Billing, Coding, and Documentation Flashcards
Functions of the medical record
- Historical vehicle that promotes excellence in care
- Faciliates care coordination
- Transcends communication barriers
- Financial, legal, and administrative functions
- Documentation for professional and facility fee reimbursement, quality and safety assessments
- Malpractice litigation and disability determinations
- Community-based care and public health initiatives
What is the purpose of computerized provider order entry?
- Replace paper based ordering systems
- Originally for improved safety of medication orders
- Now allows electronic ordering of tests, procedures, and consultations
- Maintain administration record
- Review changes to order by successive personnel
What are CPOE systems generally paired with? What is the purpose of this?
- Clinical Decision Support System
- Prevent errors at medication ordering and dispensing stages
- Improve safety
- Suggests default doses, routes of administration, and frequency
- May include drug safety features such as drug allergy checking or drug-drug, drug-laboratory interactions
- Some prevent errors of commission and omission
What are some unintended consequences of CPOE?
- Users often use workarounds to bypass safety features
- Excessive and nonspecific warnings can lead to alert fatigue, users ignore even critical warnings
- More or new work for clinicians
- Unfavorable workflow
- Never-ending system demands
- Problems related to persistence of paper orders
- Unfavorable changes in communication patterns and practices
- Negative feelings toward new technology
- Generation of new types of errors
- Unexpected changes in institution’s power structure, organizational culture, or professional roles
- Overdependence on technology
What are advantages to written patient records?
No computer delay
What are disadvantags to written patient records?
- Penmanship and misunderstanding of wording
What are templated notes?
- Preprinted paper progress notes with check boxes or electronically constructed click boxes
- Appropriate documentation tools
- Enhance legibility and facilitate efficient documentation
What is one con of templated notes?
- Cut and past errors
How do you avoid cut and paste errors
- Make each note specific to the patient on that encounter date
- Modify information and language brought forward from any previous encounters so current documentation demonstrates distinct clinical service of today
- Do not include excessive data or repetitious information that is not relevant to current service
How does medicare pay for inpatient services?
Using inpatient prospective payment system, which relies primarily on diagnosis in order to group the services delivered to an inpatient into a medicare severity-adjusted diagnosis related group
Some non-medicare payers still reimburse hospitals and facilities with a fixed payment for each day, commonly described as a per diem rate
What is the most common system used to report provider services?
American Medical Association Current Procedural Terminology
* Lists descriptive terms and identifying codes to report medical services and procedures
* Provides uniform language to accurately describe all medical, surgical, and diagnostic services and procedures
What are the 3 key components of selection of an evaluation and management level
- History
- PE
- Medical Decision Making
- Time considered a fourth component but only affects E/M when counseling and/or coordination of care dominate more than 50% of physician’s total visit time
Elements of history
- Chief complaint
- HPI
- ROS
- PFSHs
can all be included in narrative format, do not need to be separate bulleted segments
History
- Conveys information about CC, from either origin or interval between sequential patient encounters
- Eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms
- Quantified as brief (one to three elements) or extended (four or more elements)
chief complaint
- Reason for visit in patients own words
- Always document in progress note, even absent an acute complaint ie pneumonia follow up
ROS
- Fourteen systems: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic
- Problem pertinent, extended, or complete
What is a problem pertinent ROS
- Documents one system
What is an extended ROS
Documentation of two to 9 systems
What is a complete ROS
10 or more individual systems
Components of past history
- Documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations
What is a pertinent PFSH
Comment in any one of the three histories
What is a complete PFSH
Comment in each history (ie past, family, and social)
How PFSH changed if obtained during a previous encounter?
Does not need to be rerecorded if provider documents review and updating of previous information
What happens if unable to obtain history from the patient?
- Record should describe patient’s condition or the circumstance that precludes obtaining a history, and what attempts the provider has made to obtain the information
What is considered complete PFSH if new patient encounter vs subsequent or ED encounters?
- New: need all 3
- Subsequent: need 2/3
Can you document generalized PE exam such as HEENT normal?
Discouraged but yes
If abnormal, must specifically document
How is PE documented?
- Problem-focused
- Expanded problem-focused
- Detailed
- Comprehensive
What is considered a problem focused PE?
1 organ system with 1 comment
What is considered an expanded problem-focused PE?
2-7 organ systems with at least 1 comment
What is considered a detailed PE?
2-7 organ systems with more than one comment in one or more organ systems
What is considered a comprehensive PE?
> /- 8 organ systems with at least 1 comment in each
How is medical decision making categorized?
- Straightforward
- Low
- Moderate
- High
What categories must be considered to determine level of MDM complexity?
- Number of diagnosis
- Amount and complexity of data
- Risk to patient
How is number of diagnosis determined?
- Number of diagnosis and/or management options in encounter
- Only receive credit for issues considered in care plan. DIagnosis merely listed in assessment and plan without elaboration of the care or simply ascribing care to others are considered part of problem list
- Self-limited/minor problem - 1 point per problem (stable, improved, or worsening)
- Established problem (stable or improving) - 1 point per problem
- Established problem (worsening) - 2 points per problem
- New problem, without additional workup - 3 points per problem (max one problem)
- New problem, with additional workup planned (4 points per problem)
What is data considered?
- Amount and/or complexity of data reviewed or ordered by the provider during the patient encounter
- Both type and source considered are valued
- Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit (but only one point allocated per category)
- Chart note should refer to all data reviewed or ordered to capture all of the provider work
What are point values for amount and/or complexity of data ordered/reviewed?
- 1 review and/or order of clinical tests
- 1 review and/or order of tests in pathology/laboratory section of CPT
- 1 review and/or order tests in radiology section of CPT
- 1 review and/or order of tests in medicine section of CPT
- 1 Decision to obtain old records and/or history (non-healthcare provider) from someone other than the patient
- Review and summarize old records, obtain additional history, or discuss case with another health care provider = 2 points
- 2 independent visualization of actual image, tracing, or specimen
What is the third MDM category?`
Risk to the patient
Components of risk to patient
- Risk of complications, morbidity, and mortality with respect to presenting problem, diagnostic procedures ordered, or management options chosen
Levels of risk to patient
- Minimal
- Low
- Moderate
- High
consider comorbidities as well as plans of care
Also, diagnostic studies or alternatively, procedures under consideration or excluded based on excessive risk
What is considered minimal risk?
- One self-limited or minor problem
- Diagnostic procedures ordered: lab tests requiring venipuncture, CXR, ECG/EEG, UA, US, KOH prep
- Management options: rest, gargles, elastic bandages, superficial dressings
What is considered low risk?
- Two or more self-limited or minor problems
- One stable chronic illness (well controlled hypertension, noninsulin dependent diabetes, cataract, BPH)
- Acute uncomplicated illness or injury (cystitis, allergic rhinitis, simple sprain)
- Diagnostic procedures ordered: physiologic tests not under stress, noncardiovascular imaging studies with contrast, superficial needle biopsies, clinical lab tests requiring arterial puncture, skin biopsies
- Management: over the counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy, IV fluids without additives
What presenting problems are moderate risk?
- 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
- Acute illness with systemic symptoms
- Acute complicated injury (ex head injury with brief loss of consciousness
What diagnostic procedures ordered are moderate risk?
- Physiologic tests under stress
- Diagnostic endoscopies with no identified risk factors
- Deep needle or incisional biopsy
- Cardiovascular imaging studies with contrast and no identified risk factors (arteriogram, cardiac catheterization)
- Obtain fluid from body cavity (lumbar puncture, thoracentesis, paracentesis)
What management options are considered moderate level of risk?
- Minor surgery with identified risk factors
- Elective major surgery with no identified risk factors
- Prescription drug management
- Therapeutic nuclear medicine
- IV fluids with additives
- Closed treatment of fracture or dislocation without manipulation
What presenting problems are considered high risk?
- One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
- Acute or chronic illnesses or injuries that pose a threat to life or bodily function (such as multiple trauma, acute MI, PE)
- Abrupt change in neurologic status
Diagnostic procedures ordered considered high risk
- Cardiovascular imaging studies with contrast with identified risk factors
- Cardiac electrophysiological tests
- Diagnostic endoscopies with identified risk factors
- Discography
Management options considered high risk
- Elective major surgery with identified risk factors
- Emergency major surgery
- Parenteral controlled substances
- Drug therapy requiring intensive monitoring for toxicity
- Decision not to resuscitate or to de-escalate care
How is MDM complexity categorized?
- Problem-focused
- Low
- Moderate
- High
The final result of MDM complexity hinges on what?
- Two highest valued categories
- Two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level
Problem focused MDM complexity
- </- 1 diagnosis or treatment option points
- </- 1 data points
- Minimal risk
Low MDM complexity
- Diagnosis or treatment options = 2 points
- 2 data points
- Low risk level
Moderate medical decision making complexity
- 3 diagnosis or treatment options points
- 3 data points
- Moderate risk level
High medical decision making compexity
- 4 diagnosis or treatment option points
- 4 data points
- High risk level
What do initial patient encounters require?
Consideration of all three key components
What do subsequent hospital visits require?
Consideration of only two of the key components
Lowest component of the two or three key components required determines visit level
code 99221
Initial hospital care
* History detailed or comprehensive
* Exam detailed or comprehensive
* MDM straightforward or low
* Time: 30 min
Code 99222
Initial hospital care
* Comprehensive history
* Comprehensive exam
* Moderate MDM
* Time: 50 mins
code 99223
Initial hospital care
* Comprehensive history
* Comprehensive exam
* High MDM
* Time 70 mins
Code 99231
Subsequent hospital care
* Problem-focused history
* Problem-focused exam
* MDM straightforward or low
* Time: 15 min
Code 99232
Subsequent hospital care
* Expanded history
* Expanded examination
* Moderate MDM
* Time 25 min
Code 99233
- Subsequent hospital care
- Detailed history
- Detailed exam
- High MDM
- Time 35 min
How to determine level of service for time counseling/coordinating care?
- CPT assigns typical time to render service, but doesn’t need to last that long
- Inpatient: time accrues as unit or floor time in addition to face-to-face time
- When more than 50% of service time involves counseling and/or coordination of care, may select code reflecting total time spent with patient, rather than 3 key components
- TIme and corresponding counseling details must be documented in medical record as well as patient responses and all relevant history, exam, and MDM
- Amount of CCC time may be estimated at round total visit to closest average total visit time
- Tasks that count toward counseling patient include discussions of the plan, evaluation, procedures, prognosis, treatment options, risk factor reduction, and patient and family education
In order to bill for time counseling/coordinating care, what time must be documented
- Two different amounts: total visit time and portion of total visit time that was spent CCC
- Need brief description of what was discussed during time in order to prove medical necessity
