CPT DOCUMENTATION REQUIREMENTS FOR EMERGENCY MEDICINE 2009 RELATIVE VALUE UNIT (RVU)

Transcription

1 CPT DOCUMENTATION REQUIREMENTS FOR EMERGENCY MEDICINE 2009 RELATIVE VALUE UNIT (RVU) Three components comprise the initial RVU calculation for each CPT code: Work - the estimated value of the time, effort, expertise, and intensity of the service. Approximately 55% of the RVU value. Practice expense - the estimated value of overhead and other expenses necessary to run the practice. Approximately 42% of the RVU value. Professional Liability Insurance (PLI) - the estimated value of malpractice cost for the service. Approximately 3% of RVU value.

2 RVU CONVERSION TO PAYMENT CPT Code Description RVU Conversion Factor Medicare Reimbursement 9928 ED Visit, Level 0.45 $ $ ED Visit, Level $ $ ED Visit, Level 3.34 $ $ ED Visit, Level $ $ ED Visit, Level $ $ Critical Care 4.50 $ $ EVALUATION AND MANAGEMENT Evaluation and Management (E/M) services include 7 components, 6 of which are used in determining the levels of service. The first three are considered the key components:. History 2. Exam 3. Medical Decision-Making Contributing Factors: 4. Presenting problem 5. Counseling 6. Coordination of Care 7. Time (is not a factor in Emergency Medicine E/M s other than critical care time) 2

3 MEDICAL DECISION-MAKING DETERMINING MEDICAL DECISION MAKING Medical Decision Making is comprised of the following 3 components: Number of diagnoses and/or management options Amount of complexity of data to be reviewed Risk of complications and/or morbidity or mortality 3

4 NUMBER OF DIAGNOSES AND/ OR MANAGEMENT OPTIONS - EXAMPLE Dx and Management Options Number (B) Points (C) Result (B x C = D) Self Limited or Minor (stable, improved or worsened) (Max = 2) Established problem, stable, improved Established problem, worsening 2 New problem (to examiner), no additional work up planned (Max = ) 3 New problem (to examiner), additional work up planned 4 Total Score AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED Document diagnostic tests ordered, and the results. Indicate when you interpret diagnostic tests yourself (e.g. EKGs, X-Rays) Failure to do so can make a difference in the E/M code selected. Document when old records are ordered. Indicate when obtaining a history from someone other than the patient. 4

5 AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED Category Path/Lab Radiology Other Diagnostic Studies Discussion of test results Interpretation Old Records / Additional Hx Description One or more tests (CBC count, UA, etc.) One or more tests (chest x-ray, CT, etc.) One or more studies in CPT medicine section (EKG, allergy tests, pulse ox, etc [ ]) Discussion of test results with performing provider Independent visualization of image, tracing or report Decision to obtain old records / obtain hx from other than pt / discuss case with another healthcare provider Total Score: Value DETERMINING RISK Risk is based on risk to the patient associated with the presenting problem, diagnostic/therapeutic procedures and management options. Underlying diseases or other factors that increase the complexity of patient management by increasing the risk of complications, must be documented in your note 5

6 DETERMINING OVERALL MDM 2 out of 3 of these categories must be met Number Of Dx/Management Options Amount &/Or Complexity Of Data Reviewed Risk Of Complications, Morbidity Or Mortality Minimal Low Moderate High Level of MDM Level of Service Straight forward 9928 Low Moderate / High

7 DETERMINING OVERALL MDM Number Of Dx/Management Options Amount &/Or Complexity Of Data Reviewed Risk Of Complications, Morbidity Or Mortality Minimal Low Moderate High Level of MDM Level of Service Straight forward 9928 Low Moderate / High HISTORY OF PRESENT ILLNESS 7

8 HISTORY OF PRESENT ILLNESS Element Location Definition The location on/in the patient s body where signs or symptoms are experienced. Location may be inferred from the chief complaint or presenting symptom. Example Located in right upper quadrant, left foot, right hand, my stomach, nauseated (GI), short of breath (Resp). Quality The physician should encourage the patient to describe the quality of the symptom Experience sharp pain, productive cough, red discharge, crushing pain. Severity Timing Describes the severity of the sign or symptom. Relates a measure of time with reference to how often the sign/symptom occurs, or when it occurs in relationship to time of day, day of the year or month, etc. Should relate to the CC or AS&S. The pain is mild, it is progressively worsening, the pain is a 0 on the pain scale. Symptom is intermittent, waxes and wanes every day, every month, comes and goes, steady. HISTORY OF PRESENT ILLNESS Element Context Modifying Factors Associated signs and symptoms Definition Defines the setting in which signs and symptoms occurred, the activity that was occurring when the sign or symptom began, or the causation of the sign or symptom. An event that makes a sign or symptom better or worse or has the potential to make better or worse. Lists signs and symptoms that occurred in addition to the chief complaint. Example Happened in the bathtub, during dinner, riding a horse, auto accident, infection, anticoagulants (blood thinners). Becomes worse when I rest, better after taking nitroglycerine, worse when going up stairs. Also experiences nausea and vomiting, swelling, diaphoresis, blurred vision, absence of sign is significant (e.g., abdominal pain w/o vomiting, diarrhea, related symptoms). Duration The time that the signs or symptoms first began as it relates to the CC or any AS&S. Began yesterday, at 3 pm, last night, three years ago. 8

9 HISTORY OF PRESENT ILLNESS - EXAMPLE requires -3 elements requires 4 or more elements Chest pain (location). Denies SOB (associated signs and symptoms) Meets the HPI requirements for a Chest pain (location) while working in yard (context) this morning (timing). Denies SOB (associated signs and symptoms) Meets the HPI requirements for a HISTORY OF PRESENT ILLNESS Must be obtained by the physician, when billing under the physician s provider number. Elements listed in the HPI can also be counted towards the Review of Systems 9

10 REVIEW OF SYSTEMS Constitutional Eyes Ears, Nose Throat and mouth Cardiovascular Gastrointestional Musculoskeletal Endocrine Neurologic Integumentary Psychiatric Genitourinary Allergic/Immunologic Respiratory Hematologic/Lymphatic REVIEW OF SYSTEMS REQUIREMENTS 9928 Does not require a systems review Requires at least element Requires 2-9 elements Requires 0 or more elements May also be taken from the HPI or Past Medical History. May list pertinent positive and negative responses then state All other systems reviewed and are negative If the history is unobtainable, you must state the reason. 0

11 REVIEW OF SYSTEMS LEVEL 5 EXAMPLE Patient presents with SOB, exertional dyspnea and CP. Denies syncope episode, N/V, fever or chills. All other systems were reviewed and are negative. Requirements met: Respiratory Cardiovascular Neurologic Gastrointestional Constitutional All other systems were reviewed and are negative. REVIEW OF SYSTEMS Insufficient documentation in the Review of Systems is the most common cause of downcoded charts

12 PAST, FAMILY AND/OR SOCIAL HISTORY Not Required Requires Requires 2 CHIEF COMPLAINT, ROS and PFSH May be obtained by ancillary personnel Physician must indicate he/she has reviewed and agrees. The lowest score out of HPI, ROS and PFSH = the level of history 2

13 DETERMINING HISTORY LEVEL HPI ROS PFSH History Level LOS -3 elements None None Problem Focused elements Results in a loss of.57 RVU s (or $58.66 per chart) None Expanded Problem Focused elements 2 9 Detailed elements 0+ 2 Comprehensive DETERMINING HISTORY LEVEL HPI -3 elements -3 elements 4 elements 4 elements ROS None PFSH History Level LOS None Results innone a loss of 3.0 RVU s (or $5.02 per chart) Problem Focused 9928 Expanded Problem Focused Detailed Comprehensive

14 Yearly Loss In one month, 72 charts were downcoded from to or This resulted in a net loss of $22,46.00 in reimbursement. Annualized would be almost $298,992 net reimbursement loss EXAM COMPONENTS Abdomen Neck Head, including face Chest, including breasts and axilla Each extremity Genitalia, groin, buttocks Eyes ENT and mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Imm unologic 4

15 EXAM REQUIREMENTS 9928 Requires at least body area or organ system Requires 2-4 body areas and/or organ systems Requires 5-7 body areas and/or organ systems Requires at least 8 organ systems If unable to complete exam, you must state reason. Must list body areas/organ systems individually. Cannot use blanket statement (e.g. all other negative ) May list individual results as Negative. BALLPARK RULES THERE IS AN EXCEPTION TO EVERY RULE Admit rate and Generally about the same I.V. w/additives (e.g. Dilantin) - Usually start at Arrive by ambulance - Usually start at Admits/Transfers - Usually considered Thrombolytics (e.g. TPA, SK) - Usually start at or

16 9928 Examples The Nature of Presenting Problems for E/M Level 9928 is as follows: Self-limited/minor severity Runs a definite/prescribed course Is transient in nature Is not likely to permanently alter health status Has a good prognosis with management/compliance CPT 2008 lists the following examples of a 9928 E/M Level patient: ED visits for a patient for removal of sutures from a well healed uncomplicated laceration that was not originally sutured by any provider in the local ED group ED visits for a patient with several uncomplicated insect bites Examples The Nature of the Presenting Problems for E/M Level is as follows: Low severity Full recovery without functional impairment is expected Low risk of morbidity without treatment Low risk of mortality without treatment Moderate severity Moderate risk of morbidity without treatment Moderate risk of mortality without treatment Uncertain prognosis or increased probability of prolonged functional impairment CPT examples for E/M Level are as follows: ED visit for a 20 year-old presenting with painful sunburn with blister formation ED visit for a child presenting with impetigo localized to the face ED visit with minor trauma to extremity with localized pain, swelling, and bruising ED visit for otherwise healthy patient with red, swollen cystic lesion on back ED visit for patient presenting with rash on both legs after exposure to poison ivy ED visit for a young adult with injected sclera and purulent discharge from both eyes without pain, visual disturbance, or history of foreign body in either eye 6

17 99283 Examples The Nature of the Presenting Problem (s) for E/M Level is as follows: Usually moderate severity Moderate risk of morbidity without treatment Moderate risk of mortality without treatment Uncertain prognosis or increased probability of prolonged functional impairment CPT examples for E/M Levels are as follows: ED visit for a sexually active female complaining of vaginal discharge who is febrile, and denies experiencing abdominal or back pain ED visit for a well-appearing child, who has a fever, diarrhea, and abdominal cramps, is tolerating oral fluids and not vomiting ED visit for a patient with an inversion ankle injury, who is unable to bear weight on the injured foot and ankle ED visit for patient complaining of acute pain associated with suspected foreign body in eye ED visit for healthy, young adult who sustained blunt head injury with local swelling and bruising without subsequent confusion, LOC, or memory deficit Examples The Nature of the Presenting Problem (s) for E/M Level is as follows: High severity and requires urgent evaluation by provider, no immediate threat to life or physiologic function Risk of morbidity without treatment is high to extreme Moderate to high risk of mortality or high probability of severe prolonged functional impairment CPT examples for E/M Levels are as follows: ED visit for a child who fell off a bike, sustaining a head injury with brief loss of consciousness ED visit for an elderly patient who has fallen, is now complaining of pain in her hip, and is unable to walk ED visit for a patient with flank pain and hematuria ED visit for a female presenting with lower abdominal pain and a vaginal discharge 7

18 99285 Examples The Nature of Presenting Problem (s) for patients in the E/M Level is as follows: High severity Risk of morbidity without treatment is high to extreme Moderate to high risk of mortality or high probability of severe, prolonged functional impairment Level 5 poses an immediate significant threat to life or physiologic function Examples - Continued CPT examples of patients for E/M Level are as follows: ED visit for a patient with a complicated overdose requiring aggressive management to prevent side effects from ingested material ED visit for a patient with new onset of rapid heart rate requiring IV drugs ED visit for a patient exhibiting active, upper GI bleeding ED visit for adult injured in automobile accident brought to ED immobilized with symptoms compatible with intra-abdominal injuries or multiple extremity injuries ED visit for patient with acute onset of chest pain compatible with cardiac ischemia and/or pulmonary embolism ED visit for patient with sudden onset of worst headache of her life complaining of stiff neck, nausea, and inability to concentrate ED visit for patient with new onset of CVA ED visit for acute febrile illness in an adult, associated with shortness of breath and an altered level of alertness 8

19 CRITICAL CARE CRITICAL CARE Definition: Illness or injury that acutely impairs one or more vital organ systems Patient s survival is jeopardized High probability of sudden, clinically significant or life threatening deterioration Urgent intervention required. 9

20 CRITICAL CARE SERVICES PROVIDED Life and organ supporting interventions Frequent, personal assessment Ongoing manipulation of treatment options 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 patient s condition. Full physician attention to patient. Cannot provide services to any other patient during the same period. Time spent by physician does not have to be continuous. CRITICAL CARE SERVICES INCLUDE: Time engaged in work directly related to patient s care, whether or not time was spent at immediate bedside. Reviewing test results or imaging studies Discussing patient s care with other medical personnel Documenting critical care services in the medical record Obtaining patient history If patient is unable to participate in discussions, time spent with family members or surrogate decision makers in reviewing patient s condition or prognosis; discussing treatment options. 20

21 SEPARATELY BILLABLE SERVICES CPR Pericardiocentesis Endotracheal Intubation Chest Tube CVP Placement EKG Interpretation Time spent performing these services should be excluded when calculating the total critical care time. CRITICAL CARE EXAMPLES Shock Hypertensive Crisis Overdose Respiratory Distress Seizures CVA Myocardial Infarction 2

22 CRITICAL CARE EXAMPLES If you use any of the following drugs, your patient is likely to be considered critical: Multiple injections (or drip) of Cardizem Multiple injections of Adenosine Multiple injections of Adenocard Multiple injections of Varapamil Nitro drip Morphine drip DNK; SK; TPA Dopamine Tridil drip Prolonged breathing treatments Any thrombolytic Key indicators of critical care Acidosis (moderate to severe) Anaphylactic shock Angina, unstable Atrial fibrillation w/ tachycardia Asthma, multiple treatments w/ more risk Blood loss, prbcs hung Cardiac arrest Comatose/unconscious, unknown cause at presentation COPD/CHF severe exacerbation Dehydration w/ significant metabolic/blood chemistry changes GCS below 4 (depending on cause) Head injury, severe Hypoxia, severe or w/ respiratory distress Hypernatremia requiring treatment 22

23 Key indicators of critical care Intracranial hemorrhage Open fracture Overdose Pneumothorax Pulmonary edema Pulmonary emboli Emergency dialysis Seizure requiring drug management to stop Sepsis Stroke Suicidal ideation, clear and immediate threat, requiring chemical/physical restraints Trauma, multiple, altered consciousness, life or limb threatening Unstable vital signs The list above was compiled from a combination of two sources: James R. Blakeman, Emergency Groups Office, EM Seminars 2ACEP s website REQUIRED DOCUMENTATION Time with patient must be recorded. Need statement such as Spent a total of 45 minutes in the critical management of this patient. This excludes time spent in performing separately billed procedures. This can be easily documented on the back side of your T-Sheet by circling the time spent. 23

24 Splints/Casting Splinting and Casting For indicating the service provided in the application of splints and casts, specific information on the type of service and some indication of the involvement by the provider must be recorded Specific details of the type of splint / cast applied e.g. short arm splint; volar gutter splint; knee immobilizer; clavicle strap; etc Provider must indicate the degree of involvement e.g. applied by me; I assisted; supervised; participated; position checked before and after placement any indication of personal participation in the placement of the splint / cast Orthopedic Services 24

25 Orthopedic Services Please feel free to contact me if you have any questions Laurel Green, CPC Manager, Coding and Reimbursement Office: x224 Cell: