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Briefing: Documenting the ER Visit

Briefing: Documenting the ER Visit. Date: 25 March 2010 Time: 0800–0850. Who Am I . 22 years Practicing Emergency Physician Board of Directors, Virginia College of Emergency Physicians Reimbursement Committee (VaCEP) CEO, Practice Management Associates, Inc.

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Briefing: Documenting the ER Visit

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  1. Briefing: Documenting the ER Visit Date: 25 March 2010 Time: 0800–0850

  2. Who Am I 22 years Practicing Emergency Physician Board of Directors, Virginia College of Emergency Physicians Reimbursement Committee (VaCEP) CEO, Practice Management Associates, Inc. Board of Directors, nHealth Interests Physician Reimbursement Documentation and Coding 2

  3. Learning Objectives Learn why coding is foreign to physicians Review Current Procedural Technology basics Learn why communication with physician groups is important 3

  4. Realizations Problem We are victimized by systems that undervalue our work 3rd party carriers that have low reimbursement and stringent documentation/paper work requirements Coders who do not understand what really happens in a patient visit. Most are not “ER Coders” 4

  5. Opportunity Increased revenue 20-50% with better documentation and coding (this applies equally to the facility) Improved patient care, compliance 5

  6. The Problem Decreasing reimbursement Complex coding and billing rules Uncompensated care Uninsured Managed care Medicare changes Pseudo-competition 6

  7. The Problem Increasing Overhead Malpractice insurance 250% in past 9 years Employee benefit costs Staff costs Crowding causes more patients seen per hour, per EP Cost of living Budget constraints 7

  8. Solutions Change the system (or at least learn to make it work for us) Learn to make rules we’ve been given work for us, instead of against us Use documentation as a weapon against those who use paperwork to defeat us Don’t need to “upcode” (illegal) or “game the system” Improved documentation, not “more” documentation is the key 8

  9. Principles Insurance pays not for patient care, but “paperwork” For many, “paperwork” is harder and not why became a doctor H&Ps are now as much a score card for reimbursement as a tool for good patient care 9

  10. Principles To be financially successful: Physicians must be active participants in the “coding process” Because the rules change as soon as we become “too successful” Held to standards for which we have not been given the means to comply EP documentation often also affects hospital reimbursement 10

  11. How Coding Works CPT components for patient visits: Detail of history Extent of physical exam Complexity of medical decision-making Extent of counseling Coordination of care with others nature of patient’s problem(s) The time required 1-3 = key components & determine coding unless time exceeds published standards No time component for EM 11

  12. Think Like a Coder Physicians control 2 of 3 key components History Physical Complexity of medical decision-making is the only “fixed” variable CMDM usually determines maximum achievable code 12

  13. Complexity of Medical Decision-Making Medical billing is more complex than actual medical decisions Includes 3 elements: Patient risk Amount of data reviewed/ordered # of diagnostic/management options 13

  14. Basics Chief Complaint A statement describing the problem, condition Usually in patient’s own words 14

  15. Complexity of Medical Decision-Making Patient Risk This assessment is the only real fixed variable This determines max level of service Almost always, payment is based on this single sub-variable What was used to pay claims before documentation Most insurers still use this criteria to audit claims 15

  16. CMDM Patients are usually in a higher category than you think By writing a prescription, elevates to moderate 16

  17. CMDM Amount of data reviewed Must be medically necessary Old records, EKG, x-ray etc. 17

  18. CMDM Number of diagnostic options Do not necessarily need to list Usually apparent from Chief Complaint 18

  19. CMDM Risk Assessment Minimal Will need over-the-counter meds Minor surgery Self-limited minor problem: insect bite, sunburn, etc. Low 2 or more minor problems I stable problem (HTN) Simple sprain Moderate Chronic illness w/mild exacerbation 2 or more stable illnesses Prescription management High Illness with severe exacerbation Acute or chronic with threat to bodily function Major trauma, MI, PE, respiratory distress, severe pain 19

  20. CMDM Analysis Even if it seems routine to you, it may not be under coding criteria (don’t sell your services short) LOS determination CMDM establishes maximal LOS Document to at least that level (H&P) Proper coding + proper documentation = REVENUE 20

  21. Assumptions Marshfield Clinic E/M documentation audit tool 1995 CPT May use either 1995 or 1997 CPT guidelines on any single patient May not mix guidelines on any single patient You want to use 1995 – easier 21

  22. CMDM Step 1 – Risk Assessment Any single criteria Minimal Low Moderate High 22

  23. CMDM Step 1 – Risk Assessment = HIGH Patient has*: Chronic illness(es) w/ SEVERE exacerbation/ progression or side effects of ongoing treatment Acute or chronic illness/injury posing a threat to life, limb, bodily function Major trauma, MI, PE, resp. distress, severe pain Psychiatric illness with DTS/DTO Abrupt change in neurological or mental status Seizure, CVA/TIA, weakness, sensory loss *Any one 23

  24. CMDM Step 1 – Risk Assessment = HIGH Test ordered*: IV contrast study with comorbid risk (i.e., renal insufficiency, IDDM, etc.) (identify and document as such) Radiographic procedures in pregnant women (i.e., head CT) Diagnostic endospcopy with comorbid risk *Any one – are not additive 24

  25. Physical Examination Required Documentation Level 1: single body areas or organ systems* Level 2-3: 2-4 body areas or organ systems^ Level 4: 5-7 body areas or organ systems^ Level 5: 8 organ systems (not body areas)* *Recognized by 1995 CPT ^CMS Unofficial Clarification 25

  26. CMDM Data Reviewed/Ordered Amount of Data Reviewed/Ordered Point System Additive 1pt = minimal 2pt = limited 3pt = moderate 4pt = extensive 26

  27. CMDM Data Reviewed/Ordered Points per category 1 – lab test 1 – radiology test 1 – medical diagnostic test 1 – discussion of results with physician 1 – obtain old records 1 – interpretation of new or old image, tracing or specimen 2 – review old records 27

  28. CMDM Data Reviewed/Ordered 28

  29. CMDM Dx and Management Options Points per Category New Problem 4 – additional work-up (w/u) planned 3 – no additional w/u Presenting complaint Established Diagnosis 1 ea if controlled or resolving 2 ea if poorly controlled or worsening New/chronic self-limited problem 1 – if only one complaint 2 – if greater than 1 29

  30. History HPI Physician must obtain/document A chronological description of the development of the patient’s present illness from the first sign, or from the previous encounter to present Other elements May be obtained by nurse, patient, etc., but must be reviewed by physician 30

  31. History HPI 8 elements Location Level 1-3 only 1-3 elements Context Level 4-5 3+ for CPT, 4 for CMS Quality Timing Severity Duration Modifying factors Associated signs and symptoms 31

  32. History ROS (Review of Systems) “an inventory of body systems obtained through a series of questions seeking to identify signs and or symptoms which the patient may be experiencing” It helps define the problem 14 elements: Constitutional Musculoskeletal Eyes Endocrine ENT/mouth Skin and/or Breast Cardiovascular Hem/Lymph Respiratory Allergy/Immune GI Neurologic GU Psych 32

  33. History ROS Level 1 = N/A Level 2-3 = “Problem pertinent 1 system" Level 4 = 2-9 systems Level 5 = 10 systems So if there is no ROS, the best you can get is a level 1! 33

  34. History ROS (It is easier than you think) Need 10 systems for level 5 Clinically billing ROS Fever, vision problems, earaches, angina, cough, arthritis, rash, anemia, allergies, headache 34

  35. History Past History Family History Social History Only need for levels 4 and 5 35

  36. Physical Exam 7 Body Areas Head Neck Chest, breast, axilla Abdomen Back Genitalia, groin, buttock Each extremity 1995 guidelines 12 organ systems Constitutional Eyes ENT/mouth Respiratory Cardiovascular GI/abdomen GU Lymphatic Musculoskeletal Skin Neurological Psychiatric 36

  37. Physical Required documentation Level 1 Single body area or organ Level 2 -3 2-4 body areas or organ systems Level 4 5-7 body areas or organ systems Level 5 8 organ systems 37

  38. Critical Care The only EM time-based service “Critical Care includes the variety of critically ill patients in a variety of medical emergencies that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure, post operative complications, critically ill neonate)” Impact of critical care: 3-5%: EM vs. 11%: ICU IM 99285 = $144 vs. 99291 = $197 Big difference? No documentation 38

  39. Critical Care Criteria Based on type of care Constant “attention time” by physician due to medical necessity Includes time spent reviewing results, conversations, documenting, etc. Obviates need for documentation based coding except noting the time Time measurement is cumulative (not consecutive – minimum of 30 min) Time excludes separate billed procedures (i.e., intubation, CPR, chest tube) Time excludes resident management 39

  40. Critical Care Criteria Only bill one critical patient at a time Times does not have to be continuous, but must total 30-min minimum Patient does not have to be admitted to bill critical care Codes 99291 – Critical care first hour with minimum of 30 min 99292 – each additional 30 min May also bill E/M if done before patient became unstable 40

  41. Critical Care Examples Hypotension Severe respiratory symptoms Severe asthma, PE, pulmonary edema, croup Hypertension Cardiac Altered mental status Severe pain Use of medications Thrombolytics Vasopressors Anti-arrhythmic 41

  42. Caveat Only applies to LOS 5 (99285) “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.” 42

  43. What to Document Level V (99285) CC: At least one word HPI: 4 elements Location, context, quality, timing, severity, duration, modifying factors, assoc. Sx ROS: 10 systems Tet, V/D, fever, cough, ST, abd pain, dys/ freq, CP/SOB, neuro, rash, musc/ joint pain PFSH: 2 of 3 Past (meds), family, social history (OK to refer to old chart “reviewed and updated”) Physical Exam: 8 systems VS, HEENT(2), lungs, heart, ABD, extr, neuro, skin +/- GU, psych, nodes 43

  44. Lacerations Size matters Example Simple 2.5cm ($80), the next 1mm worth $40 more ALWAYS MEASURE 44

  45. Fractures Put all splints on PROVIDERS Fracture care vs. E & M plus splint 45

  46. Summary Why coding is foreign to physicians Current Procedural Technology basics Why communication with the physician group is important 46

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