By Kevin Solinsky, CPC, CPC-I, CEDC, CEMC

Transcription

1 By Kevin Solinsky, CPC, CPC-I, CEDC, CEMC

2 Learn components of the ED E&M Medical Necessity vs MDM Critical Care coding Procedure coding Orthopedic coding

3 Emergency Room Services Critical Care & Observation ,

4 There are 7 components to define the levels of E/M services: History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time (CC)

5 History Exam Medical Decision Making

6 Chief Complaint (CC) required on all charts History of Present Illness (HPI) (4 of 8 should be on every chart) Review of Systems (ROS) ( 2-9, 10 OR MORE) Past Medical, Family and Social History (PMFSH) ( 2 of the 3 should be documented)

7 The ROS and or PFSH may be recorded by ancillary staff or on a form completed by the pt. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others

8 HPI is a chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present.

9 Location Context Quality Timing Severity Duration Modifying Factors Associated Signs and Symptoms

10 Location RUQ Left Upper Lower Anterior Distal 3 rd digit Context (allows for e codes) Sharpening a knife Occurred at. During. While. Bit by rat

11 Duration For 3 hours Started this morning For a month Since yesterday Timing In the afternoons Daily Intermittent Constant 20 minutes after..

12 Quality Sharp Throbbing Stabbing Crushing burning Severity Rated a out of 10 Severe Improving moderate

13 Modifying Factors Took Motrin Tried massage Exacerbated by Relieved by Not affected by Associated Signs and Symptoms No nausea or vomiting Also with cough Also complains of

14 Brief HPI 1-3 elements from above Extended HPI at least 4 elements Charts that you could bill as 4-5 get down coded if HPI does not have 4 elements

15 Quality over Quantity Cc: Chest Pain HPI: This is a 10 year old boy who presented to the ED complaining of throbbing posterior chest pain over the past 5 hours. Pt rates pain a 7 out of 10. duration Quality Location Severity

16 Allergic/Immunologic Cardiovascular Constitutional Ears, Nose, Mouth, Throat Endocrine Eye Gastrointestinal Genitourinary Hematologic/Lymph Integumentary Musculoskeletal Neurologic Psychiatric Respiratory

17 99282/99283 Problem pertinent ROS = 1 system Extended ROS 2-9 systems Complete ROS at least 10 symptoms May make statement all other systems reviewed and are negative means you reviewed all 14 systems!!

18

19 A pertinent PFS consists of any 1 element from the PFS = pertinent A complete PFS consists of 2 elements from 2 of the PFS areas Complete need 2

20 99281 Problem Focused History CC Brief History of Present Illness 99282/99283 Expanded Problem Focused History CC Brief History of Present Illness/Problem Pertinent ROS

21 99284 Detailed History CC Extended History of Present Illness Extended Review of Systems Problem pertinent past, family social history.

22 99285 Comprehensive History CC Extended History of present illness Complete review of systems Complete past, family, social history

23 99284 or downcoded to a Only brief HPI documented. A brief HPI limits code to downcoded to requires a complete ROS requires a complete PFS History

24 If unable to get a history from pt or source You must document the reason history is not obtained and documented in the record State specifically where the documented history was obtained Indicate what other sources for history were unavailable

25 7 body areas Head including face Neck Chest including breasts and axilla Abdomen Back Genitalia, groin, buttocks Each extremity 11 organ systems Eyes ENT Cardiovascular Respiratory Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic It s just as important to document negative findings as positives.

26 99281 Problem Focused 1 body area or system Detailed 2-7 body areas or systems 1 in detail 99282/99283 Expanded problem focused 2-7 BODY AREAS Comprehensive 8 or more Organ Systems

27 Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnosis and/or or the number of management options that must be considered. The amount and/or complexity of medical records, diagnostic tests, and/or other info. That must be obtained, reviewed and analyzed. The risk of significant complications, morbidity and/or mortality, as well as co-morbidities, associated with the patient s presenting problem(s), the diagnostic procedure(s) and /or the possible management options.

28 Must meet or exceed 2 out of 3 Straight Forward Low Complex Moderate Complexity High Complexity # of diagnosis or TX options (total points) 1 = minimal 2 = Limited 3 = Multiple** 4 or more = Extensive** Amt or complexit y or Data (total points) 1 = minimal 2 = Limited 3 = Multiple** 4 or more = Extensive** Level of risk Minimal Low Moderate High

29 Problems to Examining Physician_ Points Self Limited or Minor 1 point Est problem (to examiner) stable 1 point Est problem (to examiner) worsening 2 point **New problem (to examiner) No additional workup needed 3 points **New problem (to examiner) 4 points Additional workup needed/planned

30 Level of risk Presenting problem Diagnostic Procedures Ordered Management options Selected Minimal 1 self limited or minor problem Lab tests via venipuncture, xrays, ua, EKG, US Rest, gargle, bandages dressings Low 2 or more self limited or minor problems, 1 stable chronic disease, acute uncomplicated illness/injury Physiological w/o stress, lab via art puncture, superficial biopsy, noncv imaging w/contrast Minor surgery no risk factors, OTC drugs, IV therapy no additives, PT & OT Moderate Chronic illness w/exacerbation, 2 stable chronic illnesses, acute illness w/ systemic sxs, complicated acute injury Physiological w/stress, deep biopsies, obtain fluid from body cavity, endoscopy or cv imaging no risk factors Minor surgery w/risk factors, RX drug, IV w/additives, closed tx fx or dislocation High Chronic illness w/ severe exacerbation, illness/injury that pose a threat to life or bodyily fxn, abrupt in neuro status Endoscopies or cv imaging w/ risk factors Elective minor surgery w/risk factors, emergency surgery, RX w/monitoring, DNR decision, Parental

31 History Exam MDM Problem Focused Expanded Problem Focused Expanded Problem Focused Problem Focused Expanded Problem Focused Expanded Problem Focused Straightfor ward Low Complexity Moderate Complexity Detailed Detailed Moderate Complexity Comprehensive Comprehensive High

32 99281 Self Limited or minor Low to moderate severity Moderate severity High severity, and require urgent evaluation by the doc but do not pose an immediate significant threat to life or physiologic function high severity and pose an immediate significant threat to life or physiologic function.

33 Medical Necessity verses Medical Decision Making

34 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.

35 Discussion

36 Critical Care: Evaluation and management of the critically ill or critically injured pt, requiring the constant attendance of the physician.

37 Critical care services include but are not limited to the treatment or prevention of further deterioration of CNS failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postop complications or overwhelming infection.

38 There is a high probability of sudden, clinically significant, or life threatening deterioration in the pts condition that requires the highest level of physician preparedness to intervene urgently. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the pts condition.

39 Critical Care services are billed based on the total physician attendance time at the bed side, Time entered does need to be at bedside. Time reported does not need to be continuous. The time can be totaled from multiple encounters on the same day. Must document critical care time of greater than 30 minutes.

40 Documented Critical Care time should include: Time at bedside with the pt Conversations with other personnel regarding pt Clinically necessary conversations with family when pt is unable to participate in decisions Review of test results Documentation of encounter

41 Documented Critical Care time should not include: Time performing separate billable procedures Time spent by residents managing the pt Time spent in teaching sessions with the residents

42 The interpretation of cardiac output measurements CXRT Pulse ox Blood gases Information data stored in computers Gastric intubation Transcutaneous pacing Ventilator management Vascular access procedures

43 Endotracheal intubation Periocardiocentesis Central Venous Catheter Chest Tube CPR The docs progress note must document that time involved in the performance of separately billable procedures was not counted toward critical care time.

44 Document procedures step by step and not as a whole Identify location of injury Document who performed minor procedures

45 3 levels Simple, intermediate, complex Document Number of layers closed Location of injury Length of wound Extra cleaning or debridement beyond normal

46 Procedure 3.0 cm right cheek laceration was anesthetized with 3.0ml LET Solution and subsequently Lidocaine 1% without Epinephrine 2ml via small gauge needle into the margin. The wound was copiously irrigated and 1 small foreign body was removed. 5-0 Prolene sutures simple interrupted x 4 were placed with excellent apposition of the wound edges. Pt tolerated procedure.

47 Splinting a fracture that will require reduction or other treatment at a subsequent time is considered supportive or temporary If the fx is definitively treated by splinting or other care provided in the E, the treatment is considered restorative or definitive

48 The exact location of the fracture or dislocation must be noted. Clear documentation of care provided in the Emergency Department is required. Reduction, stabilization, devices and materials utilized as well as who provided the care should be noted.

49 For non-medicare pts in the ed the doc must either apply the splint/cast or perform a post-placement check of the application in order to bill for the service

50

51

52

53 Many providers do not understand that Medical Necessity is the driving force for picking the appropriate E&M service.

54 This diagnosis is a clear example that the patient age, tests ordered and treatment plan are what drive the level of service that should be coded.

55 99282:no tests or treatment sent home to take Tylenol :You order blood, and urine no medications, home on Tylenol or Motrin 99284: Blood work, urine, IV fluids, IV or IM medications may go home on antibiotics or not : Blood work, urine, IV fluids, Spinal Tap, IV antibiotics and administration to the hospital for R/o sepsis.

56 Chest Pain or abdominal pain always generate a higher level of medical necessity due to the possibilities with regards to diagnoses.

57 This also can drive the level you bill.

58 We are going to look at charts and review all the components and determine E&M and procedures that can and should be coded.

59 Disclaimer: You can put 5 certified coders in a room together and give them the same charts. They can all code them just a little different and still have the same outcome. Coding is not a science we are not perfect and can learn from each other..

60 Questions

61 Kevin Solinsky, CPC, CPC-I, CEDC, CEMC Healthcare Coding Consultants, LLC