Course 6: Billing & Disposition Flashcards
Disposition (3)
pt’s destination after leaving the ED…
- Discharged
- Admitted
- Transferred
Hospitalist
Physician that cares for a hospitalized patient
E&M Levels
set of criteria that determine how a physician can be paid for their services
Level 5
highest level of billing
down-coded
when a physician can only be reimbursed for a lower level of care due to inadequate documentaiton
Caveat Statement
- a disclaimer—»evaluation may be limited secondary to:
- respiratory distress
- unresponsiveness
- clinical condition
- dementia
- AMS
- limited cognitive ability
- Document “Unable to obtain a complete ___ due to ___” in each section independently:
- the HPI, ROS, Past History, and Physical Exam.
- Otherwise the chart will be down coded due to the missing information.
Quality Measure
a national standard among ED physicians that dictates the care and documntation requried for each diagnosis or complaint
DC’D
[what to document] (5)
- Discharged Home—»remember to document…
- Follow-Up—» told who to follow-up with (PCP, local clinic, specialist)
- Time period in which to follow up—» # days until pt follow-up
- specific conditions for return to the ED—» specfic sx that if expereinced the pt should return to ED
- Condition: “stable for discharge”—» documented on every chart being discharged “stable for DC”
- Time of disposition—» document the time of the discharge and of the re-evaluation
Hospitalized
[what to document] - (5)
- Admitted (usually to hospitalist/internist)
- admitting physician:
- time of consult w/admitting physician—»time stamp of when physician speaks w/the consulting dr (what was discussed and who agreed to admit the pt)
-
patient condition: clinical condition of pt —»provided by dr. as…
- Good,
- Fair,
- Serious,
- Critical
- Admission Locaiton: area of hospital (ICU, Tele, OR, etc)
- Admission Time: time of admission
Transferred
[what to document] (4)
Documenting an AMA Note
(7)
How to code Level 5 for the…
HPI
How to code Level 5 for the…
ROS
How to code Level 5 for the…
PMHx
How to code Level 5 for the…
PE
CODING LEVEL 5 SUMMARY
[KNOW THIS SLIDE]
Level 5 Medical Decision Making (MDM)
(11)
Additional Documentation For Reimbursment (5)
What are the 5 Vital Signs?
Heart Rate (HR)
[normal vs. abnormal ranges]
Blood Pressure (BP)
[normal vs. abnormal ranges]
Oxygen Saturation (SaO2)
[normal vs. abnormal ranges]
Temperature (T)
[normal vs. abnormal ranges]
Common Oxygen Routes
RA
Common Oxygen Routes
NC
Common Oxygen Routes
FM
Common Oxygen Routes
NRB
Critical Care Oxygen Routes
CPAP
Critical Care Oxygen Routes
BiPAP
Critical Care Oxygen Routes
BVM
Critical Care Oxygen Routes
ETT
What are the 4 Critical Care Oxygen Routes?
What are the 4 Common Oxygen Routes?
HIPAA topic: Is it acceptable to use the physician’s charting account to enter the EKG interpretation once the physician provided approval?
No, all chart done by a scribe must be completed in the scribe’s charting account.
Does the following Past Hx meet level V billing requirements:
HTN, previous CVA in 2008 with residual LLE weakness, DM diagnosed at age 47, CABG x2 in 2011, and Tonsillectomy.
No. This is only medical and surgical history which are considered ONE element.
HIPAA topic: Give 5 examples if PHI.
- Patient’s Name,
- DOB,
- SSN,
- address,
- email,
- insurance information,
- phone number.
How many elements are required for a level V ROS with and without the “All Systems Negative” phrase?
2 with, 10 without.
True or false: The “All systems negative” phrase is used for all chart.
False.
Including the phrase is the physician’s preference AND also never used on patient’s unable to complete the interview (advanced dementia, AMS, unresponsive, etc.)
Name 4 common events that are time stamped in the chart.
- The moment the provider walks into the patient’s room for the initial evaluation,
- medication orders,
- consults,
- procedure start/end times,
- disposition times.
Describe a scenario where the R/B/A discussion would very commonly occur.
Before higher risk procedure such as the lumbar puncture, conscious sedation, cardioversion, receiving tPA, starting/stopping blood thinners, CT’s for children.
List 2 examples of a “unique exam identifier”.
- Scars,
- tattoos,
- amputations,
- G-tubes,
- trach scars,
- “zipper” sternotomy scar,
- birthmarks.
How many elements are included in this HPI:
Ariana Venti is a 24 y/o female presenting to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over the central chest and worse when leaning forward.
- 4 total = billing at level 5!
- Sharp- quality
- 4 hours ago, sudden- onset
- Central- location
- Leaning forward- modifying factor (worsening factor)
R/B/A
- Risk benefits analysis
- treatment plan, potential risks, alternatives
