) � ROS (total of 14 items) � PMSF Hx (total of 3 items) � Physical Exam (total of 14 organ systems) � Coding Level (5 major and 2 additional) � Medical Decision Making (4 levels*) Anatomy of a Chart
- 18. 🙢 � Evaluates 3components � Diagnosis and Management Options � Admission, Transfer, Complex Outpatient testing � Amount and Complexity of Data � Physician Documentation Key Medical Decision Making
- 19. 🙢 � Review andSummarization of old records 2 POINTS � Last ED Visit, Old EKG, Old X ray Reports � DC Summary…write a brief summary � Obtaining history from someone else or discussion of case with another health provider 1 point � Independent visualization of image, tracing 2 points � Review and/order clinical lab test 1 point � Review and/order radiology test 1 point � Review and/order medicine test 1 point � Discussion of test results w/performing physician 1 point � Decision to obtain old records and/or history from someone other than the patient 1 point MDM Components
- 20. 🙢 � Brief summaryof old record: last visit admit for CHF, home on increased lasix, ruled out for MI. � Document discussion of test results (CTs etc.) with performing MD � Document your decision to obtain old records � Document Independent Visualization of X‐ray/CT/EKG � Document obtaining Hx or clinical information from another source: � Family (meds, allergies, course of illness) � PMD (meds and Past Hx) � NH notes‐ summarize � EMS run sheets and interventions Pearls for Data Points
- 21. 🙢 � Level 1- Minimal � Level 2 - Low � Level 3 - Moderate � Level 4 - Moderate � Level 5 - High Medical Decision Making
- 22. 🙢 � 99285 requires: �Comprehensive History � Comprehensive Exam � High Level Medical Decision Making � Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patientʹs clinical condition and/or mental status: CPT 2012 Level 5
- 23. 🙢 Level HPI ROSPFSHx PE 1 1 0 0 1 2 1 1 0 2 3 1 1 0 2 4 4 2 1 5 5 4 10 2 8 Documentation Guide
- 24. 🙢 � Improper diagnosis �Diagnosis that insurance companies auto decline � Improper coding � Not realizing you can bill for something � CPR, Venipuncture, Ultrasound, Ortho Fx Care � Not completing your Procedure note � Not realizing critical care Lost Revenue
- 25. 🙢 � Words makea huge difference � More specific is better � Status Asthmaticus vs. Acute Exacerbation � use status if it is as it is more severe � Tooth pain – � use mouth pain/jaw pain � Pharyngitis � In addition add sore throat or throat pain � Psychiatric diagnosis � try to add another diagnosis Diagnosis
- 26. 🙢 � An E/Mwill likely apply � Wound Check � If atypical for standard postoperative course � Use low level E/M � Cellulitis‐ no procedure performed � Recheck only‐low level E/M i.e. 99282 � Additional IV Abx‐Moderate level E/M i.e. 99283 or higher � Abdominal Pain, Fever, Gastroenteritis � Likely moderate level E/M � Document a full chart to support the services you are providing! Return Visit Evaluation
- 27. 🙢 � Documentation oflocation, length, and layers � Location: � 13 cm scalp laceration � 3.12 RVUs � 13 cm Facial Laceration � 4.18 RVUs…34% increase � Length Cut offs: � 2.6 cm, 5.1 cm, 7.6 cm, 12.6 cm…Measure! � Layers � Simple‐ single layer � Intermediate‐ 2 layer or heavily contaminated Laceration Repair Opportunities
- 28. 🙢 � Repair, intermediate,wounds of scalp, axillae, trunk and/or extremities � 5.77 RVUs � Extensive cleaning of heavily contaminated wound and removal of debris � Can lead to large RVU’s Lacerations
- 29. 🙢 � The EDphysician provides the same care as the orthopedist � Must be the same � Not a temporary measure but the same ultimate care provided by the specialist � Clinically fractures require a spectrum of care: � Strictly supportive measures and pain control � Splinting � Operative fixation � Casting Fracture Care
- 30. 🙢 � Fractures generallyinvolving ED care � Fingers 5.3 RVUs � Toes 2.8 RVUs � Rib 3.4 RVUs � Nose .82 RVUs � Clavicle 6.4 RVUs ED Definitive Care
- 31. 🙢 Fracture Manipulation � Codefor all manipulations � Use the without anesthesia codes � Splint is bundled � Extremely high RVUs � Capture with 25605 ‐54 � >10 RVUS
- 32. 🙢 � Charge forvenipuncture 36415 � Must be performed by NPP or physician Femoral Stick
- 33. 🙢 � 99406 3-10min intermediate � 99407 > 10 min intermediate � 99408,9 � Problem of Dx related to tobacco use � ICD –9 Tobacco dependence 491.21 & 305.1 � Any med pt takes adversely affected by tobacco � Discussion action � Advice how to quit � Advice how to manage side effects � Referral to consultant for long term management � Record of Time Smoking Cessation
- 34. 🙢 � Needs tobe impacted 69201 � Suction, Probe, Forcep, Hook, Curette � Impacted Cerumen ICD-9 380.4 � Medical Necessity � Sole reason for encounter � Performed by NPP or Physician � Time & Effort to remove Cerumen Removal
- 35. 🙢 � FB removalrequires an “incision” o/w it is just an E/M � Removal w/ Incision vs. w/o � If you use a needle or if you push object through the skin, that is considered with incision � Simple v. Complicated � Complicated � Utilizes x-ray, fluoro, Ultrasound or debridement FB Removal
- 36. 🙢 � Superficial vs.embedded � Superficial � Loose – use swab � Embedded –use swab or needle � Cornea � Without Slit Lamp 65220 � With Slit lamp 65222 Foreign Body - Eye
- 37. 🙢 � From thetalus down 28190-28193 � CPT makes no referral to “incision” � Hand is included in 10120 FB Foot
- 38. 🙢 � Burn qualifiesfor both E/M and codes � NPP or MD needs to do E/M pertinent to problem � If you transfer pt for more burn care then only report E/M � 1st degree � 2nd degree 5-10% BSA � Remember rule of 9s Burn Coding
- 39. 🙢 � Digital Blocksare included in most procedure CPTs � Can charge for a digital block if you do it for reason other than adjuvant to procedure � Ex. Pain control for finger fracture Digital Blocks
- 40. 🙢 � Both canbe used in the ED � Anesthesia does not require endotracheal intubation � Anesthesia is used when conscious sedation is provided for another MD doing procedure � Use conscious sedation when you do sedation and procedure � Requires another provider present to record Conscious Sedation vs. Anesthesia
- 41. 🙢 � Simple vs.Complex � Complex requires � Packing � Probing � breaking loculations � close to critical structures � WE MISS THIS A LOT I & D
- 42. 🙢 � Simple vs.complex anterior bleed � Simple � Continuous pressure � Anesthetic vasoconstrictor � Nasal spray with anesthetic � Cautery � Silver nitrate � Electric � Complex � Aggressive � Nasal packing, sponge, balloon Epistaxis
- 43. 🙢 � Need toknow location � 64400 Trigeminal Nerve branch � 64450 Peripheral Nerve Dental Blocks
- 44. 🙢 � Counts numberof muscles not number of injections � 20552 injection 1 or 2 muscles � 20553 injection > 3 muscles � need to know which muscles injected � need etiology of pain for trigger point � Myalgia 729.1 � Myofascial Pain 729.1 � Muscle Spasm 728.85 � Torticollis 723.5 Trigger Point Injections
- 45. 🙢 � Code Blueon floor can be 99291 or 99231-99233 � You must be present for CPR to code for CPR � You can bill more than one CPR if there is more than one session � You can code both CPR and Critical Care on same patient � Time for CPR must be taken out of C.C. time Code Blue - CPR
- 46. 🙢 � “CPT (currentprocedural terminology) currently defines a critical illness or injury as an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. � Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. � CMS adds that in order to qualify as critical care for Medicare patients, "the failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient's condition". Critical Care
- 47. 🙢 � Currently wecall it Level 6 � Must put in exact time � Only requires 30+ minutes of dedicated critical care time � Not included in critical care time � RSI for intubation � CPR � Procedures (central line, art line) � I cannot stress how important is to document Critical Care
- 48. 🙢 � Question: ShouldI Document Critical Care Start and Stop Times? � Add up the critical care time and report that number � CMS ruled out this criterion in 2000 � they clarified that critical care was a cognitive service not dependent upon external proxies of time. � Time is dependent upon the physician’s cognitive work, not the physical location (e.g., bedside) or unit time Critical Care Time
- 49. 🙢 � Acute myocardialinfarction � especially requiring thrombolysis � Respiratory failure or distress � Requiring intubation or BIPAP � Malignant hypertension � that requires Cardizem or other drip � Unresponsive due to overdose, stroke, seizure, etc. � A Fib with RVR � Requiring cardiac drip CC Examples
- 50. 🙢 � Asthma exacerbation �Requiring multiple nebulizer treatments � Close monitoring � Use of third-line agents such as magnesium � DKA � Large amounts of IV fluid and IV insulin therapy � GI bleeding � Requiring multiple saline fluid boluses � blood transfusions CC Examples
- 51. 🙢 � These servicesare bundled into 99291 and 99292: � interpretation of cardiac output measurements � pulse oximetry � interpretation of data stored in computers � transcutaneous pacing � ventilator management � gastric intubation � EKG interpretations Critical Care – Procedures Bundled
- 52. 🙢 � If apatient arrives CPR in progress you can bill � For continued CPR � Cardiac ultrasound � Femoral Sticks for blood � Procedures done to save the patient CPR in progress /Dead on arrival CPR
- 53. 🙢 � The providerneeds to actually do the strapping/splinting in order to charge for this procedure � If this is done by a hospital employee then NPP or Doc cannot bill for this Strapping/Splinting