Charting Smarter, not Longer: Basic Concepts in Outpatient Coding

Transcription

1 Charting Smarter, not Longer: Basic Concepts in Outpatient Coding Workshop WA01 SGIM 29 th Annual Meeting April 27, 2006 Sponsored by the SGIM Clinical Practice Task Force (CPTF) Faculty: Jeannine Engel, DC Dugdale, John Goodson, Ira M. Helenius,, Stephen Sigworth, Christine Sinsky, Thomas Staiger, David Thomas

2 Learning Objectives Define the basic elements required for documentation of problem-based based E & M services Learn to choose the optimal codes for outpatient visits in your faculty practice Demonstrate efficient and effective documentation, allowing more time with the PATIENT and less time with the chart Understand the use and pitfalls of the primary care exception and optimal coding in resident clinics

3 Workshop Schedule Welcome and Introductions (5 min) Basic elements of CPT coding for new and return patients (10 min) Tips for efficient documentation (10 min) Small Groups (20 minutes each) Level 2/3 return and new pt visits Level 4/5 return pt visits Resident clinics GC/GE coding Wrap up and Session Evaluation (5 min)

4 Basic Coding Rules

5 New vs. Return A new patient has not received professional services from your group in the past 3 years Hospital = clinic = ED (if you bill from ED) Residents = Faculty = Physician extenders Multi-specialty groups: variable If a known patient has not been seen in 3 years, bill them as New

6 Elements for E&M visits History HPI, ROS, PFSH (past, family, social history) Exam number of organ systems Decision making #diagnoses or management options Amount of data/complexity risk level to patient

7 CC and HPI bullets Location Quality Severity Duration Timing Modifying factors Associated signs and symptoms

8 Physical Exam-Organ Systems Constitutional-VS, general appearance Eyes Ears, nose, mouth, throat CV (inc edema) Respiratory GI GU Musculoskeletal Skin Neurologic Psychiatric Hematologic, lymph, immunologic

9 How many ROS?? 14 Constitutional-VS, general appearance Eyes Ears, nose, mouth, throat CV Respiratory GI GU Musculoskeletal Integuementary Neurologic Psychiatric Hematologic, lymph Endocrine Allergic, immunologic

10 Decision Making Number of diagnoses Self-limited; limited; established; new problem Stable, worsening, additional testing planned Amount/complexity of data Ordering tests, reviewing tests, obtaining record Overall risk See chart

11 Overall Decision Making Table need 2 of 3 elements to qualify for given level Type of MDM Straight- forward Low Moderate High # dx Amt data 0 or Overall risk minimal low moderate high

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13 Number of diagnoses Self-limited limited or minor: 1 pt each (2 max) Established problem, stable: 1 pt Established problem, worsening: 2 pts New problem, no addt l w/u: : 3 pts New problem, with further w/u: : 4 pts Complexity (and thus level of service) Straight-forward=1; Low=2, moderate=3, high=4

14 Amount and complexity of data Review and/or order of clinical test: 1 pt Basically all labs Review and/or order of radiology: 1 pt Review and/or order of medical test: 1 pt Includes vaccines, ecg,, echo, pfts Discussion of test with performing MD: 1 pt Independent review of test: 2 pts Old records or hx from another person Decision to do this: 1 pt Doing it and summarizing: 2 pts

15 Overall Risk table Learn and Love the overall risk table 3 categories: presenting problem, dx procedures, management options Pearls: Prescription drug management: moderate 2+ stable chronic illness: moderate Abrupt MS change: high 1 chronic illness w/severe exaccerbation: : high

16 Coding New Patient Visits Need 3 of 3 elements documented (history, exam, decision making) For history, need 3 of 3 sub-elements elements (HPI, ROS, PFSH) but not on all levels of service For decision process, need 2 of 3 sub- elements (#dx dx,, data/complexity, risk) DECISION MAKING WILL USUALLY DRIVE CODING

17 Coding Return patient visits Only need 2 of 3 elements documented to meet level of service coded (History, PE, Decision process) Sub-elements elements still required- see chart DECISION MAKING (again) WILL DRIVE CODING

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19 Tips, Tools, and Pearls for Efficient Documentation

20 New Patient- outpatient visit 3/3 needed CPT HPI ROS PFSH 1-3 None None Exam 1 area/ system MDM Time None 2-4 systems Straight- forward Straight- forward systems Low All 3 8+ systems Moderate All 3 8+ systems High 10 min 20 min 30 min 45 min 60 min

21 New Outpatient Visit Need 3 of History (need all) HPI ROS PFSH Exam Complexity (2/3) #Dx Data Risk Time if counseling is >50% 1 0 No meds 1 0 No meds stable prob new no w/u or 2 stable 3 Prescription med Or 2 stable pr. 10 min new w W/U or 2 worse 4 Life threaten

22 Return Patient- outpatient visit 2/3 needed CPT HPI ROS PFSH Exam 1 MDM Time Reserved for non- hospital- based practice 1-3 None None system Straight- forward none 2-4 systems Low systems Moderate systems High 10 min 15 min 25 min 40 min

23 Return Outpatient Visit Element (Need 2 of 3) HISTORY HPI ROS PFSH (or 3 chronic) (or 3 chronic) 10 ( o/w neg ) 2 EXAM # of systems COMPLEXITY (need 2 of 3) DX 1 prob. 2 est prob-stable or 1 est prob-worse 2 stable est prob or 1 new, no W/U 2 prob-worse or 1 new, w/u DATA RISK No meds 1 stable problem prescription med or 2 stable prob severe side effects, DNR

24 Pearls You CAN and should refer to previously documented elements PFSH reviewed, no change from 7/04 visit Full 10+ organ ROS done and otherwise negative Problem list updated as part of this visit

25 Counseling When time spent counseling >50% of total visit, then TIME becomes the deciding factor for coding Total billing physician (residents( don t count) ) face to face time 99213:15 min; 99214:25 minutes Must document time spent and reason for counseling

26 Counseling is: a discussion with the pt and/or family concerning one or more of the following areas CPT book Recommended tests, diagnostic results, impressions Prognosis Risks/benefits of treatment (management) options Instructions for treatment (management) options and follow up Importance of compliance with treatment (management) options Risk factor reduction Patient and family education

27 Counseling CC: I am feeling depressed. HPI: pt reports 2 months crying since mother s death. +anhedonia,, low mood and energy. No SI. A/P: Adjustment D/O with depressed mood. I spent 25 min with pt, 20 min counseling re: above. Celexa 10mg, recommend cognitive therapy. f/u in 2 weeks. CPT: 99214

28 Tips for Efficiency Balance communication with CMS requirements- If you disappeared Single elements needed in each category to count, ie sclera-no icterus,, CV-RRR Consider templates or checkboxes, especially for Physical exam, ROS

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30 SMALL GROUPS 20 minutes each Group 1: New pt & Level 2/3 Return Group 2: Level 3/Level 4 Return Group 3: GC/GE Resident Clinic billing

31 Teaching Physician Guidelines Huh? GC? GE?

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33 Teaching Physician Guidelines Fall 2002, new CMS guidelines released. The main intent is to decrease the duplicative documentation of details of H&P by faculty for E/M services. Rules apply to inpatient and outpatient scenarios

34 Teaching Physician Guidelines As the teaching physician, you need to: Personally evaluate the patient, Participate in the management of the patient by discussing diagnosis and treatment with house staff, Review the resident s note, AND SAY YOU DID ALL THIS IN A NOTE

35 Teaching Physician Guidelines I saw and evaluated the patient. I discussed with the resident and agree with Dr. Fantastic s findings and plan as documented in his note of 3/10/03, with the following additions:

36 The GOOD I I saw and evaluated the pt. I reviewed the resident s note and agree, except See resident s note for details. I saw and evaluated the patient and agree with the resident s findings and plan as written.

37 The BAD Agree with above Rounded, Reviewed, Agree. Discussed with resident, agree. Seen and agree A signature only

38 The NITTY-GRITTY Electronic notes with no patient-specific information ARE NOT considered adequate for GC documentation Resident s note MUST be completed and in the chart in order for you to refer to it Can ONLY use ROS and PFSH from a medical student, NP or PA note. Resident s signature DOES NOT make it an MD note

39 GC sample documentation GC Attestation by Dr X. I provided this service on 2005/08/24. ROS, PFSH and HPI were reviewed and confirmed with the patient. Pt here for annual exam, also c/o chronic rash and erectile dysfunction treated with viagra in the past. I examined the patient and confirmed the examination performed by the physician below. CV- RRR lungs- clear skin- lacy macular rash on arms. no pustules or vesicles. I have reviewed the chart, tests, and labs. I have discussed the differential Dx, work-up and treatment plan with the physician below, and approved the plan.

40 Primary Care Exception (GE) Operating under the Medicare Primary Care Exception (GE modifier) Continuity practice for residents in IM, Peds, FP, Ob/Gyn or Psychiatry 4 or fewer residents per attending MD NO OTHER DIRECT PATIENT CARE for attending MD Resident must be in training >6 months (ie, can not code GE for intern during July- December)

41 Primary Care Exception (GE) Attending must be physically present during clinic session Documentation must show that the patient was DISCUSSED with attending, either at the time of visit, or shortly thereafter (Attending must document KEY ELEMENTS of history, PE and medical decision making)-not ANYMORE!!

42 Primary Care Exception (GE) The new guidelines do not change what you do, only what you document Review the care provided by the resident during or immediately after each visit review pt s hx, PE, dx and treatment plan AND document the extent of your participation in the review and direction of the services furnished to each patient.

43 Primary Care Exception (GE)- sample documentation GE Attestation by Dr X I provided this service on 2005/08/23. The physician listed below presented this patient's history. The physician listed below also presented this patient's physical exam. Together we reviewed this information, formulated a clinical impression or diagnosis for each problem and developed a comprehensive plan for therapy during or immediately following the patient's clinic visit. I have approved these. End of Attestation

44 GE modifier- the kicker Only level 1,2 or 3 visits may be billed using GE!!!!! , 99203, 99212, Options if level 4 or 5 service is provided: Bill level 3-GE. 3 THIS IS OK per Medicare Bill level 4 or 5-GC. 5 If you do this, you MUST SEE THE PATIENT and repeat the key elements of history, PE, and medical decision making

45 GE Modifier- Annual exam? Medicare allows use of GE modifier for new Welcome to Medicare PE (G0344), but not for routine (non-covered) PE Other payors- variable and potentially confusing. Must be decided by individual institution.

46 GC Modifier MUST be used if all requirements for GE are not met YOU CAN code both GE and GC during the same session (not on the same pt ) If residents are getting swamped, you can see one of their pts (not one of yours) independently and still use GE for other pts during the session

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48 QUESTIONS? PLEASE FILL OUT EVALUATIONS!