Case Presentation

1. Case Presentation Elad Bicer January 31, 2007

2. The signout… • 60 Female • h/o COPD • CC: SOB, Cough • Sats 87%  intubated  tx for pnemonia. BP 105/60. Right femoral central line placed. 3L given past 3 hours. ICU screened in. • Sounds good I say…

3. The Chart… Not Billable!

4. Documentation for Billing A brief tutorial for SLR ED providers Anthony Carrozza MD Elad Bicer MD Richard Lanoix MD Patricia Carey MD Dan Wiener MD

5. I’m just a resident… is this really necessary? • Master the skills that will: • Increase your marketability • Improve your groups income • Improve staffing, equipment, better working environment • Improve your own income

6. Physician Reimbursement 101 • Documentation for reimbursement is the process of communicating the value of the medical care you provide. • The basic premise is simple: • Document what you thinkand what you do.

7. Communicate… • The goal of this tutorial is to teach you the process of documenting the value of your services. • The value of each patient encounter is conveyed via the CPT (Common Procedural Terminology) system. • The basic structure of the system and requirements for each CPT code will become clear shortly…

8. Cognitive payments • Your medical training has provided you the analytical tools for performing a complex decision making process • Furthermore, these “analytic tools” or decision-making capacity is what distinguishes you from all other members of the health care team • This “cognitive” effort has a lot of monetary value

9. Getting paid for thinking… • Now you need the tools to communicate your thinking according to the rules- the CPT guidelines. • Communicating your thinking/rationale in these terms allows the hospital to appropriately bill for your indispensable services.

10. The basic idea • The level of complexity of each patient encounter can be categorized into certain “levels”. • These levels take into account the: • Complexity of presenting problem • Complexity of diagnostic workup • Risk of Diagnostic workup • Risk of Treatment plan

11. The structure of CPT Coding Levels • Most of the value in Emergency Medicine is contained in five basic CPT codes. • Each correlates with an increasing complexity of service. • These codes are: • 99281- “Level 1” • 99282- “Level 2” • 99283- “Level 3” • 99284- “Level 4” • 99285- “Level 5”

12. Documentation Requirements • Each of these codes has specific documentation requirements. • It may seem overwhelming to memorize the requirements of each CPT code. • Learning a few basic points is all that is required to document correctly.

13. Coding vs. Billing • “Coding” in the context of this presentation, is the act of translating the written chart into CPT codes. • This is the responsibility of trained “coders” • These CPT codes are then used to generate a bill for the patient or third party payer.

14. Putting things into perspective

15. Nation vs. SLR • Your patients are just as sick and you should document accordingly. • As a rough guideline, in the Main ED you will see: • 30% “Level 3” • 30% “Level 4” • 30% “Level 5” • 10% “Level 1, 2, and Critical Care”

16. Reality Check • Coders have a superficial understanding of medicine • Communicate the complexity by: • Fulfilling basic documentation requirements • Documenting your decision making process • In the Land of Billing and Coding you get paid for what you have written, not for what you actually did.

17. Tips for this presentation • Please do not be compelled to memorize the many details of this presentation. • This is mainly an overview to be used in conjunction with the “Quick Reference for Billing” cheat sheet • It is readily available in the ED during your shift.

18. Required items for every chart • 1- Name • 2 – CC • 3 – Linkage • 4 – Dx • 5 – Signatures

19. The Chief Complaint • In order to write a clear HPI and make your life easier, the CC should be a symptom- NOT a diagnosis or event. • “SOB” instead of “Asthma” • “Back pain” instead of “MVC” • “R arm weakness” instead of R/O CVA

20. Past Medical, Family, Social History • These are three distinct elements of the chart, which are simply counted by the coder. You need: • 2 out of 3 elements for Level 5 • 1 out of 3 for other levels • Example of 2 of 3 elements:

21. ROS Requirements • According to CPT guidelines: • 10 ROS are needed for a Level 5 chart • 2 ROS for a Level 4 chart or lower • Note: The requirements are for categories of ROS, not individual ones. SOB and Cough are considered ONE ROS (respiratory).

22. ROS FAQ • What if I am unable to obtain the ROS for some reason? • There is a section above the ROS, which allows you to check the reason for not being able to obtain the ROS • Completing this section gives you credit for the ROS requirements of a level 5 chart

23. History of Present Illness • 4 Modifiers of the CC are required for Levels 4 and 5. • Since these codes are the majority of your charts, just try to make it a habit of documenting them first. • Modifiers include: • Timing, Duration, Intensity, Location, Quality, Aggravating/Alleviating factors, Associated symptoms, Context

24. How easy it is… • Example of chart with 8 modifiers: • Example of chart with 6 modifiers:

25. Solution • Document 4 modifiers for your main CC down on paper first, then continue with your narrative if that’s what you choose. • For billing purposes, the amount of writing is not as important as the content. • Tip: If you can’t get a sufficient HPI, state why : • “Unable to obtain additional Hx secondary to patients altered mental state, and other sources unavailable.” • You get credit for all 4 HPI elements!

26. Common Pitfall- Too many complaints, not enough modifiers • 40 yo c/o mild Back pain for 2 days. Dysuria, mild x 2 days, assoc with vag discharge. Right leg pain, 7/10. • There are at least 3 complaints: • Back pain- 2 modifiers • Dysuria-3 modifiers • Leg pain- 2 modifiers • Solution: Pick the most relevant CC and go with it!

27. Physical Exam • There are 12 Physical Exam organ systems. • These are reflected by the 14 ROS systems minus endocrine and immunologic.

28. Physical Exam Requirements • According to CPT guidelines, • Level 5 charts- 8 systems • Level 4 charts- 5 systems • Level 3 charts- 2 systems • Note: Only one PE finding is necessary for credit in one system, and stating “Normal” counts!

29. Example of all 12 PE Elements • Tip#1 You don’t need to write the category • Tip #2 You don’t have to state a finding. “Nml” counts.

30. Level 5 Clause • If for some reason, urgency prevented you from performing parts of the History and Physical- you can still get credit for a level 5 chart! • State - “Unable to perform PE secondary to treatment urgency” • Ie: active cpr, pt being wheeled to Cath Lab, etc.

31. Physical Exam Myth #1 • “The physical exam needs to be written in categories, with each finding in the corresponding section.” • Ie. CVS- RRR, no M/R/G • Reality is that the physical exam can be written in paragraph or list form. It is the coder that decides which finding is included in each category. • Ie. RRR, PERRL, CTA, +BS = 4 systems

32. Medical Decision Making (MDM) • MDM reflects the complexity and severity of the patient encounter. • In order to accurately reflect MDM the chart should include: • Brief Differential Diagnosis • Diagnostic Plan • Treatment plan • Reassessment notes

33. High Yield MDM Documentation • Differential Diagnosis • Documenting the severe or life threatening possibilities strengthens your MDM. • Diagnostic Plan • Invasive modalities (LP, IV contrast) strengthen your MDM more than noninvasive procedures (Xray, EKG).

34. High Yield Documentation cont… • Treatment plan • More complex treatment options results in higher MDM. • Document IV/IM meds, consults, prescriptions given, records reviewed, PMD spoken to. • Reassessment notes • These matter since they reflect the frequency of your attention to the patient.

35. Medical Decision Making Components

36. Procedure Coding • Procedures are also represented by CPT codes. • Some are much more valuable than even the E/M level 5 code! • Therefore, it is important to document your actions as well as your thoughts.

37. Documenting your procedures • The description of each procedure is best documented in steps and in the order they were performed. • The more descriptive you are, the better for both billing and medico-legal purposes.

38. Tips for Common Procedures • Wound care • The length and complexity of the repair is probably the most important. • If you repaired it in layers, say it. • Fracture care • State if reduced • State the type of splint used • Document your neurovascular exam

39. Keep in mind… • There are many procedures that we frequently do not document such as: • CPR • Nerve blocks • Procedural sedation • Slit lamp examination with corneal staining • EKG and Xray interpretations can be billed as procedures. Just write your findings and indicate “12 lead”.

40. Procedure Note Example • “1% lidocaine injected locally. Wound irrigated, explored, debrided. 4-0 vicryl x 2 for deep sutures. 5-0 nylon in simple interrupted fashion. Total length 5.5 cm.” • “right ulnar gutter splint placed, cap refill <2sec no motor/sensory deficits”

41. The BIG picture • Your thoughts (E/M level) and actions (Procedures) can result in multiple CPT codes for a single patient encounter • The aggregate value of these codes is reflected by your professional fee.

42. Back to our pt’s chart • NB due to name of resident • If name written: Billable 99283 with intubation (?)

43. What was missing you ask? • Level 5 Charting • Central Line placement • CC Note • Missed opportunity: • Any ideas?

44. Attending Specific Issues • Linkage statement • Check box “I examined the patient…” • Write: “I agree with resident note and plan” • Facility Charges • Critical Care billing!

45. Facility Charges • Each patient encounter not only generates a professional fee, but also a fee for the hospital. • This is called the Facility Fee. • Facility Fee reflects resources utilized during the delivery of care; i.e.: • Space occupied by patient • Nursing and support staff • Supplies • Utilities

46. Documentation for the facility fee • Currently at our institution, documentation for the facility fee is a matter of checking boxes on the charge ticket.

47. Critical Care-The Heartof EM • Critical Care is the essence what we do as EP’s. • It is what distinguishes us from many specialties. • Competency in performing critical care medicine is extremely valuable. • Let’s see how to communicate that value…

48. What qualifies as Critical Care(CC)? • Critical Care is performed when there is a high probability of imminent or life threatening deterioration. • At SLR, this occurs on a more common basis than currently perceived. • Critical Care includes most… • medical activations. • trauma activations. • ICU screens.

49. Requirements for the CC note • Chief complaint • Course of events, justifying critical care. • TIME STATEMENT – • This is the most important item. • CC must be at least 30 min to be billed. • CC has no history, ROS, or PE requirements.

50. Writing a CC Chart • The CC note can be thought of as a procedure note. • Requirements for the CC CPT code does not include most details needed for E/M 1-5 codes • In fact, it takes more effort to write an E/M Level 5 chart than it does for a CC chart • Let’s see how easy it is…