Rational Physician Coding for Emergency Department E/M Services and Critical Care. Redacted Version. Peter R. Jensen, MD, CPC

Transcription

1 Rational Physician Coding for Emergency Department E/M Services and Critical Care Peter R. Jensen, MD, CPC

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3 Rational Physician Coding for Emergency E/M Services Peter R. Jensen, MD, CPC For clinically driven E/M coding education, go to ER E/M Coding E/M = Evaluation and Management How patient encounters are translated into 5 digit numbers to facilitate billing For ED E/M services, there are five levels of care: $ $ $ $ $ % 1

4 Goals Learn the documentation requirements for ED E/M services and critical care Ensure compliance Streamline the documentation process Identify the highest ethical level of care Maintain the focus on patient care E/M Code ER E/M Documentation History PF EPF EPF Det Comp Exam PF EPF EPF Det Comp MDM SF Low Mod Mod High Time NA NA NA NA NA 3 out of 3 key components must qualify 2

5 E/M = Cognitive Labor = The E/M Guidelines Developed by the AMA and CMS First set released in 1995 Second set released in 1997 Based on three Key Components History Physical Exam Medical Decision-Making 3

6 History Physical Problem Focused Expanded Problem Focused Detailed Comprehensive History Physical MDM MDM Straightforward Low Complexity Moderate We think Complexity of the key components as being random, but they re really not High Complexity Problem Focused Expanded Problem Focused History Detailed Comprehensive Physical Straightforward Low Complexity Problem Focused Expanded Problem Focused Detailed Comprehensive MDM Moderate Complexity High Complexity This is how auditors look at the E/M guidelines. They view the history, physical exam and medical decision-making in very concrete terms. 4

7 PMH FH Physical SH ROS Exam Bullets HPI Organ Systems Physical Diagnoses Risk Data Reviewed Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on overdocumentation or getting distracted from our real job of taking care of patients. 5

8 Primacy of Medical Decision-Making MDM = s: Problems Data Risk 6

9 The Importance of Medical Necessity Medical Necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate = to bill a higher level of E/M 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. Correct Level of Care Problems Data Risk The quote above is taken directly from the Medicare carrier manual and it 7

10 Determining the MDM Number of Diagnoses Minimal Limited Multiple Data Reviewed Minimal Limited Moderate Risk Minimal Low Moderate Level of MDM Straight- Forward Low Complexity Moderate s - voluntary basis. 8

11 Independent review of image, tracing, or specimen Decision to obtain old records Problem Points Problems/DDx Self limited or minor (Max 2) Established problem, stable Established problem, worsening New problem, no additional work-up planned Review/order tests in the medicine section (echo, EKG, LHC, PFTs) Discussion of test results with performing MD Review and summation of old records Points The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your findings in the chart

12 Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis Low Moderate High Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled HTN, DM2, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain One or more chronic illness, with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis Acute complicated injury, e.g., head injury, with brief loss of consciousness One or more chronic illness, with severe exacerbation, progression, or side effects of treatment Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss Table of Risk Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/ Echocardiogram KOH prep Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, (e.g., LP or thoracentesis) Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography Rest Gargles Elastic bandages Superficial dressings Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis This is the official table of risk for both the 1995 and 1997 E/M guidelines. The rules explicitly state that it only takes one element in any of the categories above to qualify for any given level of risk. Use highest level of risk present to stratify the overall level of risk for any encounter. 10

13 Calculating the Overall MDM MDM Complexity Problems Data Risk Straight 1 1 Forward Low 2 2 Minimal Low f History Physical Exam 11

14 History CC HPI ROS PFSH History PF EPF Detailed Comp Problem Focused Expanded Problem Focused Detailed Comprehensive Levels of History HPI Brief Brief Extended Extended ROS None PFSH None None 1 out of 3 3 out of 3 For ER E/M encounters, a comprehensive history requires only TWO out of THREE components of PFSH. 12

15 HPI A narrative of the patient s symptoms or illnesses since onset or since the previous encounter Every level of history requires and HPI, which may be referred to as an interval history for follow-up encounters The HPI is the only component of history which MUST be personally obtained and documented by the provider Location Duration Timing Quality Elements of HPI Severity Context Modifying factors Associated signs or symptoms 13

16 Location HPI Elements Duration Location Quality Severity Duration Timing Context Context Modifying Factors Associated Signs/Symptoms Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/10 in severity, is worse with exertion and is associated with SOB and nausea. Severity Quality Timing Modifying Factors Associated Signs or Symptoms Example of an extended HPI using all eight of the HPI elements. Brief HPI Requires only one to three HPI elements Levels of HPI Extended HPI Requires four HPI elements or the status of three chronic or inactive problems 14

17 What if the patient has no complaints? more chronic or inactive problems. Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory GI GU ROS on the status of three or Musculoskeletal Skin Neurological Psychiatric Endocrine Hem/Lymphatic Allergic/Immunologic The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire. 15

18 PFSH Past Medical History Previously existing illnesses, prior operations, current medications, allergies, immunizations Family History Health status of parents/siblings/children including relevant or hereditary diseases Social History Marital status, employment, DOA, education, sexual history The PFSH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire. History PF EPF Detailed Comp Levels of History HPI Brief Brief Extended Extended ROS None PFSH None None 1 out of 3 3 out of 3 The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation. For ER E/M encounters, a comprehensive history requires 16

19 History Tips and Shortcuts 1. You need a chief 17

20 Physical Exam 1997 Physical Exam 15 Organ Systems and 59 bullets Exam PF EPF Detailed Comp Bullets Physical Exam Organ Systems Constitutional Eyes Ears, nose, mouth and throat Neck Respiratory Cardiovascular Chest (breasts) Gastrointestinal GU (male, female) Musculoskeletal Lymphatic Skin Neurologic Psychiatric See individual bullets on next page. 18

21 Constitutional Three vital signs General appearance Eyes Inspection of conjunctiva and lids Examination of pupils and irises (PERRLA) Ophthalmoscopic discs and posterior segments Ears, Nose, Mouth, and Throat External appearance of the ears and nose Otoscopic examination of the external auditory canals and tympanic membranes Assessment of hearing Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid Respiratory Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions) Percussion of chest Palpation of chest (e.g., tactile fremitus) Auscultation of the lungs Cardiovascular Palpation of the heart (PMI) Auscultation of the heart Assessment of lower extremity edema Examination of the carotid arteries Examination of abdominal aorta Examination of the femoral pulses Examination of the pedal pulses Chest (Breasts) Inspection of the breasts Palpation of the breasts and axillae The 1997 Multi-System Exam Bullets Gastrointestinal (Abdomen) Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing Genitourinary (Male) Examination of the scrotal contents (e.g., tenderness of cord) Examination of the penis DRE of the prostate Genitourinary (Female) Examination of the external genitalia Examination of the urethra Examination of the bladder (e.g., fullness, masses, tenderness) Examination of the cervix Examination of the uterus (e.g., size, contour, position, mobility) Examination of the adnexa (e.g., masses, tenderness, nodularity) Musculoskeletal Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, ischemia) Examination of the joints, bones, and muscles of one or more of the following six areas: 1. Head and neck 2. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation, subluxation, or laxity Assessment of muscle strength and tone with notation of any atrophy or abnormal movements Lymphatic Palpation of lymph nodes two or more areas Neck Axillae Groin Other Skin Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic Test cranial nerves with notation of any deficits Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi) Examination of sensation (e.g., by touch, pin, vibration, proprioception) Psychiatric Description of patient s judgment and insight Brief assessment of mental status, which may include: Orientation to time, place, and person Recent and remote memory Mood and affect 19

22 1995 Exam Rules Body Areas Organ Systems Head/face Neck Chest/breast/axillae Abdomen Genitalia/groin/buttocks Back/spine Each extremity Constitutional Eyes ENMT Cardiovascular Respiratory GI GU Musculoskeletal Skin Neuro Psychiatric Hematologic-lymphatic Problem Focused: a limited exam of affected body area or organ system Expanded Problem Focused: a limited exam of the affected body area or organ system and other symptomatic or related organ systems Detailed: an extended exam of the affected body area or organ system and other symptomatic or related organ systems Comprehensive: a general multi-system exam or complete exam of a single organ system The 1995 exam rules are included here for the sake of completeness. We recommend using the 1997 physical exam rules because they are less open to individual interpretation and therefore more likely to stand up against an audit. 20

23 M 1. What E/M Code ER E/M Services History PF EPF EPF Det Comp Exam PF EPF EPF Det Comp MDM SF Low Mod Mod High Time 3 out of 3 key components must qualify NA NA NA NA NA 21

24 Hx E/M Code out By far freque code f encou Reimb about E/M Code PF History Exam MDM History PF PF Exam PF SF MDM Time NA NA 3 out of 3 key components must qualify SF Time Problem Focused History Problem Focused Exam SF/Low Complexity MDM HPI ROS PFSH Exam Bullets MDM Prob Pts Data Pts Risk PF Brief None None PF 1 5 from any systems SF Min EPF Brief 1 None EPF 6 11 from any systems Low 2 2 Low Det Ext 2 9 1/3 Det 12 from any systems Mod 3 3 Mod Comp Ext 10 3/3 Comp 2 from 9 systems High 4 4 High Requires two out of three 22

25 What Does a Look Like? A 42 year Problems/D Self limited or minor Established problem Established problem worsening New problem, no ad work-up planned New problem, additi work-up planned MDM Points s, s Pts Total ts = 0 23

26 Moderate High One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status MD Comp S Lo Mod Hi Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Calculating the Overall MDM Prescription drug management IV fluids, with additives Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Need 2 out of 3 to qualify for given level of MDM 24

27 E/M Co ime NA NA NA NA NA 3 ou fy P Straightforward MDM 3 out of 3 key components must qualify 25

28 CC: HPI History PF HPI ROS PFSH Brief None None 3 out of 3 key components must qualify Target Code History PF History Location Exam PF E/M Insight: Problem Focused History The requirements for a problem MDM counts as one HPI element. That s all you need. SF which 26

29 Exam Constitutional Eyes ENMT Neck Lungs Physical Exam CV GI GU ration; wound R bu sy y compone History PF ght: Probl Chest/Breasts Skin 1 2 culoskeletal eurologic ychiatric DM cused histor blem foimal, it s diffi to qualify one to five b e included th F ms. That s all you need. 27

30 Medical Decision-Making As Pl Ta It litera All you On On Min The e limited 28

31 99281 One HPI Element CC: Follow-up HPI: The patie from a left arm 4 cm well heal clean; no fluct Assessment: Plan: No f Target Requires three out of three qualifying key components History Exam MDM PF PF SF 29

32 99282 E/M Code History Exam MDM Time Hx Se fre co en Re ab E/M Co EPF EPF Low NA 3 out of 3 key components must qualify EPF History EPF Exam Low Complexity MDM HPI ROS PFSH Exam Bullets MDM Prob Pts Data Pts Risk PF Brief None None PF 1 5 from any systems SF Min EPF Brief 1 None EPF 6 11 from any systems Low 2 2 Low Det Ext 2 9 1/3 Det 12 from any systems Mod 3 3 Mod Comp Ext 10 3/3 Comp 2 from 9 systems High 4 4 High Requires two out of three 30

33 What Does a Look Like? You see a 19 year old college student with benadryl and Burrow's solution Problems/D Self limited or minor Established problem Established problem worsening New problem, no ad work-up planned New problem, additi work-up planned MDM Points, PRN Total Pts = 0 31

34 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, Laboratory tests Chest X-rays Rest Gargles High Undiagnosed new problem, with uncertain prognosis One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status identified risk factors Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Calculating the Overall MDM MDM Complexity Problems Data additives Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Risk Need 2 out of 3 to qualify for given level of MDM 32

35 Selecting the Target Code E/M Code History Exam MDM Time 33

36 History History EPF HPI Brief ROS 1 PFSH None CC: HPI: T intens ROS Target Code out of 3 key components must qualify History EPF E/M Insight: Expanded Exam EPF MDM Low d ts The example qualifies by reviewing the CV system. 34

37 Exam 5 General: NAD, conversant, well nourished WF looks stated age Skin: Warm ms 3 out of 3 key components must qualify Target Code History EPF Exam EPF E/M Insight: Expanded Problem Focused 6 MDM Low 7 35

38 Medical Decision-Making Assessment: E/M Insight: Low Complexity MDM The acuity of care required for this leve Low risk The example above qualifies b

39 99282 of low risk. Target History EPF Exam EPF MDM Low 37

40 99283 E/M Code History Exam MDM Time Hx PF EPF out Third m freque code fo encoun Reimb about E/M Code EPF EPF Mod History EPF Exam EPF MDM Mod NA Time NA 3 out of 3 key components must qualify EPF History EPF Exam Moderate Complexity MDM HPI Brief ROS None PFSH None Exam PF Bullets 1 5 from any systems Brief 1 None EPF 6 11 from any systems Low 2 2 Low Det Ext 2 9 1/3 Det 12 from any systems Mod 3 3 Mod Comp Ext 10 3/3 Comp 2 from 9 systems High 4 4 High MDM SF Prob Pts 1 Data Pts 0-1 Risk Min Requires two out of three 38

41 What Does a Look Like? You see a 34 YOF days Problems/DDx Self limited or minor (Max 2) Established problem, stable Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned Total Points Bactrim DS BID for three MDM Points 39

42 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging Over the counter drugs Minor surgery, with no risk factors Need 2 out of 3 to qualify for given level of MDM 40

43 Selecting the Target Code Comp vs The Three Questions 41

44 99283 vs Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M 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. Detailed Medicare Carrier Manual vs dial it down a notch and re-test the documentation. you should 42

45 Target Code: MDM SF Low Mod Mod High Time NA NA NA NA NA must qualify ntation 3 out of 3 key components must qualify 43

46 History History EPF HPI Brief ROS 1 PFSH None HPI: ROS Target Code Requires a Constitutional: Negative for fevers/chills/anorexia GU: Negative for flank pain, hematuria History Exam One HPI Element Duration MDM E/M Insight: Expanded Problem Focused History 44

47 Exam Constitutional Eyes ENMT Neck Physical Exam CV Lungs: CTA Chest/Breasts Skin Musculoskeletal Palpation of the skin 45

48 Medical Decision-Making Assessment: Uncomplica 46

49 Chief Complaint: Bu Target History Exam MDM 47

50 Hx PF EPF Det Comp E/M Code Se fre co en R ab E/M Code Det History Exam MDM Time Det Mod 3 out of 3 key components must qualify History Det Exam Det NA 1.64% 2 4.5% % % % MDM Mod Time NA 3 out of 3 key components must qualify EPF History EPF Exam Moderate Complexity MDM HPI Brief Brief Ext Ext ROS PFSH Exam Bullets None None PF 1 5 from any systems 1 None EPF 6 11 from any systems 2 9 1/3 Det 12 from any systems 10 3/3 Comp 2 from 9 systems MDM SF Prob Pts 1 Data Pts 0-1 Risk Min Low 2 2 Low Mod 3 3 Mod High 4 4 High Requires two out of three 48

51 What Does a Look Like? You see a 58 YOM Proble Self limited or Established pr Established pr worsening New problem, work-up plann New problem, work-up plann Total Points = 3 Total Points = 4 49

52 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast Over the counter drugs Minor surgery, with no risk factors PT/OT 50

53 Target Code:

54 ROS CV: Negative for 52

55 Physical Exam Constitutional Eyes ENMT Neck Lungs CV G GU Chest/Breasts Vitals: 148/90, 18, 96, 98.6 Skin Lungs: Clear to auscultation and percussion bilaterally CV: RRR, no MRGs Ext: No peripheral of peripheral edema Musculoskeletal Neurologic Psychiatric 53

56 Medical Decision-Making Assessment: Acute 54

57 Chief Complaint: Abdominal pain. HPI: The patient is a pleasant 58 YOWM who presents with intermittent le UA: No WBCs; RBCs TNTC /3 PFSH SH Target History Exam MDM 55

58 Hx PF EPF Det Comp* Most E/M Code HPI Brief Brief Ext Ext ROS None History PFSH None None 1/3 3/3 Comp* Exam PF EPF Det Comp Exam Comp Bullets 1 5 from any systems 6 11 from any systems 12 from any systems 2 from 9 systems MDM High Time Comprehensive* History Comprehensive Exam High Complexity MDM MDM SF Low Mod High Prob Pts NA Data Pts Risk Min Low Mod High Requires two out of three *For ER E/M services, only two out of three components of PFSH are needed to qualify for a comprehensive history. 56

59 What Does a Look Like? You see an elderly After reviewing the labs and the CXR, y Problems/DDx Self limited or minor (Max 2) Established problem, stable Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned MDM Points Pts Data Reviewed Total Points Pts 57

60 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Moderate Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast ABG Skin biopsies Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives Prescription drug management IV fluids, with additives 58

61 Target Code: E/M Code History Exam PF PF EPF EPF EPF EPF Det Det Comp Comp MDM SF Low Mod Mod High Time 3 out of 3 key components must qualify Plan Out the Documentation Comprehensive History Comprehensive Exam High Complexity MDM 3 out of 3 key components must qualify NA NA NA NA NA 59

62 History Comp* HPI Extended History ROS 10 PFSH 2/3 CC: Altered mental status HPI: This is a 79 YOWM NH resident with multipl PMH: per HPI, plus dyslipidemia and CABG in 1992 Target Code out of 3 key components must qualify History Comp* Exam Comp E/M Insight: Comprehensive* History Requires an extended HPI (four or Current Medications Lisinopril 10 mg QD Lipitor 20 mg QD Imdur 30 mg QD 70/30 inslulin 20 BID MDM High examiner. history caveat states that this will not be held against the 60

63 Exam P y ical Target Code History Exam E/M Insight: Comprehensive Exam MDM Requires at least two bullets from EACH of NINE organ systems. The example above qualifies based on the following bullets and organ systems: Constitutional Three vital si General app 61

64 Medical Decision-Making Requires High risk The example above E/M Insight: High Complexity MDM data points MDM Prob Pts Data Pts 0-1 Risk Min Requires two out of three 62

65 Chief Complaint: Altered mental status HPI: 79 YOWM NH resident with multiple medical problems including well- CXR: RML infiltrate F M /3 PFSH PMH, SH Two Bullets from EACH of NINE systems (See bullets on previous page) Target History Exam MDM 63

66 Critical Care Critical care is the direct delivery What is a Critical Illness? A critical illness AMA CPT Manual 64

67 Organ System Failure Critical Care Physician Services Critical care frequent, personal assessment and manipulation by the physician Withdrawal of, o condition in the patient's 65

68 Services Included with Critical Care Ganz catheter (93503) Central line (36556) Coding for Critical Care Add l 30 min $

69 99291 Reported for 2,636,587 encounters in 67

70 Critical Care is a Time-Based Service Total Duration of Critical Care CPT 4 Codes 3 or f) minutes x 1, Calculating Critical Care Time side or i performing es 68

71 Critical Care Documentation Must document Critical Care in the ED d document a

72 ED Visit: Services Provided Coding for this Patient (Level Total Services $783.00, Significant * separately identifiable evaluation and management service by the same physician on the same day of the procedure or other Service 70

73 Interval History CTSP stat following earlier evaluation for CHF exacerbation. Pt found unresponsive with SBP less than 80 Critical Care Coding Pearls Add up TOTAL time 71

74 History Physical MDM Select the correct level of care Let the patient s Peter R. Jensen, MD, CPC Online and On-site Physician-to-Physician E/M Coding Education U-EM-CODE pjensen@emuniversity.com Practical E/M Coding Education 72