Volume 2. Issue 3. March 2013 Cristy Donaldson, CPC, CPMA Coding Specialist

Transcription

1 Volume 2. Issue 3. March 203 Cristy Donaldson, CPC, CPMA Coding Specialist Are you struggling with knowing how to document and code for a Preventive and Problem visit on the same day? As a certified coder and a certified auditor, I frequently hear complaints from both providers and patients about this. Here are a few simple tips and reminders for you to follow. This will help you stay out of hot water with patients and insurance carriers: ) When a patient calls to schedule an appointment, ask if the patient is new or established AND ask if the patient is requesting a preventive/well visit or a problem visit. Make notes in your computer about this. 2) When the patient arrives for their appointment, the reception area should view the notes in the computer to determine what type of visit is occurring. Many preventive/well services are now covered at 00% and do not require a co-payment; in fact, it may be considered improper to collect a copayment on such services. 3) Upon triage, the nurse or medical assistant should again ask if the patient is having any problems that need to be addressed during today s visit, particularly if the patient s chief complaint/reason for visit is for a preventive/well visit. 4) Providers should review this in the chart before initiating the encounter. If the patient in the examination room appears to be a preventive/well visit but mentions a problem to you the provider, you must determine the course of action. You can treat the problem, provide the preventive/well service, or both; however, this must be clearly communicated to the patient. Patients will accept their financial responsibility much better if they know how you intend to bill their insurance before they leave your office. 5) If you the provider elect to provide both services, you should only bill separately for the problem visit if the problem was significant and separately identifiable. What does that mean? It means the work involved for the problem must require additional history, exam and work-up beyond what would normally be performed during the preventive/well visit. If the problem could easily be treated within the scope of the preventive/well visit, it would be inappropriate to bill separately for it. If the problem is significant and separately identifiable, append modifier 25 to the problem visit. The key word is significant. 6) Documentation trumps all. If the provider s documentation does not clearly support all of the services billed, you may find yourself in a sticky spot with the patient and/or the insurance carrier. The Chief Complaint/Reason for Visit must demonstrate all of the above. If a preventive/well service is billed, all the requirements of that service must be performed and documented. Did you know that a Preventive Medicine Visit requires a comprehensive history and examination as appropriate for the age and gender of the patient? If you report a preventive/well and a problem service, your documentation should support BOTH. Continued Page 2

2 Page 2 / Catch the Coding Wave 7) Some insurance carriers have a hard rule and will not pay for both on the same day. It is a good idea to get familiar with which insurance carriers have a rule about this. Lastly, it is never appropriate to change a code just to please a patient. If the patient presented for a preventive/well visit but you determined a problem visit must be performed instead, you must explain this to the patient. It is not appropriate to change the code to please the patient. Furthermore, if the documentation is audited by the insurance carrier and it does not reflect the services performed, you may lose your reimbursement altogether. Because the determination of risk is complex and not readily quantifiable, the table of risk includes clinical examples rather than absolute measures. The highest level in any one category on the table determines of the overall level of risk. See page 3 of the Audit Tool. References: CMS 995 Guidelines Taking an Anatomy & Physiology course is a great way for coders and/or anyone non-clinical to begin their education for ICD-0. There are online and class room based courses available with a variety of vendors. Consider AAPC, AHIMA, your local community college or an online college. The key component of Medical Decision Making is broken down into three sections: ) Number of Diagnoses or Treatment Options 2) Amount and/or Complexity of Data 3) Table of Risk Each of these sections receives a score and is applied to the MDM table. The overall MDM score is determined by the highest 2/3 sections. This month we will focus on the Table of Risk. This table stratifies the risk of significant complications, morbidity and/or mortality, as well as the co-morbidities associated with the patient s presenting problem(s), the diagnostic procedures(s) and/or the possible management options. Thank you for taking the time to review this information. If you have any questions regarding the content of this newsletter, please feel free to contact me directly at: Cristy Donaldson, CPC, CPMA Coding Specialist Phone: cdonaldson@utmck.edu

3 DOCUMENTATION WORKSHEET Color Key: Items/descriptions in black represent '95 guidelines and items that did not change in '97. Items/descriptions in blue represent changes made in the '97 guidelines. Black and white duplication may alter the intent of this tool. THIS TOOL IS INTENDED TO BE USED ONLY AS A COMPANION TO THE PUBLISHED '95 AND '97 E/M DOCUMENTATION GUIDELINES (located a EITHER THE '95 OR '97 GUIDELINES MAY BE USED, BUT THE TWO SETS OF GUIDELINES CANNOT BE COMINGLED Patient Name: DOB: DOS: Chief Complaint: HPI HISTORY Brief=-3 Extended=('95) 4 or more elements or assoc. comorbidities Extended=('97) 4 or more elements or status of at least 3 chronic/inactive conditions Location Quality Severity Duration Timing Context Modifying Factors Associated Signs/Symptoms (Where problem is located) (sharp, dull, stabbing) (scale of - 0, etc) (how long) (how long it lasts, after meals, etc) (when walking,etc) (feel better after applying ice, etc) (swelling, redness, etc.) ROS Pertinent= Extended= 2-9 Complete= 0 or more Constitutional Eyes ENT/Mouth Cardio Resp GI GU Endo Musculo/Skel Integumentary (skin/breast) Neuro Psych Hem/Lymph Allerg/Immun PFSH Pertinent= Complete= 2 or more Initial visits require at least one item from all three PFSH areas Past Medical Family History Social History HPI ROS PFSH History Level Brief N/A N/A Prob Focused Brief Pertinent N/A Exp Prob Focused Extended Extended Pertinent Detailed Extended Complete Complete Comprehensive To qualify for a given level of history, all three elements in the table must be met. History level based on '95 Guidelines History level based on '97 Guidelines Developed incorporating CMS/AMA 995/997 copyrighted materials Form Date: 02/0/06 Form Date: 0/03/05

4 EXAM BODY AREAS ('95) with '97 specific elements ORGAN SYSTEMS ('95 & '97) *Please refer to '97 Single Organ System Exam Elements of '97 Gen. Multi-System Exam guidelines for specific bullet and numeric Head, incl face Constitutional ('95).Any 3 vitals 2.General appearance requirements for each category of single Neck Eyes.Conjunctivae and lids 2.Pupils & irises 3.Optic discs organ system exam '97. Neck (masses, etc.) 2. Thyroid ENT, Mouth.Ext ears & nose 2.EACs & TMs 3.Hearing 4.Oropharynx 5.Septum, turb 6. Lips, teeth, gums Cardiovasc.Palpation of heart 2.Auscultation 3.Carotids 4.Abd aorta 5.Femoral arteries Chest, incl breasts or axillae 6.Pedal pulses 7.Extremities for edema and/or varicosities '97.Inspect breasts 2.Palpation breasts/axillae Respiratory.Respiratory effort 2.Percussion 3.Palpation 4.Auscultation GI (Abd.).Masses, tenderness 2.Liver & spleen 3.Hernia 4.Anus, perineum & rectum 5.Occult test Abdomen GU (male) ('97).Scrotal contents 2.Penis 3.Prostate gland GU (female) ('97).External genitalia 2.Urethra 3.Bladder 4.Cervix 5.Uterus 6.Adnexa/parametria (w/w.out speci) Genitalia, groin, buttocks Musculoskeletal.Gait & station 2.Digit and nail 3.Joint(s), bone(s), muscles of at least one of these areas: a) head, neck; b) spine, ribs, pelvis; c) any one of 4 extremities, & exam to include: Back, incl spine ()inspection &/or palpation (2)ROM (3)stability (4)muscle strength & tone Skin.Inspection of skin & subcutaneous tissue 2.Palpation of skin and subcutaneous tissue Each extremity Neuro.Cranial nerves 2.Deep tendon reflexes 3.Sensation Psych.Judgment & insight 2.Brief mental status: (a)orient to time, place, person (b)memory (c)mood Hematologic/lymphatic/immunologic.Palpate lymph nodes in 2 or more areas: a) neck b) axillae c) groin d) other Prob Focused Exp Prob Focused Detailed Comprehensive '97 Guidelines: General Multi- System Exam Single Organ System Exam Perform and document - 5 bulleted elements in one or more systems or body areas Perform and document - 5 bulleted elements, whether in shaded or unshaded box Perform and document at least 6 bulleted elements in one or more systems or body areas Perform and document at least 6 bulleted elements, whether in a shaded or unshaded box Perform and document at least 2 bulleted elements from at least 6 systems or body areas, or at least 2 bulleted elements from 2 or more systems or body areas Perform all bulleted elements from at least 9 systems/body areas (unless specific directions limit content) and document at least 2 bulleted elements from each selected area Perform and document at least 2 Perform all bulleted elements, whether in bulleted elements (except for eye & shaded or unshaded box; document psych exam, which should be at least every element in each shaded box and at 9 bulleted elements) whether in least one element in each unshaded box. shaded or unshaded box '95 Guidelines: Body Area(s) or Organ System(s) Limited exam of affected body area or organ system () Limited exam of affected body area/system and other related/sympt. systems (2-7) Extended exam of affected body area/system and other related systems (2-7 in more depth) General multi-system exam of 8 or more systems or complete exam of a single system* Exam level based on '95 Guidelines Exam level based on '97 Guidelines *('95)Comprehensive Exam must be 8 or more organs systems; cannot combine systems with body areas. All lower level exams can combine organ systems and body areas MEDICAL DECISION MAKING ('95 and '97 Guidelines) Number of Diagnoses or Treatment Options Amount and/or Complexity of Data Number & category of problems/treatment options mentioned in the record (2 categories have a max allowable). Identify data reviewed and circle number in points column *Multiply A x B = C Problem Number A x Points B Result C Points* Reviewed Data Self-limited or minor (stable, improving or worsening) max=2 x Review/order of clinical lab tests Review/order of tests in radiology section of CPT Review/order of tests in medicine section of CPT Established problem to examiner; stable; improved Established problem to examiner, worsening New problem to examiner, no further workup planned max= x x 2 x 3 Discuss test with performing/interpreting physician Decision to obtain old records or obtain history from someone other than patient Review & summary of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider & documentation of relevant findings 2 New problem to examiner, additional workup planned x 4 Independent visualization of image, tracing or specimen itself (not simply review of report) 2 Total Total Minimal= < Limited = 2 Multiple = 3 Extensive = 4 Minimal= < Limited = 2 Multiple = 3 Extensive = 4 or more *Number values are not part of the '95 or '97 guidelines. The values are added here as a means of quantifying elements of medical decision making Form Date: 0/03/05

5 Table of Risk of Complications and/or Morbidity or Mortality (highest level of risk in any category determines overall risk) Use the risk table as a guide, understanding that it is only a guide. Circle most appropriate risk factor in each category. Level of Risk Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected Minimal One self-limited/minor problem, e.g., cold, insect bite Lab tests requiring venipuncture Chest x-rays Rest Gargles EKG/EEG Elastic Bandages Urinalysis Superficial dressings Ultrasound, e.g. echo KOH prep Low Two or more self-limiting/minor problems One stable, chronic illness, e.g., well controlled hypertension or non-insulin dependent DM, cataract, BPH Physiologic tests not under stress, e.g., pulmonary function tests Non-cardiovascular imaging studies with contrast, e.g., barium enema Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain Superficial needle biopsies Clinical lab tests requiring arterial puncture Occupational therapy IV fluids without additives Skin biopsies Moderate One or more chronic illnesses 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 Physiologic tests under stress, e.g., cardiac stress test, fetal contractions stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis Acute complicated injury, e.g., head injury with brief loss of consciousness Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac cath Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis IV fluids with additives Closed treatment of fracture or dislocation without manipulation High One or more chronic illnesses with severe exacerbation, progression, or side effects of tx Cardiovascular imaging studies with contrast with identified risk factors Elective major surgery (open, percutaneous, or endoscopic with identified risk factors) Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive, severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure Cardiovascular electrophysiologic tests Diagnostic endoscopies with identified risk factors Discography Emergency major surgery (open, percutaneous, or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis Abrupt change in neurologic status, e.g, seizure, TIA, weakness, sensory loss (2 of 3 elements must be met or exceeded to qualify for a level of Decision Making) DX/Mgmt Options Data Risk Type of Med Dec Making Minimal Minimal or none Minimal Straightforward Limited Limited Low Low complexity Multiple Multiple Moderate Moderate complexity Extensive Extensive Level of Decision Making High High complexity Form Date: 0/03/05

6 Determining level of E&M for New Patient Office; Office/Outpatient Consult; Inpatient Consult (3 of 3 components required) Prob Focused Prob Focused Straightforward 9920 / 9924 / 9925 Exp Prob Focused Exp Prob Focused Straightforward / / Detailed Detailed Low Complexity / / Comprehensive Comprehensive Moderate Complexity / / Comprehensive Comprehensive High Complexity / / Determining level of E&M for Established Patient Office (2 of 3 components required) N/A N/A N/A 992 Prob Focused Prob Focused Straightforward 9922 Exp Prob Focused Exp Prob Focused Low Complexity 9923 Detailed Detailed Moderate Complexity 9924 Comprehensive Comprehensive High Complexity 9925 Determining level of E&M for Initial Observation Care; Initial Hospital Care; Observation or Inpatient Including Admission and Discharge (3 of 3 components required) Detailed/Comprehensive Detailed/Comprehensive Straightforward or Low 9928 / 9922 / Comprehensive Comprehensive Moderate Complexity 9929 / / Comprehensive Comprehensive High Complexity / / Determining level of E&M for Subsequent Hospital Care (2 of 3 components required) Prob Focus Interval Prob Focused Straightforward or Low 9923 Exp Prob Focus Interval Exp Prob Focused Moderate Complexity Detailed Interval Detailed High Complexity Determining level of E&M for New or Established Initial Nursing Facility Care (3 of 3 components required) Detailed/Comprehensive Detailed/Comprehensive Straightforward/Low Comprehensive Comprehensive Moderate Complexity Comprehensive Comprehensive High Complexity Determining level of E&M for New or Established Emergency Room (3 of 3 components required); Subsequent Nursing Facility Care (2 of 3 components required) Prob Focused Prob Focused Straightforward 9928 / Exp Prob Focused Exp Prob Focused Low Complexity / Exp Prob Focused Exp Prob Focused Moderate Complexity Detailed Detailed Moderate Complexity / Comprehensive Comprehensive High Complexity / 9930 Final level based on '95 Guidelines Final level based on '97 Guidelines