intro - coding and billing Flashcards
family medicine
-oldest medical specialty
-Most diverse - covers peds to geriatric
-Provide dx, therapeutic, and preventive care across pts lifespan
-Routine checkups
-Health risk assessments
-Immunizations
-Screening tests
-Healthy lifestyle counseling
-Tx of common chronic conditions
-minor surgical procedures
internal med vs family med
INTERNAL MED
-in depth training for adult medicine -> EM, critical care, subspecialties
-most training in inpt -> 3 yrs
-only perform minor procedures, very infrequent
-mostly inpt focused on chronic adult ds
FAMILY MED
-broader range of medical subspecialties -> peds, obgyn, other
-some training inpt but majority outpt
-will perform what is needed if in rural setting
-major focus on preventative care
inpatient vs out pt
inpatient
-tx administered to pt whose condition requires tx in hospital and pt is formally admitted to facility by doctor
outpt:
-consultation, procedure, tx, service without overnight stay
-MC- routine PE by PCP
-preventative services - colonoscopy, dx imaging/mammo, chemo/radiation tx
-same day procedures:
-hip and knee replacement
-dental surgery
-gastric bypass
-breast augmentation
benefits of outpatient
-recover from tx or surgical procedure in home
-improve pt experience
-decrease risk of hospital acquired conditions and healthcare associated infection
why does admission status matter
-important for Original Medicare beneficiaries, because:
-Medicare Part A pays for inpatient.(with a single deductible for the 1st 60 days of care in a benefit period.
Whereas,
-Medicare B pays for outpatient care, with a deductible pays coinsurance based on services provided
observation status
-pt has condition that provider wants to monitor to see if you require inpatient admission.
-Observation status is outpatient status, but it can also last for multiple days, depending on the circumstances (ie, the fact that you’re in the hospital overnight doesn’t necessarily mean you’ve been assigned inpatient status).
ICD-10 vs CPT codes
ICD: international classification of ds
-describes pts signs, sx, condition, complaint, problem
-justify pts medical necessity
-ex. 4 procedures = 4 different ICD to prove medical necessity
-these are in the assessment
CPT: current procedural terminology
-describes medical, surgical, and dx services
-communicates uniform information about medical services and procedures among physicians, coders, pts, accreditation, organizations, and payers for administrative, financial, and analytical purposes
-time includes prework and writing the note
🔹 ICD = Illness (Diagnosis) → “WHY the patient needs care”
🔹 CPT = Care Provided (Procedure) → “WHAT the provider did”
3 components to determine acuity of pt:
-based on how many dx or management that youre writing ab in ur note
-if you dont write out ruling stuff out and all the things you did -> you lower acuity
-elaborate note = higher acuity
History Component
-CC- required & cannot be inferred
-HPI-cannot be documented by staff
-ROS-& PFSH can be documented by staff
-PFSH (past, family, social history)
Physical Examination
-Number of organ systems examined
Medical Decision Making: Assessment and Plan
-# diagnoses or management options
-Amount of data/complexity
-Risk level to the patient
ethics and coding
-Actual Service Performed
-Coding for coverage- Not picking the best code for the procedure , just something that is covered
-Upcoding
-Double billing- when the PA and doctor bill for the same thing
-Unbundling- billing for something that included in the bundle you billed for (ex. you bill for ICU and then also bill for IV -> That included)
-something that can be justified is central line or chest tube
-Separating coding- billing for excisional biopsy and then plastics closure -> if you bill for excisional bx obviously you are going to close it
timeline for evolution of medical billing
SOAP Note Structure
S (Subjective): History, chief complaint (CC), HPI, ROS, past medical history. what are the patient’s current complaints
O (Objective): Physical exam, diagnostic results relevant, what is the examination summary
A (Assessment): Differential diagnosis and ICD-10 CODING!!!
P (Plan): Treatment plan, further testing; what is the medical decision making?
level 99201-99205 what components to determine which code?
- Each level is determined by history, examination, decision-making complexity, risk, and time
Emergency Department (ED) Codes
- Level of service must reflect the interventions performed and the medical necessity of care.
- Documentation must support ED E/M codes to justify the level of billing.
Two Components of ED Billing:
- Professional Codes: Based on cognitive effort, complexity, and decision-making.
- Facility Codes: Reflect resource usage and intensity of resources used
