Focus On Signs and Symptoms

Transcription

1 Focus On Signs and Symptoms Decreasing Primary Care Access Help Your Patients with Their Insurance Benefits Risk Management and Reimbursement Align Don t Forget to Document Abnormal Vitals and Labs Document Multiple Diagnoses for Procedures Document Well and Avoid Insurance Denials

2 1 LogixHealth provides expert coding and billing services for millions of ED visits annually.

3 Decreasing Primary Care Access Almost all patients that come to our emergency departments do so for a good reason. They are usually experiencing a symptom that is of concern to them, and which in their opinion warrants an ED evaluation. Often they do not have any access to a primary physician (this applies to both insured and uninsured patients) as PCPs are increasingly unable to accommodate potentially sick and unscheduled patients; many times patients are instructed by their physicians office to simply go to the emergency department, and meanwhile others delay their care and become sicker as a result of their lack of access. As a result, higher acuity patients are presenting to our EDs. It is important to document on the medical record the signs and symptoms that prompted the patient to seek care in the emergency department, as failure to do so often results in an insurance payment denial due to the ED visit supposedly being medically unnecessary and the patient subsequently gets stuck with the bill. This newsletter will help arm you to use diagnosis coding to support your patients and the financial health of your practice. Help Your Patient With Their Insurance Benefits As ED physicians we may ultimately diagnose a patient complaining of abdominal pain with gastritis, or a coughing patient with a fever and dehydration as a viral syndrome. In such cases, if no other supporting diagnosis is documented on the chart that supports the reason for the ED visit, the patient may be stuck with the bill (after their insurance denies the claim due to it supposedly being an inappropriate ED visit). The insurance company will say to the patient that going to the ED for a viral syndrome is not medically warranted per their contract. This frequently results in complaint letters from the patient who looks to the ED group for help, and requires multiple interactions with the insurance company in an effort to get the bill paid. Ultimately, the contract between the patient and their insurance company may only cover medically necessary ED visits and insurance carriers often seek to show that seeking ED care was unreasonable on the part of the patient. There also may be state laws (although these laws only cover managed care plans) that require the insurer to cover ED care under circumstances when the patient sought care acting as a prudent layperson. For example, the scenario in which a child receives an evaluation and a head CT for a potentially serious head injury, and is discharged with a diagnosis of well child, may result in a claim denial. Similarly, there should be a presenting complaint and diagnosis documented on the chart to justify why the head CT was performed in order for the hospital to be reimbursed for the study. It is appropriate to list the actual injury as your diagnosis, as this is what you evaluated and used your expertise and diagnostic studies to investigate. If clinically warranted, listing scalp contusion or head injury as your diagnosis is accurate. Indeed, you will often send home such patients with head injury instructions looking for signs of delayed bleeding, etc. Including the patient s chief complaint and the presenting signs and symptoms helps communicate to the patient s insurance company the way the patient appeared when they presented to the ED, and paint the picture of the medical necessity for the visit. Patients usually do not present to the ED complaining of viral syndrome or gastritis; they come to our EDs with symptoms rather than a diagnosis. They may present to the ED with a complaint (symptom) of chest pain (with a cough maybe), abdominal pain, fever, shortness of breath, vomiting, or headache, etc. Additionally, on exam their mucous membranes may be mildly dehydrated. It is important to document these types of signs and symptoms, and for the coders to capture these important diagnoses with the appropriate codes. Founded by emergency physicians to better serve their own practices, LogixHealth is one of the nation s leading providers of ED coding and billing services. 2

4 Risk Management and Reimbursement Align From a risk management perspective, we tend to focus on the pertinent negatives that should be included on the chart, such as a supple neck, and list out the signs and symptoms that the patient was lacking (e.g. no shortness of breath, no chest pain ). In addition to documenting negatives it is also important to list the symptoms that prompted a typical layperson to seek emergency care, or the patient might be stuck fighting with their insurance company when it comes time for payment. If a work up for upper abdominal/low chest pain results in a presumptive diagnosis of gastritis, a poorly documented chart may result in an insurance denial and subsequently the patient may be billed directly. This is not fair to you or the patient. For example, in the case of a patient with gastritis/reflux who presented with lower mid chest pain and upper abdominal pain, it is very helpful if you include, right in the diagnosis section, the symptom chest pain, abdominal pain, and in the text of the chart indicate that it was likely gastritis and close instructions were given to return if worse etc. Important conditions to consider that document medical necessity include: Abdominal Pain* Chest pain Dehydration Dyspnea Extremity pain^ Fever Flank pain Headache Neck pain Pelvic Pain Vomiting *specify location ^such as ankle or wrist pain Furthermore, you can help your hospital avoid denials by working with your coders to assign codes that justify ancillary testing. For example, if a patient ultimately was diagnosed with GERD, but an EKG was ordered due to the chest pain symptom, Medicare has specifically instructed that chest pain should be included as a diagnosis. Interestingly, documentation of a sign or symptom as the final diagnosis is one area where many feel that risk management and reimbursement interests are well aligned. Signs and symptoms are often used as a diagnosis, and many risk management experts instruct the frequent use of these instead of a firm diagnosis (especially with abdominal pain). Therefore, listing signs and symptoms as your final diagnosis will help the chart to be coded accurately, and may assist with risk management. This applies to patients with known and unknown causes for their symptoms. The person with vague multiple complaints may be diagnosed with arm numbness, abdominal pain, chest pain, headache, etc. while the likely gastritis or viral syndrome patient may be diagnosed with vomiting, abdominal pain, chest pain, fever, dehydration. Of particular note, when a parent notes a fever at home, but the child is afebrile in the department, you can indicate fever as one of your diagnoses. The same would be true for transient difficulty breathing or any other resolved symptom. The resolved symptoms frequently contribute to the seeking of the emergency medical evaluation, and documenting the symptoms that prompted the evaluation on the chart is accurate and will help to avoid unfair insurance denials. Don t Forget to Document Abnormal Vitals and Labs As mentioned above, the documentation of the patient s symptoms is important. Additionally, documenting abnormal vital signs (such as tachycardia), and any abnormal lab values (such as anemia and hypokalemia) help to paint a better picture of the patient for the coder and the insurance company. Furthermore, keep in mind that injury diagnoses (such as leg or hand injury) are helpful to describe the patient s initial presentation to the ED. Final diagnosis such as viral syndrome, URI, UTI, gastritis, GERD, and diarrhea may be used, but do not preclude using signs and symptoms to provide a more complete description of the reason for the visit and the subsequent testing performed. 3

5 Document Multiple Diagnoses for Procedures When performing a procedure (such as a laceration repair) in addition to a separate Evaluation and Management (E/M) service, it is important to document at least two diagnoses for the coder. Insurance companies often routinely deny the E/M portion of the visit, and only reimburse for the laceration repair (or other procedure such as an I&D of an abscess). For example, if a patient falls and has a scalp laceration, the physician must perform an evaluation that includes a determination of the extent of the injury and any potential neurological issues, the mechanism of injury, location, how old the wound was, the immunization status of the patient, if antibiotics are warranted, etc. Those services typically justify the E/M service, and in such cases the laceration repair is a distinct service from the E/M service. Both the E/M and the laceration codes, when submitted on a claim, should correspond to a specific diagnosis. When there is only one diagnosis used (such as 3 cm face laceration ) and it corresponds on the claim to both the E/M and the procedure CPT code, many insurance companies deny payment for the E/M. Document Well and Avoid Insurance Denials After all of your conscientious work documenting the HPI, ROS, procedures, etc. you may still face an insurance denial based on medical necessity. Your documentation of the diagnosis is the final minefield to navigate through on the bomb-laden reimbursement highway! We hope this map helps you and your patients avoid the frequent reimbursement traps related to diagnosis coding. 4

6 5 LogixHealth s state-of-the-art data warehouse continuously monitors coding distributions and provides productivity, outlier and RVU reports.

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