Course 6: Dispositions/Billing Flashcards
Dispositions
- Discharged (DC’d)
- Admitted
- Transferred
DC’d document:
- Follow-Up
- Time period in which to follow-up
- Specific conditions for return to the ED
- Condition: “Stable for discharge”
- Time of disposition
Hospitalized (admitted) document:
- Admitting physician
- Time of consult with admitting physician
- Patient Condition (good, fair, serious, critical)
- Admission location
- Admission time
Transferred document:
- “Patient stable for transfer”
- Time of consult with accepting facility
- “ED records accompanying patient”
- “Appropriate mode of transfer arranged”
Levels of reimbursement
Evaluation and Management Levels (E&M)
Your goal as a scribe
Eliminate ALL down coded charts
Elements for level 5 billing
- HPI-4
- ROS-10 or 2 “All systems negative”
- PHM/SH/FH-2
- Physican exam-8
Elements for coding Level 5 for the HPI
- Location
- Quality
- Timing
- Severity
- Duration
- Associated Sx
- Modifying factors
- Context
Elements for coding Level 5 for the ROS
- Constitutional
- Eyes
- E/N/T
- Cardiovascular
- Respiratory
- GI
- GU
- Musculoskeletal
- Neurological
- Integumentary
- Hematological
- Lymphatic
- Immunological
- Psychological
Elements for coding Level 5 for the PMHx
- PMHx/PSHx
- SHx
- FHx
Elements for coding Level 5 for the Physical Exam
- Constitutional
- Eyes
- E/N/T
- Cardiovascular
- Respiratory
- GI
- GU
- Musculoskeletal
- Neurological
- Integumentary
- Hematological
- Lymphatic
- Immunological
- Psychological
Unable to get information
“Unable to obtain a complete… due to…” in each section
Level 5 MDM
- Old records ordered and results
- Lab and radiology orders and results
- Consultations
- Discussion with pt/family
- Multiple differential Dx
- References to Lab/Rad results
- Medications and treatments in the ED
- Multiple Re-Evaluations
- Arranging Follow-up
- Discussion of specific risks
Critical Care Time documentation:
Minimum of 30 minutes
Pulse Ox Interpretation documentation:
Normal or Hypoxic
Xray Interpretation documentation:
Always record the number of views, as well as “Interpreted by EP”. Include three findings minimum
EKG Interpretation
Must have the rate, rhythm, and at least two other findings
ED procedures
Commonly missed procedures are Splint applications, Laceration repairs, Bedside US, and Foreign body removals.
One of the most important ways to help your doctor is:
Ask if they would like Critical Care for pt’s that may qualify
Vital signs
- Heart rate
- Blood pressure
- Oxygen saturation
- Temperature
Oxygen routes
- Room Air
- Nasal Cannula
- Facial Mask
- Non-Rebreather Mask
RA
Room Air
NC
Nasal Cannula
FM
Facial Mask
NRB
Non-Rebreather Mask
Critical Care Oxygen Routes
- Continuous Positive Airway Pressure
- Biphasic Positive Airway Pressure
- Bag-Valve-Mask
- Endotracheal Tube
CPAP
Continuous Positive Airway Pressure
BiPAP
Biphasic Positive Airway Pressure
BVM
Bag-Valve-Mask
ETT
Endotracheal Tube
ED Core Measures
- Acute MI
- CP
- Syncope
- Ischemic CVA
- PNA
- PE
- Otitis Externa
- Female Abd pain
- Pregnant Abd pain
- Pregnant Vaginal Bleeding
- Pregnant Rh Negative
- Central Line Placement
- Long Bone Fx
- Hospital-Acquired Conditions
Acute MI document:
ASA 324 mg given at arrival
CP (Non-Traumatic) document:
12-Lead EKG performed in ED
Syncope document:
12-Lead EKG performed in ED
Ischemic CVA document:
- Document :last known well” date and time
- Document tPA eligibility (within three hours of onset)
PNA document:
- Vital signs, O2 saturation, mental status
- Abx Selection and Timing
- Blood Cultures
Acute PE document:
Anticoagulation (Heparin) ordered
Acute Otitis Externa (Outer Ear Infection) document:
- Topical therapy
- Pain assessment
- Avoidance of PO (systemic) abx
Abd pain- female pt document:
Pregnancy test (uHCG) was ordered
Pregnant abd pain document:
US was ordered to determine the location of the pregnancy (r/o ectopic)
Pregnant and Rh Negative document:
Rhogam was ordered
Central Line Placement document:
Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine
Consent document:
“Consent obtained”
“Consent precluded by clinical urgency”
Unique physical identifiers document:
Any unique physical identifier in the physical exam portion of the record. Old scars, tattoos, old amputations, or obvious surgical implants.
Times document:
ALWAYS remember to document the time for everything. Initial contact, medications, consults, and the time the pt is dispositioned
HIPAA
Health Insurance Portability and Accountability Act:
Laws that protect the private health information of pt’s across the country
PHI
Protected Health Information:
Any type of information that can be directly or indirectly tied to a particular pt or visit
HITECH
Health Information Technology for Economic and Clinical Health Act:
PHI may not be transferred electronically, copied, emailed, stored on external devices, or sent without special security known as encryption.
Rules and regulations:
- Scribes cannot touch pt’s
- Beware of provider entrapment.
- Remove yourself from unprofessional situations/conversations
- Follow the dress code
- You cannot enter the facility unless you have your badge and your own EHR login.
- No cell phones at work
- Do not access family, friend, VIP’s or your own medical records.
- Never share your password
- Do not post any work-related information on social media
- Report all incidents or concerns to ScribeAmerica management .
HIPAA/HITECH violations will end up in…
- Being fired
- Reported to the Office of Civil Rights
- Charged with civil and criminal offense (criminal charges)
- Black-listed from medical schools
- Fined tens of thousands of dollars (minimum fee of $50,000)
Disposition
The pt’s destination after they leave the ED.
Hospitalist
Physician who cares for hospitalized pt
E&M Levels
Set of criteria that determine how a physician can be paid for their services
Level 5
Highest billing leve
Down-coded
When a physician can only be reimbursed for a lower level of care due to inadequate documentnation
Caveat
A disclaimer
Core Measure
A national standard among EP that dictates the care and documentation required for each Dx or complaint
Protected Health Information
Any information that can be tied to a particular pt
