Lecture 3: Billing Flashcards
What is CPOE?
Computer provider order entry to allow electronic entry vs paper
Paired with a clinical decision support system (CDSS)
CPOE fails when staff assume orders are correct because they seem specific.
What is a CDSS? (2)
- Suggests default values for dosing, administrations, etc.
- Include drug allergy/interaction checks
What are the pitfalls of CPOE? (2)
- People develop workarounds to the safety features
- Alarm fatigue
Who is the biggest insurance reimburser in the US?
CMS (Center for Medicare Services)
What is IPPS?
Inpatient prospective payment system, which is how medicare pays inpatient services.
What is MS-DRG?
Medicare severity adjustment diagnosis related group, which is how medicare groups services for reimbursement for inpatient services.
Some non-medicare use fixed payment daily, aka per diem.
Medicare will look at the primary diagnoses to group services.
How are provider services reported?
AMA’s CPT (current procedural terminology)
Describes procedures, services, etc.
What are the 3 + 1 key components of documentation?
- History
- PE
- MDM (Medical decision making)
- Time
Evaluation and management level is determined by this!
Time is 4th, only affects E/M level when counseling/coordination of care is more than 50% of the physician’s visit time.
What is considered a brief HPI? Extended?
- Brief = 1-3 elements
- Extended = 4+
- Elements: LOCATES + modifying factors
What are the 3 levels of a ROS for E/M determination?
- Problem-pertinent: 1 system
- Extended: 2-9 systems
- Complete: 10+ systems
What is a pertinent vs a complete PFSH?
- Pertinent: a comment in 1 of the 3 histories
- Complete: comment in all 3 histories
Past Medical, Family, or Social
Chart for determining level of history
Chart for PE levels
What 3 things determine the complexity of MDM?
- Number of diagnoses
- Amount and complexity of data
- Risk to patient
Straightforward, low, moderate, high
What counts as a diagnosis in MDM?
Diagnoses that are considered in the care plan, not merely mentioned or ascribed to a different provider.
If not elaborated on, it is part of the problem list instead.
Chart of diagnoses for MDM
Point values just for assignment
Chart of data for MDM
Point values just for assignment
What are the 4 levels of patient risk in MDM?
- Minimal
- Low
- Moderate
- High
Assessing risk of complications, morbidity, or mortality
Image of minimal and low risk in MDM
Image of moderate and high risk in MDM
Overall, once all categories of the MDM are rated, what determines MDM complexity?
The lower of the 2 highest valued categories
I.e. if you have A B C, you eliminate A since its the lowest. You then choose between B and C. B is chosen because it is the lower of the 2.
Chart of CPT codes for Initial inpatient visit
Chart of CPT codes for Subsequent inpatient visits
When can time override normal CPT E/M codes?
When counseling/coordination of care exceeds 50% of total visit time, you can switch to a time-based CPT code.
Must be documented, as well as patient response to counseling.
What two things must be documented for time to be billed?
- Total visit time
- Portion of total time spent coordinating care
What determines CPT level of service for a first time hospitalization? subsequent hospital visits?
- First time: Lowest of the 3 key components.
- Subsequent: Lowest of the 2 key components.
List some examples of things that count towards counseling the patient (7-8)
- Discussions of plan
- Evaluation
- Procedures
- Prognosis
- Tx options
- Risk factor reduction
- Pt/family education
If you want to bill for time counseling/coordinating care, what two things must be documented?
- Total visit time
- Portion of visit time spent on counseling/coordinating care (CCC).
