Lecture 2: Business of Medicine Flashcards
What are the 3 steps of provider reimbursement?
- Appropriate coding of dx from encounter (ICD-10 codes)
- Appropriate coding of services from encounter (CPT outpatient, ICD-10-PCS inpatient) + modifiers
- Insurance determines appropriate fee based on codes
Define ICD-10 CM and ICD-10 PCS
- ICD-10 CM = Clinical management, which is Diagnosis codes
- ICD-10 PCS = Procedure coding system, which is inpatient procedure codes
ICD = International Statistical Classification of Diseases and Related Health Problems
What is CPT and who is in charge of it?
- Current Procedural Technology
- The AMA publishes CPT codes
How are dx typically listed in order?
Either order of importance or time spent
What are the primary goals of medical auditing?
- Improve efficiency and quality of delivery of care to patients
- Avoid undercharging or overcharging for services rendered
- Ensure adequate documentation of encounters
- Eliminate use of outdated or inappropriate coding
Internal/external auditing can occur.
You can be fined for undercharging patients too!
What are diagnostic procedures vs therapeutic procedures?
- Diagnostic: Imaging, UA, EKG, Wet mount/slide, spirometry
- Therapeutic: Nebulizers, injection, wound care
What are the elements of a history for billing purposes?
- CC
- HPI
- ROS
- PFSH
Define a brief HPI vs an extended HPI
- Brief: 1-3 elements
- Extended: 4+ elements or 3+ chronic
What are the 3 ROS classifications for billing?
- Problem pertinent: only system directly related to HPI issue
- Extended: system + 2-9 additional
- Complete: System + 10+ additional
Define a pertinent vs complete PFSH
- Pertinent: at least 1 item
- Complete: 2 for established/ER, 3 for new/consults
Image of PE exam levels for a multi-PE exam
In order to get detailed, every system must have 2+ details.
Image of PE exam levels for a single system
Image of MDM elements
- Dx/Mgmt options
- Complexity/Data Reviewing
- Risk Assessment
What things can increase data complexity for billing purposes?
- Reviewing old med records
- Discussing test results with the person that ordered it
- Personal review of imaging/specimens
At what level does risk become moderate for MDM in terms of chronic illness?
When you have either a worsening chronic issue or 2+ stable chronic issues.
What CPT code range refers to a new patient for an outpatient visit?
99201-99205
What CPT code range refers to an established patient having an outpatient visit?
99211-99215
What CPT code range refers to an outpatient consultation?
99241-99245
What CPT code range refers to an initial inpatient visit?
99221-99223
What CPT code range refers to a followup inpatient visit?
99231-99233
What big change in 2021 did medicare make to outpatient documentation requirements?
Primary emphasis on either time spent caring for encounter or level of MDM overrides H&P reqs
Also, as long as you meet lvl 2, you get paid regardless from level 2-4 visits.
What big change in 2023 did medicare make to inpatient documentation requirements?
Primary emphasis on either time spent caring for encounter or level of MDM overrides H&P reqs
When was ICD-11 implemented?
Jan 1, 2022
Its gunna take like another decade to implement fully
