John Sanchez, D.O. August 18, 2013

Transcription

1 John Sanchez, D.O. August 18, 2013

2 Ø Coding Caps Ø Relevance to Clinical Practice Ø Current Guidelines 1995 (organ systems) 1997 (bullets) Ø Definitions ICD- 9 CPT E/M ( 99 _ ) Ø Who Should Determine the Appropriate E/M Level?

3 Ø Outpatient* Ø Inpatient Ø Critical Care Ø Consultations Ø Emergency Room Ø Home Visits Ø Skilled Nursing Facility Ø Rest (nursing) Home

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5 Ø C/C Fever Ø HPI This is a 20 y/o Hispanic female who presents to the office with a c/c of fever. She was seen in the ED for the same complaint 3 days ago Ø ROS Constitutional admits to F/C and night sweats, also generalized weakness ENT/Mouth/Neck denies ear pain, nasal congestion, sore throat CV admits to heart racing, denies CP Respiratory admits to slight cough, denies SOB/wheezing GI admits to nausea, denies vomiting/diarrhea/abdominal pain GU denies dysuria/flank pain/vag discharge MS denies joint pain/swelling Integument denies rash

6 Ø PE Constitutional Vs noted, pt appears WNWH/NAD ENT/Mouth/Neck TM lucent, pharynx pink, neck supple s masses CV Tachycardic, reg rhythm s MRG Respiratory LCTAB GI Abd soft c +BS and minimal epigastric TTP, no RRG GU no suprapubic/cv TTP MS FROM x 4 ext, joints s edema/erythema/calor Skin no rash noted Neuro no Kernig s/brudsinski s Hem/Lymphatic/Immunologic no pethechiae/purpura/ ecchymoses/adenopathy

7 Ø A/P 1) Fever (etiology?) UA CBC CXR Request/Review ED Record

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9 C/C Follow up on DM HPI DM BS s ranging HTN tolerated the Norvasc that was started on the last visit BPH no changes to report since last seeing his urologist ROS CV denies CP/LE edema Respiratory denies SOB nor orthopnea PFSH Reviewed/Unchanged

10 PE Vs noted, otherwise not performed A/P 1) DM controlled 2) HTN worsened 3) Increase Norvasc to 10mg One Daily #30 1 refill 4) RTC 1 mo.

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12 C/C Annual Physical HPI This is a 55 y/o white female who presents to the office to establish care and for her annual physical exam. She needs refills on her meds ROS Constitutional denies fatigue/weakness/wt changes Eyes denies changes in vision ENT/Mouth/Neck admits to constant nasal congestion and sneezing CV denies CP/palpitations/LE edema Resp denies SOB/cough/wheezing GI denies abd pain/indigestion/changes in bowel habits MS denies joint/muscle pain/stiffness as long as she takes her meds Integument concerned about a mole on her right hand Psych denies recent stressors or changes in mood/personality/sleep Endocrine denies heat/cold intolerance or polyuria/polydipsia Hem/Lymph denies easy bruising/bleeding or swollen glands

13 PFSH PMHx HTN, GERD, Glaucoma, Skin Cancer, OA PSHx None Meds Norvasc, Ranitidine, Ibuprofen, Eye gtts All PCN FH Colon CA, DM SH Denies x 3

14 PE Constitutional Vs noted, pt appears WNWH, NAD CV RRR s MRG, no LE edema noted Respiratory LCTAB Skin Macule on dorsum of right hand, ~6mm diameter with irreg borders, asymmetric appearance, and jet black in color

15 A/P 1) HTN controlled 2) GERD controlled 3) OA controlled 4) Glaucoma stable 5) AR new onset 6) NUB 1) Norvasc 10mg QD #30 6R 2) Ranitidine 150mg BID PRN #60 6R 3) Begin Nasonex 2 sprays/ nostril once daily #1 1R 4) Dermatology Consult 5) Schedule screening colonoscopy 6) CMP/Lipids/TSH/CBC 7) Follow up in 2 wks for complete PE, EKG, and discussion of blood work. Patient agrees with plan Total face- to- face time 60 min.

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17 1) History 2) Physical Exam 3) Medical Decision Making

18 Chief Complaint (C/C) History of Present Illness (HPI) Review of Systems (ROS) Past Medical/Family/Social History (PFSH)

19 The medical record should clearly reflect the chief complaint.

20 Location Quality Modifying Factors Onset/Duration Timing/Frequency Associated Signs and Symptoms Context Severity

21 Constitutional Eyes ENT/Mouth/Neck Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integument Neurologic Psychiatric Endocrine Hem/Lymph Allergic/Immunolo

22 PMHx PMHx PSHx OBGynHx Meds Allergies FH SH

23 Problem Focused Expanded Problem Focused Detailed Comprehensive

24 History C/C HPI ROS PFSH Physical Exam Medical Decision Making

25 Ø Exam Type General Multi- System Exam* Single Organ System Exam Ø Exam Format Organ Systems (1995)* Bullets (1997)

26 Constitutional Eyes ENT/Mouth/Neck Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurological Psychiatric Hem/Lymph/Immuno

27 Problem Focused Expanded Problem Focused Detailed Comprehensive

28 History C/C HPI ROS PFSH Physical Exam Organ Systems (1995)* Bullets (1997) Medical Decision Making

29 Diagnosis and/or Management Options Amount and Complexity of Data Overall Risk

30 Straightforward Low Complexity Moderate Complexity High Complexity

31 History C/C HPI ROS PFSH Physical Exam Organ Systems (1995)* Bullets (1997) Medical Decision Making Diagnosis and/or Management Options Amount and Complexity of Data Overall Risk

32 Demographic Information Assess Appropriate Level 1) History 2) Physical Exam 3) Medical Decision Making New vs. Established patient Document Appropriate E/M Level on Encounter Form

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34 Demographic Information Assess Appropriate Level 1) History 2) Physical Exam 3) Medical Decision Making New vs. Established patient Document Appropriate E/M Level on Encounter Form

35 History C/C HPI ROS PFSH Physical Exam Organ Systems (1995)* Bullets (1997) Medical Decision Making Diagnosis and/or Management Options Amount and Complexity of Data Overall Risk

36 The C/C, HPI, and PFSH may be listed as separate elements, or they may be included in the description of the HPI. A ROS and/or PFSH obtained during an earlier encounter need not be re- recorded if there is evidence that the provider reviewed and updated the previous information, as evidenced by: describing any new ROS/PFSH or noting there has been no change and noting the date and location of the earlier ROS/PFSH

37 The ROS/PFSH may be recorded by ancillary staff or on a form completed by the patient. If the provider 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. For the ROS, the patient s positive responses and pertinent negatives for the system related to the problem should be documented.

38 Specific abnormal and relevant negative findings of the exam of the affected/symptomatic organ systems should be documented. A notation of abnormal without elaboration is insufficient. Abnormal/unexpected findings of the exam of the unaffected/asymptomatic organ systems should be documented. A brief statement or notation indicating negative or normal is sufficient to document normal findings related to unaffected/asymptomatic organ systems.

39 When the record indicates that the specific element of the exam was deferred, the reasons for the deferral should be documented. To receive credit for the Constitutional organ system of the exam, at least 3 vital signs must be recorded

40 Ø Diagnosis and/or Management Options For a presenting problem with an established diagnosis, the record should reflect the current status of the problem (ie., improved, well controlled, resolving, resolved, poorly controlled worsening, unchanged, etc.). For a presenting problem without an established diagnosis, the assessment may be stated in the form of presenting signs or symptoms followed by consider, rule out, etc. Comorbidities/underlying diseases are not considered in selecting the level of E/M service unless their presence significantly increases the complexity of the medical decision making.

41 Ø Amount and Complexity of Data The review of tests should be documented. An entry on the progress note such as WBC elevated or CXR unremarkable is acceptable, or the review may be documented by initialing and dating the report containing the test results. Relevant findings from the review of the old records or additional history should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of old records reviewed or additional history obtained from family without elaboration is insufficient.

42 Ø Overall Risk Comorbidities/underlying diseases that increase the complexity of the medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented.

43 Time is the least significant factor that determines the correct E/M level of service. The only instance where time may be used as the sole basis to determine level of E/M service is when the total time (face- to- face) the provider spends with the patient is dominated (>50%) by counseling and/or coordination of care. Documentation Total time spent (be sure that the chart clearly indicates that >50% of the total time spent was dominated by counseling/coordination of care) Describe the content (see criteria) of counseling/coordination of care. Consult coding chart to select appropriate E/M level of service.

44 - 25 It is used to bill and office visit (E/M service) on the same date as a procedure or surgical service Its purpose is to demonstrate that a significant, separately identifiable E/M service (i.e., diagnosis) was required by the same provider on the same day of a procedure [ ] Neoplasm of Undetermined Signif. (ICD- 9) This is an E/M modifier (i.e., it gets attached to the office visit level code on the encounter form) [11000] Biopsy of a Lesion, 1 st lesion (CPT)

45 Blank Progress Notes Templates Dictation Electronic Medical Records (EMR) Templates Voice Recognition

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47 Ø C/C Fever Ø HPI This is a 20 y/o Hispanic female who presents to the office with a c/c of fever. She was seen in the ED for the same complaint 3 days ago Ø ROS Constitutional admits to F/C and night sweats, also generalized weakness ENT/Mouth/Neck denies ear pain, nasal congestion, sore throat CV admits to heart racing, denies CP Respiratory admits to slight cough, denies SOB/wheezing GI admits to nausea, denies vomiting/diarrhea/abdominal pain GU denies dysuria/flank pain/vag discharge MS denies joint pain/swelling Integument denies rash

48 Ø PE Constitutional Vs noted, pt appears WNWH/NAD ENT/Mouth/Neck TM lucent, pharynx pink, neck supple s masses CV Tachycardic, reg rhythm s MRG Respiratory LCTAB GI Abd soft c +BS and minimal epigastric TTP, no RRG GU no suprapubic/cv TTP MS FROM x 4 ext, joints s edema/erythema/calor Skin no rash noted Neuro no Kernig s/brudzinski s Hem/Lymphatic/Immunologic no pethechiae/purpura/ ecchymoses/adenopathy

49 Ø A/P 1) Fever (etiology?) UA CBC CXR Request/Review ED Record

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51 C/C Follow up on DM HPI DM BS s ranging HTN tolerated the Norvasc that was started on the last visit BPH no changes to report since last seeing his urologist ROS CV denies CP/LE edema Respiratory denies SOB nor orthopnea PFSH Reviewed/Unchanged

52 PE Vs noted, otherwise not performed A/P 1) DM controlled 2) HTN worsened 3) Increase Norvasc to 10mg One Daily #30 1 refill 4) RTC 1 mo.

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54 C/C Annual Physical HPI This is a 55 y/o white female who presents to the office to establish care and for her annual physical exam. She needs refills on her meds ROS Constitutional denies fatigue/weakness/wt changes Eyes denies changes in vision ENT/Mouth/Neck admits to constant nasal congestion and sneezing CV denies CP/palpitations/LE edema Resp denies SOB/cough/wheezing GI denies abd pain/indigestion/changes in bowel habits MS denies joint/muscle pain/stiffness as long as she takes her meds Integument concerned about a mole on her right hand Psych denies recent stressors or changes in mood/personality/sleep Endocrine denies heat/cold intolerance or polyuria/polydipsia Hem/Lymph denies easy bruising/bleeding or swollen glands

55 PMFSH PMHx HTN, GERD, Glaucoma, Skin Cancer, OA PSHx None Meds Norvasc, Ranitidine, Ibuprofen, Eye gtts All PCN FH Colon CA, DM SH Denies x 3

56 PE Constitutional Vs noted, pt appears WNWH, NAD CV RRR s MRG, no LE edema noted Respiratory LCTAB Skin Macule on dorsum of right hand, ~6mm diameter with irreg borders, asymmetric appearance, and jet black in color

57 A/P 1) HTN controlled 2) GERD controlled 3) OA controlled 4) Glaucoma stable 5) AR new onset 6) NUB 1) Norvasc 10mg QD #30 6R 2) Ranitidine 150mg BID PRN #60 6R 3) Begin Nasonex 2 sprays/ nostril once daily #1 1R 4) Dermatology Consult 5) Schedule screening colonoscopy 6) CMP/Lipids/TSH/CBC 7) Follow up in 2 wks for complete PE, EKG, and discussion of blood work. Patient agrees with plan Total face- to- face time 60 min.

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