Determine Level of 99 Code

1. Determine Level of 99 Code

2. Determine Level of 99 Code EM Rules in CPT Manual 9 pages, starting pg 4, CPT 2013 EM Rules by Medicare 15 pages of 1995 Documentation Guidelines (DG) for EM Services 53 pages of 1997 DG for EM Services (skip pg.14-24, 27-45)

3. Determine Level of 99 Code November 2005- Medicare carriers are to use 1995 and 1997 DGs to review EM Services (whichever is more advantageous to the physician) until further notice

4. Determine Level of 99 Code Non-Medicare plans may or may not use DGs Advantages to use them anyway – a) Defendable during audit b) Improves on ambiguity of CPT

5. Determine Level of 99 Code Website for DG 95 & 97 http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

6. Determine Level of 99 From Chart Documentation Only way to guard against audit losses

7. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM)

8. Determine Level of 99 From Chart Documentation Grade each Main Element Use chart to choose final 99 Code Slow start - Quicker as weeks pass

9. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM)

10. Determine Level of 99 From Chart Documentation History Inadequate history is single most common reason for downgrading during audit Record history the same way, the same detail, for all patients

11. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History

12. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History

13. Determine Level of 99 From Chart Documentation Chief Complaint (CC) Concise statement describing symptom, problem, condition, diagnosis, physician recommended return, or other factor or reason for encounter Usually stated in patient's words

14. Determine Level of 99 From Chart Documentation Chief Complaint Staff may take CC If staff takes CC, physician must validate CC in documentation

15. Determine Level of 99 From Chart Documentation Chief Complaint Required for every level of 99 code No CC means visit is not medically necessary, and not medically billable

16. Determine Level of 99 From Chart Documentation Chief Complaint Record as many CC as patient mentions Record as many as you are following at that visit Numbering 1, 2, 3, etc.

17. Determine Level of 99 From Chart Documentation Chief Complaint Related to complexity of Medical Decision Making MDM is "number of possible diagnoses" More complaints create more diagnoses

18. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History.

19. Determine Level of 99 From Chart Documentation History of Present Illness (HPI) Chronological description of development of patient's present illness from first sign and/or symptom, or from previous encounter to present Only physician can take HPI .

20. Determine Level of 99 From Chart Documentation HPI Elements(record 4 of 9) Location Quality Severity Duration Timing

21. Determine Level of 99 From Chart Documentation HPI Elements(record 4 of 9) Context Modifiers Assoc signs Other

22. Determine Level of 99 From Chart Documentation HPI Always record FOUR Less than 4 means highest EM Level is: Level 2 New Patient Level 3 Est. Patient

23. Determine Level of 99 From Chart Documentation HPI 4 or more means no restriction on choice of EM level HPI examples available – email me

24. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History

25. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Inventory of body systems obtained through questions to identify signs or symptoms

26. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Patient or staff can fill out ROS Physician must review ROS and make notation in chart

27. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Does not need to be re-recorded if there is evidence physician reviewed & updated prior ROS Once done, always done

28. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Review & update may be documented by: • describing new ROS information, or noting there is no change in information; and • noting date and location of earlier ROS

29. Determine Level of 99 From Chart Documentation Review of Systems (ROS) A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. ROS must be reviewed by pt & doc validate each visit

30. Determine Level of 99 From Chart Documentation Review of Systems (ROS) A note indicating all systems are negative is permissible

31. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements(record 10 of 14) Constitutional Eyes Ears nose mouth throat Cardiovascular Respiratory Gastrointestinal

32. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements(record 10 of 14) Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine

33. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Elements(record 10 of 14) Hematologic/Lymphatic Allergic/Immunologic

34. Determine Level of 99 From Chart Documentation Review of Systems (ROS) Always record TEN 2 – 9 means highest EM is: Level 3 New Patient Level 4 Est. Patient

35. Determine Level of 99 From Chart Documentation History Elements a) Chief Complaint b) History of Present Illness c) Review of Systems d) Past, Family, Social History

36. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Patient or staff can fill out PFSH Physician must review PFSH and make notation in chart

37. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) No need to re-record if evidence that physician reviewed & updated prior PFSH Once done, always done

38. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Review & update may be documented by: • describing new PFSH information, or noting there is no change in information; and • noting date and location of earlier PFSH

39. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Past History elements (record 1 of 7) Prior major illness & injury Prior operation Prior hospitalization Current meds

40. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Personal History elements (record 1 of 7) Allergies Immunization status Dietary status

41. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Social History elements (record 1 of 7) Marital status/Living arrangement Current employment Occupational history Use of drugs, alcohol, tobacco

42. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Social History elements (record 1 of 7) Level education Sexual history Other social factors

43. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Family History elements (record 1 of 3) Medical events Diseases Hereditary conditions

44. Determine Level of 99 From Chart Documentation Past, Family, Social History (PFSH) Always record ONE FROM EACH CATEGORY Recording 1 means highest EM is: Level 3 New Patient Level 4 Est Patient

45. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History(to review) Every patient: document history as if supporting highest level EM ~Good medicine ~Reveals issues needing management

46. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History ~Minimizes History as factor in grading final EM

47. Determine Level of 99 From Chart Documentation 3 Main Elements of 99 Codes 1. History 2. Examination 3. Medical Decision Making (MDM)

48. Determine Level of 99 From Chart Documentation Examination What level examination is justified? Extent of examination is based on -Clinical judgment -Patient history -Nature of presenting problems

49. Determine Level of 99 From Chart Documentation Examination Elements(of 14, record all that apply) Visual Acuity Confrontation VF Ocular motility test Conjunctiva Ocular adnexae Pupils & Irises

50. Determine Level of 99 From Chart Documentation Examination Elements(of 14, record all that apply) Corneas Anterior Chamber Lenses IOP Optic Discs Posterior Segments