Академический Документы
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Part I
Billing Background
Learning Objectives
Definition of ICD-9 CM codes Definition of CPT codes Medical Necessity and the interplay between diagnosis and coding
ICD-9 CM
ICD-9 CM: International Classification of Diseases, 9th Revision, Clinical Modification System modified from ICD, includes more specificity for clinical and billing purposes Revised annually ICD-10 CM currently under testing, may be in use in coming years.
ICD-9 CM Cont
ICD-9 CM diagnosis codes range from general to specific More specific codes may better support billing i.e. justify why higher level of service was deemed necessary
ICD-9 CM 427.9 427.31 250.01 Diagnosis Arrhythmia, NOS Atrial fibrillation Diabetes type I
250.03
595.0 590.10 428.1 428.30
Medical Necessity Rule: CMS (centers for Medicaid and Medicare Services) official statement
Medical necessity is determined based on the diagnosis submitted for that service or supply. Specificity and accuracy of diagnosis code and linkage on the claim form determine payment.
Part II
Using E&M Codes
Learning Objectives
The new versus established patient The three key components of the document
History Physical Exam Medical decision making
Level 1 2 3 4 5
The New versus Established patient Cont You work in a large multispecialty practice group. A gastroenterologist in your group, Dr. WW, follows a 50 yo man for IBD. Dr. WW refers him to you to establish primary care. The patient has never had a primary care MD before. New or established?
NEW
ESTABLISHED
NEW
1 1
2 2
3 3
4 4
Minimal Low
Moderat High e
Chief Complaint
Not considered one of the key components because does not determine which CPT code you can use but Required for EVERY level of billing, so ALWAYS include a chief complaint Chief complaint of follow-up is not sufficient Chief complaint of follow-up on diabetes is sufficient
History
Includes 3 components
HPI ROS PMH/FH/SH
HPI
Includes qualifiers that specifically refer to the chief complaint
Location Quality Duration Timing Severity Context Aggravating/Relieving factors Associated symptoms
HPI Cont
Refer to card
Brief = 1-3 qualifiers (levels 2-3) Extended = 4+ qualifiers (levels 4-5)
Eg. 65 yo man with cc of abdominal pain. Pain is severe, located in mid-epigastrum, radiates to back, is worsened by food. Also has a rash and urinary frequency. *Note that rash and urinary frequency may not count as HPI b/c dont refer to chief complaint abd pain.
Minimal Low
Moderat High e
HPI Cont
Chronic Conditions
Because chronic medical conditions often do not have symptoms amenable to description through qualifiers, you can instead document the status of 3 chronic conditions in place of an extended (ie >/= 4 qualifiers) HPI Eg: A 72 yo male comes in with cc of f/u on hypertension, coronary artery disease and hypercholesterolemia. Documenting the status of each of these as improved, stable or worse can replace the HPI qualifiers
ROS
14 systems recognized by MediCare Constitutional Eyes Ears, Nose, Mouth Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Neuro Skin and Breast Psych Heme/Lymph Endocrine Immuno/allergy
ROS Cont
Refer to your card
Problem Pertinent = 1 system (level 3) Extended = 2-9 systems (level 4) Complete = >/= 10 systems (level 5) * Medi-Cal requires 14 systems)
You may use a patient completed checklist for your ROS You must specifically document that you have reviewed the patient document, and state if it is an extended or complete ROS
1 1
2 2
3 3
4 4
Minimal Low
Moderat High e
PMH/FH/SH
Past History includes:
Past Medical history Past Surgical History Medications Allergies Immunizations
On a followup visit you may refer to a review of prior documentation of the past history Refer to your card - 1 components = level 4, 2 = level 5
Remember!!!
To meet a given billing level for the History key component, you must document at that level for EACH of the 3 subcomponents, HPI, ROS and PMH
Physical Exam
12 recognized organ systems for exam
Constitutional (includes vitals and general appearance) Eyes Ears, Nose, Mouth Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin and/or Breast/Chest Neurologic Psychiatric Hematologic/lymphatic
1 1
2 2
3 3
4 4
Minimal Low
Moderat High e
Diagnoses/Problems
Self limited/minor problem (2 max) = 1 point Established prob (stable/improved) = 1 point Established prob (worse) = 2 points New problem w/o planned w/u = 3 points New problem w/ planned w/u = 4 points *Billing level is based on point system; comprehensive/level 5 = 4 points * Remember to document new vs established problems and stability vs improvement/worsening
1 1
2 2
3 3
4 4
Minimal Low
Moderat High e
Data Review
Complexity of data reviewed is determined by point system. Different types of data and different means of reviewing receive different points.
Review of test with performing MD Decision/attempt to obtain outside records Review and summary of outside records
1 point
1 point
1 point
1 1
2 2
3 3
4 4
Minimal Low
Moderate High
Risk
Determined by AMA guidelines re:
Severity of problem, Invasiveness of diagnostic procedures/ tests Risk of medications/treatments
Risk Cont
Risk
Low
Problem
1 chronic stable problem 2 minor problems 1 acute non-systemic problem 2 stable chronic 1 new prob with unclear diagnosis 1 mild exacerbation Acute or chronic life threat prob Severe exac of chronic prob Acute AMS Psych risk to self
Data/Tests
ABG/PFT/UGI
Treatments
OTC meds PT/OT Minor surgery w/o RF IV medications Prescription rx Minor surg w/ RF Elective major surgery w/o RF Intense monitoring for drug toxicity (dig levels, heparin, coumadin) Elective surg w/ RF New DNR IV narcotics
Moderate
LP/thoracentesis Low risk cath Low risk endoscopy Excisional bx High risk cath High risk endoscopy EP test
High
Level of MDM
Determined by highest 2 of 3 MDM subcomponents (ie problem, data, risk) Note this is different than the History component when all 3 sub-components (HPI, ROS and PMH) must meet/exceed billing requirements
Other tips
Consultations
Consultation request must be documented by requesting physician The name of the requesting physician must be documented by the consulting physician There must be documentation of communication back to the requesting physician
Attending Observation
Attending can use coding modifiers for outpatient visits that they supervise Attendings must directly supervise all patients in the following settings:
All new patients All patients seen by resident in first 6 months of training All patients billed >/= level 4
Counseling
If > 50% of patient encounter is spent with face to face counseling, you can bill for counseling time Total time with patient and percentage of time spent counseling must be documented