The Business of Medicine Flashcards
1
Q
What are the 3 steps of provider reimbursement?
A
- Appropriate coding of diagnosis from associated encounter - ICD-10-CM codes or ICD-11 codes
- Appropriate coding of services from encounter - CPT codes (outpatient) or ICD-10PCS (inpatient), may use modifiers to indicate extra level of care
- Insurance determines appropriate fee based on codes
2
Q
What is ICD-10?
A
- International Statistical Classification of Diseases and Related Health Problems, 10th edition
- Published by WHO for standardization of assessments/diagnosis of patients, assists with storage and retrieval of diagnostic info, helps with assembling data with certain diagnosis
- ICD-10CM (clinical management): diagnosis codes
- ICD-10PCS (procedure coding system): hospital inpatient procedures
- HIPAA requires use of standardized coding system
3
Q
What is CPT?
A
Current procedural technology published initially by american medical association in 1966
Standardizes and quantifies complexity of an encounter based on
* Types and number of diagnosis discussed/addressed
* Extensiveness of history and physical exam
* Extensiveness and complexity of decision-making process/care plan
4
Q
What is the role of providers in medical billing and coding?
A
- Many facilities require to select appropriate dx codes based on problems discussed with patient, typically listed in order of importance/time spent
- Many require to select appropriate procedure codes based on what was carried out at visit
5
Q
What is the role of providers in medical reimbursement?
A
- Facility is reimbursed based on visit codes: higher-level = higher reimbursement
- Different insurances = different reimbursements
6
Q
What are the primary goals of a medical audit?
A
- 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- Eliminate use of outdated or inappropriate coding
May be done internally (by your facility) or externally
Can be fined for overcharging or undercharging
7
Q
What codes are used for outpatient procedures? Inpatient?
A
- CPT codes (outpatient)
- ICD-10-PCS codes (inpatient)
8
Q
What are examples of diagnostic procedures that can be assigned codes? Therapeutic?
A
Diagnostic: imaging, UA, EKG, wet mount
Therapeutic: nebulizer treatment, injection, wound care
9
Q
How do you decide which code to use?
A
Most facilities have reference database
10
Q
What are examples of special circumstances that require modifiers?
A
- Multiple visits on the same day
- Repeat tests in a short period of time
11
Q
What elements are required for a problem focused history?
A
- CC
- Brief HPI
- No ROS
- No PFSH
12
Q
What elements are required for a expanded problem focused history?
A
- CC
- Brief HPI
- Problem-pertinent ROS
- No PFSH
13
Q
What elements are required for a detailed history?
A
- CC
- Extended HPI
- Extended ROS
- Pertinent PFSH
14
Q
What elements are required for a comprehensive HPI?
A
- CC
- Extended HPI
- Complete ROS
- Complete PFSH
15
Q
How can a HPI be classified? How many elements need to be documented for each?
A
- Brief: 1-3 HPI elements
- Extended: 4+ HPI elements or status of 3+ chronic conditions
16
Q
What are classifications of ROS?
A
- Problem pertinent
- Extended
- Complete
17
Q
What is considered a problem pertinent ROS?
A
- Only system directly related to problem in HPI
18
Q
What is considered extended ROS?
A
- System directly related to CC plus 2-9 additional
19
Q
What is considered complete ROS?
A
- System directly related to CC plus 10+ additional
20
Q
What are classifications of PFSH?
A
Pertinent or complete
21
Q
What is considered a pertinent PFSH?
A
- Reviews at least one item from any of the 3 areas pertinent to the HPI
22
Q
What is considered a complete PFSH?
A
Review of 2 or all 3 areas
Two areas: for established or ER visits
Three areas: for new patients, hospital or consultation visits
23
Q
How can history be documented?
A
Separately as CC, HPI, ROS, PFSH with own headings
Congruently as one HPI paragraph
24
Q
Do you need to re-record each time you document a established patient?
A
It’s okay to update but be sure to review the history each time and document you did
25
What qualifies as problem focused physical exam?
* 1+ organ systems/body areas
* 1-5 elements
26
What qualifies as a expanded problem focused physical exam?
* 1+ organ system/body area
* 6+ elements
27
What qualifies as a detailed physical exam?
* 6+ organ systems/body areas
* Each system/area-2+ elements
* Alternative- 12+ elements over 2+ organ systems/body areas
28
What qualifies as a comprehensive physical exam?
9+ organ systems/body areas
Each system/area 2+ elements
29
How is a single system physical exam qualified as problem focused?
* 1 to 5 elements
30
What is included in a single-system expanded problem focused exam?
6+ elements
31
What is a single system detailed exam?
12+ elements
If eye or psych 9+ elements
32
What is a single system comprehensive exam?
All elements
33
Is abnormal okay to document for the affected area?
NO always need to document abnormal findings
34
Is normal okay to document for the affected system/area
Not really-should always spell out pertinent normal findings
35
Is abnormal okay to document if it's not the affected area?
No, if you find something abnormal you need to explain
36
Is normal okay to document if it's not the affected area?
For billing, yes. For the same of other providers no
37
What elements are required for a straightforward type of decision making?
* Minimal number of diagnosis or management options
* Minimal or none amount and/or complexity of data to be reviewed
* Minimal risk of significant complications, morbidity, and/or mortality
38
What elements are required for low complexity decision making?
* Limited number of diagnosis or management options
* Limited amount and/or complexity of data to be reviewed
* Low risk of significant complications, morbidity, and/or mortality
39
What elements are required for moderate complexity decision making?
* Multiple diagnosis or management options
* Moderate amount and/or complexity of data to be reviewed
* Moderate risk of significant complications, morbidity, and/or mortality
40
What elements are considered high complexity decision making?
* Extensive number of diagnosis or management options
* Extensive amount and/or complexity of data to be reviewed
* High risk of significant complications, morbidity, and/or mortality
41
How do you determine the number of diagnosis/management options?
* How many distinct entities were addressed today?
* Were there numerous treatment options to choose from, or only a few?
* Improving/resolving problems are less complex than worsening/failing to change as expected problems
* If you have to refer someone out, it's probably a more complex issue
42
What increases the amount/complexity of data to review?
* Reviewing old medical records or other data sources
* Discussing contradictory or unexpected test results with the performing/interpreting physician
* Personally reviewing images/specimens rather than just relyinf on the report/interpretation
43
How is the risk of complications, morbidity, mortality decided?
* Based on risk associated with presenting problems/diagnosis, any diagnostic procedures ordered, and the possible management options
* Highest level of risk in any one category determines the overall risk
* Consider their comorbidities, the type of procedure, and the urgency of the procedure or treatment
44
idk if we need to know all of the examples and everything or not
45
What is the patients over paperwork initiative?
Attempt to reduce administrative burden and stop providers from trying to document to code rather than to the needs of the pt/visit
46
What were 2019 medicare coding changes?
* Optional documentation changes for E/M visits (evaluation and management)
* Home visits no long require documented medical neccesity
* H&P may focus on waht has changed for established patients (no need to re-record required elements if evidence the provider has reviewed and updated previous information as needed)
* CC &HPI for new and established pts no need to re-document info already documented by the pt/staff
47
What were 2021 Medicare Coding Changes?
* Single rates: condensing rates for level 2-4 applied to both new and established patients
* Add-on codes: to address additional resources for level 2-5 visits
* Extended visit codes: to address additional time in level 2-4 visits
* Options for documenting: may document charge based on current framework with levels or based on time
48
What do you have to document if using time?
Medical necessity of visit and that the billing practitioner personally spent the required amount of time
49
What do you have to document if using current framework?
Levels 2-4 visits must only meet criterion for level 2 visits
Primary emphasis on either time spent caring for encounter or level of medical decision-making, not H&P requirements
50
What are 2023 medicare coding changes?
* Facility-based (inpatient) E/M services are similar to office outpatient services
* Primary emphasis on either time spent caring for encounter or level of medical decision-making and not H&P requirements
* Eliminating codes: merged some codes for services like observation into existing hospital care codes
* Prolonged service codes: to addresss additional time or resources used in visits
* Virtual and AI care: new codes to reflect billing for use of technology like remote monitoing, AI applications
51
Why did we stop using ICD-9?
* Outdated
* Nonspecific codes
* Limited data collection
* Insufficient to adequately descibe pts conditions and diagnoses
52
What are major changes in ICD-10?
* Increased number of codes from 13,000 to over 68,000
* Increased specificity
* Allows for clarification
* Expandibility (room to add more diagnosis)
* Combination codes (multiple diagnosis in one code)
53
Why did we stop using ICD-10?
* Already outdated
* Areas of non-congruence with current medical science advances
* New diagnostic categories and reported greater ease of use (searchable), codes like antimicrobial resistance
* However, clinical implementation often lags behind formal approval
54
Can you use a symptom/sign as a diagnosis code?
* Where possible, a specific condition is preferred as a diagnosis
* However, if a specific diagnosis has not been found by the end of the encounter it is appropriate to report codes for a s/s in lieu of a diagnosis
55
How many digits should I go to for a diagnosis code?
Providers should choose a code with as many digits as are available- using an incomplete code may result in rejection of the claim
56
What if there are 2 principal diagnoses for a given encounter
If there are 2 principal diagnoses, either may be listed first in the assessment
57
There are practice questions you can get to from the slides! I don't really understand this lecture so I'm going to come back to it
58
What is the ICD-10 code format?
* Alpha 1st digit
* Numeric 2nd digit
* Alpha or numeric 3rd digit
1st, 2nd, and 3rd are category
Characters 3-7 can be any combination of alpha or numeric and are etiology, anatomical site, and severity. 7th digit is a extension
