BILLING, CODING, DOCUMENTING

1. BILLING, CODING, DOCUMENTING

2. Type of Codes: Diagnosis Codes • ICD-9-CM (International Classification of Diseases)—codification of patient problems • World Health Organization is author • Establishes the medical necessity for visits and procedures • The first diagnosis code is the primary reason/concern for the visit

3. Types of Codes: CPT Codes • CPT=Current Procedural Terminology • Codification of physician service • Evaluation & Management Level Codes • Procedures Codes • AMA is author • Developed by Physicians in 1966 for Billing Purposes • 7,500 Discrete Codes • 5 digit codes representing visits, procedures, and diagnostic studies • 2 digit modifiers are indicators why claim be paid

4. Evaluation & Management Levels (E/M) • 3 Key Components to an E/M Service Level • History (Hx) Level---Subjective • Examination (PE) Level---Objective • Medical Decision Making (MDM) Level—Assessment & Plan • E/M Level = Hx Level +PE Level+MDM Level • Levels indicate the wide variations in skill, time, effort and resources required to diagnose and treat an illness/injury • Levels are incremental • Specific level is referring to the last digit in each E/M service code • ie 99281 is referred to as a “ED Patient, level 1”

5. History Component Introduction • History level are determined by four elements *Chief Complaint (CC) *History of Present Illness (HPI) *Review of Systems (ROS) *Past, Family, and/or Social History (PFSH) • Can be completed by anyone i.e.; patient, family, medical student, PA, APN, resident • Must be reviewed by the attending physician • If unable to obtain information from the patient due to altered mental status, this must be indicated in the chart • Not all histories will need all elements

6. History Component: Chief Compliant • Concise statement describing the symptom, problem or condition for the patient visit • Compliant should be recorded in the patient’s own words • Chief Compliant forms the foundation for medical necessity

7. History Component: HPI • 8 elements of “History of Present Illness” • Location – Where the symptom or problem is occurring • Severity - A rating or description of severity of the symptom or pain • Timing – When symptom or pain occur • Quality – The character of the sign or symptom • Duration – How long a pain or symptom lasts, has been present, or persisted • Associated signs/symptoms – Any organ system or body area complaints associated with the chief complain • Context – Instances or items that can be associated with the chief compliant • Modifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse • Two Levels • Brief – 1-3 elements • Extended – 4 or more elements

8. History Component: ROS • 14 systems • Constitutional symptoms (fever, weight loss, etc) • Eyes • Ears, nose, mouth, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic • Number of systems reviewed & documented determines the level *Pertinent—1 *Extended---2-9 *Complete---10 or more • Can’t just say ROS is negative or non-contributory • Must document pertinent positives & negatives

9. History Component: PFSH • PFSH = Past hx + Family Hx +Social Hx Past: • Medications, Surgeries • Allergies • Immunization status Family Social • Marital status, children, • Living situation, employment status • Tobacco, alcohol, recreational/illicit drugs • Two Levels 1) Pertinent-- 1 specific item from any of the 3 history areas 2) Complete--1 specific item from each of the 3 history areas

10. HPI Location Severity Timing Modifying Factors Quality Duration Context Associated Signs/SX Brief 1-3 Extended 4 or more ROS Constitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/Lymph Eyes Card/Vasc GI Neuro Allergy/Immune Resp Musculo GU Psych All Others Neg None Pertinent to Problem 1 Extended 2-9 Complete PFSH Past Medical History Family History Social History None Pertinent Complete OVERALL HISTORY LEVEL Problem Focused Expanded Problem Focused Detailed Comprehensive History Level (UCD Chart) • History level is equal to the lowest Hx component documented in the record

11. Examination Component • Physical Exam Elements • Body Areas • Organ Systems • Cannot combine Body Areas and Organ Systems for Comprehensive Exam • Four Levels • Problem Focused—0-1 • Expanded Problem Focused----2-4 • Detailed ----5-7 • Comprehensive-8 or more • Level of exam is determined by the number of body are 0r organ system that are examined & documented • Can’t just say complete physical exam is negative

12. Body Areas: Head/face chest, including breasts & axillae Neck back, spine each extremity genitalia, groin, buttocks abdomen 0-1 2-4 5-7 >=8 Organ Systems: Constitutional ears, nose, mouth, throat Eyes resp GI GU Cardio skinneuro psych Hem, lymph, immune musculo OVERALL EXAMINATION LEVEL Problem Focused Expanded Problem Focused Detailed Comprehensive Examination Level (UCD Chart)

13. Medical Decision Making Component • Three Elements • Number of Diagnoses or Treatment Options • Amount and/or Complexity of Data to be Reviewed • Risk of Complication and/or Morbidity/Mortality • Two out of three elements must be met or exceeded to determine the level of MDM • Four Levels • Straightforward • Low Complexity • Moderate Complexity • High Complexity

14. Medical Decision Making Level

15. Overall E/M Level • Overall E/M Level equal to lowest of three level (Hx, Exam, MDM)

16. Critical Care Codes • Time based code • Time is the actual time of the attending not fellow or resident • Critical care time less than 30 minutes duration is reported with E/M Code • Documenting w/ clock time interval is best

17. RVU • Relative Value Units (RVU)—”points” you generate by taking care of patients (your productivity) • RVUs are determined by 2 components: • Evaluation and Management Codes (E&M) • Procedures Codes

18. Increasing RVU • Increase quality of documentation to achieve greater E&M codes per visit. (i.e. document more ROS, Physical Exam) • Increase number of procedures done and documented • Procedure RVU’s are addedto the E&M code • Providers can receive credit for procedures done by ancillary staff • Ie: ED physician assistant removes ear wax for conductive hearing loss E&M 99283 (RVU= 0.67) + ear wax removal (RVU = 0.61). TOTAL = 1.28 RVU • Increase number of patients seen per hour

19. Documentation for billing • If the documentation does not justify the coding then payment is denied or reduced • It is not appropriate to upcode (bill a higher level of E/M when a lower level of service is warranted • Extensive write up (coding) for a minor problem

20. Documentation for billing • Understand that the physician is ultimately responsible for every claim, no matter who does the billing • Improper billing, even without intent to defraud is considered fraud

21. Acceptable Teaching Physician Documentation (UCD) • “I saw the patient with the resident and agree with the resident’s findings and plan we developed.” • “I saw and evaluated the patient. Discussed with the resident and agree with the resident’s findings and plan we developed as documented in the resident’s note.” • “See the resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans we developed as written.”

22. Unacceptable Teaching Physician Documentation (UCD) • “Agree with above.” • “Rounded, Reviewed, Agree.” • “Discussed with resident.” “Agree.” • “Seen and Agree.” • “Patient seen and evaluated.” • A legible countersignature and/or identity alone does not meet State and Federal payer requirements

23. Documenting: Do’s and Don’ts • Every Chart should be “bulletproof” • Be absolutely objective & non-judgmental in your charting • Remember what you write today…You may be reading back in a courtroom some day • Don’t leave loose ends • Address all patient’s complaints • Justify your diagnosis, treatment & billing • Read nurse’s note and address discrepancies

24. Documenting: Do’s and Don’ts • Think worst case scenario & provide documentation that you have considered it & ruled it out • Avoid dangerous words (ie malingering) • Discharge “Golden Rule Statements” 1-Return to ED immediately if worse or any other concerns 2-Follow up with “X” clinic/pvt md in “Y” hrs/days • Never alter the chart after the fact because the agency or attorney has already gotten the chart before you are notified of the suit or complaint

25. Documenting: Do’s & Don’ts • Emergent procedures (life and death) or situations where the patient is not able to give consent & no legal substitute is present…document that the consent was not available, that the situation warranted the intervention, and thus that the consent was felt to be implied • If in doubt about whether or not to get informed consent, get informed consent

26. DOCUMENTING: DO’s & Don’t • DON’T *Delete material or destroy record *Use correction take or fluid *Make self-serving statements *Be cavalier, sarcastic or inappropriate *Use the record to “vent” even to defend yourself

27. Documenting: Do’s & Don’t “When finishing the encounter in the chart - review it and ask yourself how it will appear to a reviewing agency, an adverse or friendly attorney, and to nonmedical persons (a jury)” Jorge Martinez MD-JD

28. Author Credit – Billing, coding, documentationDavid Cheng MD & Greg Hall MD Questions

29. 1) Career Planning – Garmel 2) Careers in Academic EM – Sokolove 3) Private Practice Career Options - Holliman 4) Fellowship/EM Organizations – Coates/Cheng 5) CV – Garmel 6) Interviewing – Garmel 7) Contracts for Emergency Physicians – Franks 8) Salary & Benefits – Hevia 9) Malpractice – Derse/Cheng 10) Clinical Teaching in the ED – Wald 11) Teaching Tips – Ankel 12) Mentoring - Ramundo 13) Negotiation – Ramundo 14) ABEM Certifications – Cheng 15) Patient Satisfaction – Cheng 16) Billing, Coding & Documenting – Cheng/Hall 17) Financial Planning – Hevia 18) Time Management – Promes 19) Balancing Work & Family – Promes & Datner 20) Physician Wellness & Burnout – Conrad /Wadman 21) Professionalism – Fredrick 22) Cases for professionalism & ethics – SAEM 23) Medical Directorship – Proctor 24) Academic Career Guide Chapter 1-8 – Nottingham 25) Academic career Guide Chapter 9-16 – Noeller Postresidency Tools of the Trade CD