Billing and Coding for Physicians

1. Billing and Coding for Physicians Kirk Bronander, MD

3. Objectives • Name the 3 key components of Evaluation and Management. • Understand the components of Medical (billing) Decision Making. • Understand what constitutes a “comprehensive” History and Physical. • Be able to document a compliant note for a typical patient you would see.

4. Why do we document? • To communicate to other health professionals. • To provide a medical legal document. • To allow billing

5. Coding Speak • Words have different meanings to the coders Medical Decision Making: Medical billing decision making as opposed to a Medical Assessment and Plan. Risk: May or may not be risky to a clinician. Lay persons (bean counters) have their own ideas of what is risky. Chief Complaint: Why you are seeing the patient. Must be present in every note!

6. The Three Key Components of Evaluation and Management • 1) History • 2) Physical Exam • 3) Medical Decision Making • Which in turn has 3 components… -Risk -Data -Diagnosis For initial visits all 3 components are required. Only 2 of 3 required in subsequent visits.

7. Start with Medical Dec. Making • Calculate the MDM before any other component. • Then let the level of MDM guide the other components. • For example….why do a comprehensive H&P for a bug bite?

8. Medical Decision Making (MDM) • Risk • High Risk – not necessarily what you would think. • If your pt has… • One or more chronic illnesses with severe exacerbations, progression or side effects of treatment • Acute or chronic illnesses that pose a threat to life or bodily function • Abrupt change in neurological status. • If you are ordering… • Cardiovascular imaging studies with contrast with risk factors • Cardiac electrophysiological tests • Diagnostic endoscopy with risk factors

9. High Risk cont’d • If the pt will need… • Elective major surgery (open, percutaneous or endoscopic) with identified risk factors. • Emergency major surgery (open, percutaneous or endoscopic) • Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision for DNR or to de-escalate care because of poor prognosis

10. Moderate Risk • If your pt has… • One or more chronic illnesses with mild exacerbations, progression or side effects • Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis • Acute illness with systemic symptoms (pyelo, colitis) • If you are going to order • Obtaining fluid from a body cavity • Needle biopsy

11. Moderate Risk • If the pt will need… • Elective major surgery with no risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with additives

12. Low Risk • If your pt has… • Two or more self limited or minor problems • One stable chronic illness • Acute uncomplicated illness (simple UTI) • If you are going to order… • Physiologic tests not under stress (PFTs) • Non-CV imaging studies with contrast (BE) • Superficial needle biopsies • Skin biopsies • If pt will need… • OTC drugs • Minor surgery • PT/OT • IV fluid without additives

14. Data • Point system • Maximum number of points is 4

17. Diagnosis

19. Computing the MDM • Tally the result in each column • The lowest of the two highest is the complexity of MDM.

20. An Example • 65 yo male is admitted with severe COPD exacerbation requiring increased oxygen and you believe he may end up on the ventilator. RISK= high, “severe resp distress” • Data reviewed includes labs, CXR, EKG and personal intrepretation of both CXR and EKG Data = extensive (4) • Diagnosis = New Problem (3 points) + several other chronic problems (2 points) Dx = extensive (4)

22. MDM Example 2 • 36 yr healthy male with alcoholism comes to ER for pancreatitis. He has no other medical problems and needs admission mostly for pain control as he is requiring IV narcotics. • Data reviewed was only CT abdomen and labs • Diagnosis is a new diagnosis and you feel there is no need for additional work up at this time.

24. Caution • If Risk is the lowest of the components of MDM you should review your information!

25. HISTORY and PHYSICAL EXAM • After calculating MDM you now need to document an appropriate level of History and/or Physical Exam. • This requires that you know what level they (the bean counters) expect.

26. HISTORY and PHYSICAL EXAM • Problem Focused • Expanded problem focused • Detailed • Comprehensive

27. HISTORY

28. ROS Categories (14) • · Constitutional symptoms (e.g., fever, weight loss) • · Eyes • · Ears, Nose, Mouth, Throat • · Cardiovascular • · Respiratory • · Gastrointestinal • · Genitourinary • · Musculoskeletal • · Integumentary (skin and/or breast) • · Neurological • · Psychiatric • · Endocrine • · Hematologic/Lymphatic • · Allergic/Immunologic

29. Caution! • The bean counters do not recognize “non-contributory” in Family History (even though we know it truly is sometimes). AVOID THIS TERM. NONCONTRIBUTORY

30. Physical

31. Comprehensive • Physical Exam • At least 9 organ systems or body areas with at least 2 bullet elements. • · Constitutional (e.g., vital signs, general appearance) • · Eyes • · Ears, nose, mouth and throat • · Cardiovascular • · Respiratory • · Gastrointestinal • · Genitourinary • · Musculoskeletal • · Skin • · Neurologic • · Psychiatric • · Hematologic/lymphatic/immunologic

32. New Patients - Ambulatory ** All three must meet or exceed the level of service you have chosen

33. Established Patients- Ambulatory ** Two out of the three elements must meet or exceed the level of service you have chosen

34. Example of compliant note for 99214 • Mr. Jones is a 57 yo diabetic with HTN and Dyslipidemia. • Nursing note says he is complaining of nasal discharge. VS BP 140/75, HR 82, RR 12, Temp 98 • You have a HbA1C and recent lipid panel to review. • MDM- Risk: 2 or more stable chronic illnesses - MOD Data: Lab – 1 point Diagnosis: Depends on findings but likely 4 (3 stable established dx) and one new self limiting problem. Overall MDM : Moderate…..therefore detailedhistory and physical needed.

35. Example of compliant note for 99214 • History CC: 57 yo male here for f/u HTN, DM, DL and c/o 5 days of rhinorrhea HPI: HTN is not well controlled given DM. DM managed well currently on metformin, last A1C 6.5, DL, LDL last checked was 70 on statin. (status of 3 med problems) ROS: Pt reports no fever, chest pain, SOB, numbness, or changes in vision (5 ROS categories)

36. 99214 note cont’d • Physical VS – BP 140/75, HR 82, RR 12, Temp 98 Gen- WD/WN male ENT – yellow rhinorrhea noted, slight erythema in oropharynx, Neck – no LA CV – S1S2 RR, 2+ DP pulses Lung – normal excusion with normal BS Abd – mildly obese, nontender, no organomegaly Neuro – feet with normal sensation to monofilament Skin – no open sores or pressure ulcers on extremeties.

37. 99214 note cont’d • A/P – 1. HTN – not well enough controlled given DM. Would increase ACE/HCTZ combo. • 2. DM – well controlled on metformin • 3. DL – LDL of 70 on simvastatin is excellent. • 4. Likely viral URI – self limiting, explained to return if fever, HA, and discharge persists more than 10 days.

38. Initial Hospital Admission **Three out of the three must meet or exceed the level of service you have chosen

39. Subsequent Hospital Visits ** Two out of the three elements must meet or exceed the level of service you have chosen

40. Time based coding • You can bill based on time but you will find it is impossible to have a full schedule of patients and meet your financial needs. • Example: The time must be at least what is listed for the E&M code 99214 = 25 min. • Half the time must be face-face with pt. • Documentation should include why it took so long and face to face time. • You could only see maximum of 18 pts in 8 hour day with ½ hour for lunch.

41. Other time based codes • Discharge from inpatient • Time spent <30 min = 99238 • Time spent >30 min = 99239 • Critical Care Services • >30 min – 1 hour providing bedside or unit critical care = 99291 • Each additional 30 min after the initial hour = 99292

42. Hospitalized Observation Pt • An observation admission is technically an OUTPATIENT. • The pt should only be Observation for at max 48 hours • There is a set observation admit codes and a discharge code (99217). There are NO follow-up codes.

43. OBS Example • Mild asthma exacerbation admitted at 11 PM • Coded level 2 obs admit • Still wheezing on rounds at 9 am. You decide to keep another day. • Discharged at 8 AM on third day – OBS discharge 99217. • Question: What do you do with the 2nd day?

44. Answer • Day number 2 should be coded as an Outpt follow-up code since technically OBS is outpt. • Alternatively you can write an order on day number 2 to “change to Acute admission” Charge an initial admit charge on that date and then a hospital discharge 99238 the 3rd day.

45. Objectives – How did I do? • Name the 3 key components of Evaluation and Management. • Understand the components of Medical (billing) Decision Making. • Understand what constitutes a “comprehensive” History and Physical. • Be able to document a compliant note for a typical patient you would see.