Evaluation and Management (E/M) Training. Module 12

Transcription

1 Evaluation and Management (E/M) Training Module 12

2 AMA Disclaimer CPT copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah CODE (2633), Fax , All rights reserved. CPC, CPC-H, CPC-P, CIRCC, CPMA, CPCO, and CPPM are trademarks of AAPC. CPT copyright 2011 AMA. All rights reserved. Page ii E/M Training

3 Module 1 M o d u l e 12 Specialty: Emergency Department Emergency departments (ED) see a wide range of illnesses from something as simple as an ankle sprain to something as complex as a traumatic ATV accident. Included in these conditions are laceration or wound repairs, fracture care, and removal of foreign bodies. Each time a patient is seen in the ED, the patient is treated as a new patient. Because of this, the ED E/M codes do not distinguish between new and established patients. While many minor procedures are performed by the ED physicians, when more extensive procedures are required for care of the patient, the patient is transferred for care by a physician of another specialty. Documentation in the ED is typically done using a template (eg, T-System). This allows for documenting expeditiously. As a result, when auditing, one might often see a check mark for normal instead of detail on a certain system. The 1997 Documentation Guidelines for Evaluation and Management services indicates, a brief statement or notation indicating negative or normal is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). Wound Repair Wound repair codes describe separately reportable or stand-alone services. Note that wound repair is generally included in more extensive procedures. There are three categories of repairs: Simple repairs ( ) include local anesthesia, and chemical or electrocauterization of wounds. Closure with adhesive strips only is not counted as a simple repair, but is instead included in any E/M service reported for the date of service. Simple wound repair is included in lesion removal procedures, but documented intermediate and/or complex repairs may be reported separately with lesion removal. Medicare generally specifies a 10 day global period for simple repairs. Intermediate repairs ( ) are more substantial, and may include layered closure. These repairs reach into the subcutaneous and non-muscle fascia, and closing the wound in layers requiring more extensive work. In addition, this type of repair may involve removing particulate from the wound. Medicare generally specifies a 10 day global period for intermediate repairs. Complex ( ) repairs require more than just a layered closure for deep wounds. Debridement of a wound generally correlates to a complex repair, as does scar revision. As well, cosmetic closures are usually complex repairs. These repairs might involve some mattress stitching or undermining before closing, and usually involve longer (90-day) global periods. Wound repair codes are selected based on the complexity of repair, as we have seen, as well as the site of laceration or wound, and the length of the wound repair. Wound measurements should be made prior to administration of topical or injectable anesthetic. When coding for multiple repairs, consider first the location of each wound. Wound repair in different parts of the body are coded differently because of the degree of difficulty. Laceration or wound repair in the face is more difficult than on the arm. For all wound repairs of the same severity in the same location category, you should sum the lengths of each wound to determine a single code that describes the total length of the wounds repaired. CPT copyright 2011 AMA. All rights reserved. Page 1 E/M Training

4 For example, a patient puts his hand through a window and suffers multiple lacerations. For each separate simple repair in the same location, you would sum the lengths to arrive at a total length. You would repeat this process for each separate intermediate repair in the same location, and again for each separate complex repair. You may need to append a modifier (such as modifier 51 or modifier 59, depending on payer preference) when reporting multiple repairs in separate areas within the same repair location. Without the modifier, some payers may bundle simple repairs into more complex repairs in the same location category. Fracture Care Broken bones are inevitably seen in the ED. The ED physician typically treats the immediate needs of the fracture by manipulating the fracture and/ or applying a cast. The follow up care is usually provided by an Orthopedist after the ED visit. To accurately report this, the ED physician must append modifier 54 to the fracture code to indicate he/she performed the surgical care only. If the ED provider only applies a splint, without providing any restorative (manipulation/ reduction) treatment, with the expectation that the patient will follow up with an Orthopedist for treatment, the ED provider will report a code for applying the splint. In this case, the ED physician applies the splint to provide comfort to the patient until he or she is able to meet with an Orthopedist. Temporary splints applied by the ED physician are not considered pre-operative care; therefore, modifier 56 is not required. CPT copyright 2011 AMA. All rights reserved. Page 2 E/M Training

5 Documentation Dissection CHIEF COMPLAINT: Coughing, choking. 1 HISTORY OF PRESENT ILLNESS A 72-year-old female who said she originally started with a scratchy sore 2 throat 3 earlier this week, 4 that has actually gotten better. 5 She states she is swallowing secretions fine, did have difficulty with odynophagia earlier in the week. 6 Started having coughing spells earlier in the day today. She is a former smoker but states she quit quite some time ago. No complaints of chest pain, dyspnea, dyspnea on exertion. No orthopnea. 7 No abdominal pain, nausea or vomiting. 8 States she has felt that she may have a fever. 9 No back or flank pain. 10 History of PE, but no symptoms consistent with this. 11 No joint pain or inflammation. Because of the cough, she has had some problems sleeping at night. 12 She is also having congestion, some postnasal drip, 13 so came in to the ED. She states that every spring she has some bad problems with allergies. 14 REVIEW OF SYSTEMS Ten systems reviewed and other than in chief complaint and HPI, systems reviewed and negative. 15 PAST MEDICAL HISTORY Seasonal allergies, hypertension. 16 PAST SURGICAL HISTORY She has had C-section, hysterectomy, total abdominal hysterectomy, tonsillectomy, adenoidectomy. 17 SOCIAL HISTORY She is a nonsmoker. No current alcohol or illicit drug use. 18 ALLERGIES No known drug allergies Chief Complaint. 2 HPI: Quality. 3 HPI: Location. 4 HPI: Timing. 5 HPI: Severity. 6 ROS: ENT. 7 ROS: Respiratory. 8 ROS: GI. 9 ROS: Constitutional. 10 ROS: Musculoskeeltal. 11 ROS: Cardiovascular. 12 HPI: Severity again. 13 HPI: AS&S. 14 ROS: Allergic/Immunologic. 15 ROS: Complete. 16 PMH: Allergies, prior illnesses. 17 PMH Prior Surgeries. 18 Social History Drug & Tobacco Use. 19 Past History: Allergies. CPT copyright 2011 AMA. All rights reserved. Page 3 E/M Training

6 MEDICATIONS The patient is on blood pressure medicines, cannot remember the name. PHYSICAL EXAM Vital signs: 20 Temperature is 97.8, pulse 86, respirations 20, BP 137/85, pulse ox 99%. Exam: A pleasant 72-year-old female, alert and oriented x Does not appear tachypneic. No audible wheezing or stridor. 22 Head: Atraumatic. Face symmetric. 23 Eyes PERRLA. Nonicteric, no nystagmus. 24 Ears: TMs pearly gray, reflective. Canals clear. Nose without rhinorrhea. Throat without exudate. Neck is supple. No stridor or meningeal signs. Trachea midline. 25 Lungs clear bilaterally. No wheezing, rhonchi, or rubs. 26 Heart: Regular rate and rhythm. 27 Abdomen: Bowel sounds x 4, soft, no rebound, tenderness or guarding and no hepatospenomegaly. 28 Back: No CVA tenderness. Extremities without clubbing, 29 or pedal edema. 30 Neuro: CN II XII intact. Speech is clear. 31 DIAGNOSTIC DATA X-ray of the chest showed some atelectasis with no other acute abnormality. 32 MEDICAL DECISION-MAKING Feel this is more like an allergy. We will have her take Allegra-D OTC. 33 Have her see her doctor in a few days. Return, new or worsening symptoms or any concerns. IMPRESSION Allergic rhinitis. 34 PLAN As above. DISPOSITION The patient is discharged home. 20 Exam: Constitutional. 21 Exam: OS Psych. 22 Exam: OS Respiratory. 23 Exam: BA Head, including face. 24 Exam: OS Eyes. 25 Exam: OS ENT. 26 Exam: OS Respiratory again. 27 Exam: OS Cardiovacular. 28 Exam: OS GI. 29 Exam: OS MS. 30 Exam: OS Cardiovascular again. 31 Exam: OS Neuro. 32 MDM: Chest X-ray no report, not reported separately, used in MDM for EM. 33 Risk: Low based on Management Options Selected. 34 Risk: Low based on Presenting Problem # Diagnosis: 1 diagnosis new to provider. CPT copyright 2011 AMA. All rights reserved. Page 4 E/M Training

7 CPT Code: ICD-9-CM code: Rationale: CPT code: Emergency department visits required 3 of 3 components. History HPI (extended), ROS (complete), PFSH (Complete) = Comprehensive Exam Comprehensive Exam (eight systems Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Musculoskeletal, Neurological, Psychiatric) MDM New problem, no additional work-up. Radiology reviewed. Risk Low (Acute uncomplicated injury or illness and OTC medications = Low MDM ICD-9-CM code: Diagnosis is stated as Allergic Rhinitis. Look in the ICD-9-CM Alphabetic Index for Rhinitis/Allergic and you are directed to Verification in the Tabular List confirms this code selection. CPT copyright 2011 AMA. All rights reserved. Page 5 E/M Training