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2. Goals. Understand concepts/rulesCorrect coding = $$$$
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1. 1 Coding and Billing for the Pediatric Hospitalist
2. 2 Goals Understand concepts/rules
Correct coding = $$$$
“Show ME the MONEY” Goal #1
Correct coding = compliance
“But keep me out of jail” Goal #2
GOAL #3 M.I.S.S. (make it simple S…)
“Senor”
3. 3 Show Me CPT (Current Procedural Terminology) Codes
More than 8,000 codes developed by AMA
Official code set for electronic billing for CMS/insurance companies
Translates work done by medical provider to the payer
4. 4 Show Me Evaluation and Management Codes (RVUs)
Observation Discharge (99217) (1.28)
Observation Care (99218-99220) (1.28-2.99)
Initial Hospital Care (99221-99223) (1.28-2.99)
Subsequent Hospital Care (99231-99233) (0.64-1.51)
Same day Admit/Discharge (99234-99236)
Hospital Discharge (99238-99239) (1.28, 1.75)
Outpatient Consult (99241-99245)
Inpatient Consult (99251-99255)
ER Visits (99281-99285)
5. 5 Show Me RVUs (Relative Value Units)
Translates work to $ amount
$36.0666 per unit (2009)
Payment based on Total RVUs (aka RBRVS)
Work + Facility + Malpractice
1.28 + 0.46 + .05 = 1.79 ($64.56) for 99221
2.99 + 1.04 + .10 = 4.13 ($148.96) for 99223
Geographic variation conversion factor(CF)
6. 6 Show Me Two main E/M guidelines (95 and 97)
Either acceptable
95 more “friendly”
System based
97 more subspecialty base
System or specific organ based
Difference is Exam
www.cms.hhs.gov/medlearn/emdoc.asp
7. 7 Show Me E/M service codes
History
Examination
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
History- HPI, ROS, PFSH
Exam -History- HPI, ROS, PFSH
Exam -
8. 8 Show Me 4wk old with fever to 101. Admitted and discharged after 3 hospital days.
E/M codes?
a. 99222, 99231, 99238
b. Depends on the clinical case
c. E/M codes, what’s that?
d. Who cares, I’m salaried!!!!!
9. 9 Show MeInitial Hospital Care (99221-99223) Examples from CPT 2009
99221
Mono with dehydration
Cellulitis of foot requiring IV abx
99222
Fever, limp, and painful hip motion of 18 hours
Acute asthma attack unresponsive to outpt tx
99223
High Fever and proptosis
DKA with vomiting, fever, and tachypnea
10. 10 Show MeInitial Hospital Care (99221-99223)
IHC History Exam MDM (Time)
221 Detailed Detailed Straight/Low (30 min)
222 Comprehensive Detailed Moderate (50 min)
Comprehensive Comprehensive High (70 min)
Must meet all three for given level
Obs admit (99218-99220), same day admit/discharge(99234-99235) uses same criteria
11. 11 MISS (History Summary) History
Levels HPI ROS PFSH
Problem focused brief n/a n/a
Expanded p.f. brief pro pert n/a
Detailed extended extended pertinent
Comprehensive extended complete compre
12. 12 MISS (History) HPI
Brief (1-3) Extended (>=4)
Modifying Factors Context
Quality Location
Timing Duration
Severity Associated Signs/symptoms
13. 13 MISS (History) Review of Systems
Problem Pertinent (1)
Extended (2-9)
Complete (>=10)
Constitutional Musculoskeletal
Eye Psych
ENMT Integumentary (skin and/or breast)
CV Endocrine
Resp Neurologic
GI Allergic/Immunologic
GU Lymphatic/Hematologic
14. 14 MISS (History) PFSH
Pertinent (1 of 3) Comprehensive (2 of 3)
Past History
Medical, Surgical, Allergies, Medications, Immunologic
Family History
Pertinent family medical history
Social
Marital status/living arrangements, occupation, sexual history, education level, use of etoh, tobacco, drugs
For comprehensive PFSH must have 3 of 3 for initial hospital care, initial observation care and consultations
15. 15 MISS (History Summary) History
Levels HPI ROS PFSH
Problem focused 1-3(brief) n/a n/a
Expanded p.f. 1-3(brief) 1(pro pert) n/a
Detailed >=4(extend) 2-9(extend) 1 of 3(detail)
Comprehensive >=4(extend) >=10(complete) 2 of 3(compre)
For comprehensive PFSH must have 3 of 3 for initial hospital care, initial observation care and consultations
16. 16 MISS (Exam) Exam – four levels
Problem focused 1 “limited exam of affected body area”
Expanded p.f. 2-4 (?) p.f. + “other symptomatic or related organ system”
Detailed 5-7 (?) extended exam + “other symptomatic or related organ system”
Comprehensive >=8
95 E/M guideline - does not delineated exact number
Baylor compliance 2-7 for both exp p.f, detailed
17. 17 MISS (Exam) Exam
Organ systems Body area
Constitutional
Eyes Head including face
ENMT Neck
CV Chest
Resp Abd
GI Back
GU Genitalia, groin, buttocks
Musculoskeletal Each extremity
Skin
Neurologic
Psychiatric
Heme/lymph/immunologic
18. 18 Show MeInitial Hospital Care 4 wk old with fever to 101
IHC HPI ROS PFSH Exam
99221 >=4 2-9 1 of 3 5-7(?)
99222 >=4 >=10 3 of 3 5-7(?)
99223 >=4 >=10 3 of 3 >=8
95 guidelines (no exact number delineated)
19. 19 $$$$Initial Hospital Care CC must be present
HPI/PFSH/Exam
Should not be a problem for comprehensive
ROS
ROS lacking in most
“All other ROS negative”
Psychiatric, Endocrine, Hematologic/Lymphatic
Standardized HPI/PFSH/ROS/Exam form (see attachment)
Don’t draw line
Patient/parent questionnaire (see attachment)
20. 20 Show MeInitial Hospital Care 4 wk old with fever to 101
IHC Hx/Exam MDM
99221 (1.79) no issue Straight/Low
99222 (2.97) no issue Moderate
99223 (4.13) no issue High
21. 21 MISS (MDM) MDM (DRIVER)
Four levels based on
#DX/TX, Complexity, Risk
22. 22 MISS (MDM) Number of #DX/Tx options
Minimal, Limited, Multiple,
Extensive
Identified vs. unidentified problem
Number and type of diagnostic tests/procedures
Improving, resolving, worsening, or failing
Consultations with other MDs
23. 23 MISS (MDM) Amount of Data/Complexity
None/Minimal, Limited, Moderate, Extensive
Diagnostic test ordered or reviewed
Review old records
Hx from other than patient
Discussions with MD who performed/interpreted initial test about contradictory or unexpected results
Personal review of image tracing
24. 24 MISS (MDM) RISK (See Handout)
Minimal, Low, Moderate, High
Presenting problem
Diagnostic procedure ordered
Management options selected
Highest level determines risk
25. 25 MISS (MDM)
26. 26 MISS (MDM)
27. 27 MISS (MDM)
28. 28 MISS (MDM)
29. 29 MISS (MDM) Initial Hospital Care (99221-99223) MDM #of Dx/TX Complexity Risk
(2 of 3)
30. 30 MISSInitial Hospital Care (99221-99223) Alternative MDM (used by coders/auditors)
Point system
# of Dx/TX options
Self limited or minor 1 point
Est. Problem, stable or improves 1 point
Est. problem, worsening 2 points
New problem, no additional w/u 3 points
New problem, additional w/u 4 points
Case = 3 or 4 points
31. 31 $$$$Initial Hospital Care (99221-99223) # of Diagnosis or Treatment options
At least moderate complexity since the problem is new to the MD
32. 32 MISSInitial Hospital Care (99221-99223) Complexity
Review and/or order lab tests 1 point
Review and/or order radiology test 1 point
Review and/or order other test (EKG,etc) 1 point
Discussion with initial MD of tests 1 point
Review and summarize old records 2 points
Obtain hx from other than patient 2 points
Discussion of case with another MD 2 points
Independent review of image, tracing etc 2 points
Case = 1 point
33. 33 Show MeInitial Hospital Care (99221-99223)
34. 34 Show MeInitial Hospital Care (99221-99223)
35. 35 Show MeInitial Hospital Care (99221-99223)
36. 36 Show MeInitial Hospital Care (99221-99223)
37. 37 Show MeInitial Hospital Care (99221-99223) MDM #of Dx/TX Complexity Risk
(2 of 3)
38. 38 Show MeInitial Hospital Care (99221-99223) 4 wk old with fever
IHC History Exam MDM
221 (1.79) Detailed Detailed Straight/Low
222 (2.97) Compre Detailed Moderate
(4.13) Compre Compre High
E/M Code?
99222 (2.97) or 99223 (4.13)
39. 39 $$$$Initial Hospital Care (99221-99223) Time
if >50% for counseling and/or coordination of care face to face then this becomes the PRIMARY component not the E/M documentation
99222 (2.97) by documentation but total time spent >= 70 min (>50% counseling/coordination of care)
“80 min total. 45 min on counseling/coordination of care” MAY NOT qualify.
“80 min total of which 45 minutes were used to discuss the current care of John in regards to abnormal lab results….”
99223 (4.13) instead of 99222 (2.97)
40. 40 $$$$Initial Hospital Care (99221-99223) Use benchmarks for comparison
99221 (1.79) 99222 (2.97) 992239 (4.13)
Seattle 5% 61% 34%
AAP SOHM Survey
Av 1% 54% 44%
TCH/BCM 1% 67% 31%
MD1 2% 3% 95%
MD2 6% 94% 0%
MD3 0% 96% 4%
Melzer et al Pediatrics July 2001;108:79-84
41. 41 $$$$Initial Hospital Care (99221-99223) Four D’s
Document
Coders/Compliance = Lawyers
“If it’s not legible, it’s not documented”
“If it’s not documented, it wasn’t done”
Develop
Templates
HPI/ROS/PFSH/Exam
Pt/parent questionnaire
Discover
Periodic audits/distribution
Discuss
Coders/Compliance the “gray areas”
42. 42 $$$$Initial Hospital Care (99221-99223) MD A (same group/billing ID) sees patient in the EC and then you admit the pt on the same day. Which CPT code/s are used?
You IHC (99221-99223); MD A (nothing)
Baylor Pediatric Dept (one billing ID)
Me IHC (99221-99223); MD A (99281-99285)
Patient was in observation and subsequently admitted the next day by same MD. Different MD?
IHC 99221-99223 for both scenarios
43. 43 Show MeSub Hospital Care (99231-99233) Examples from CPT 2009 as guide
99231 “stable, and recovering or improving”
Day three of meds for uncomplicated pneumonia
Responding to IV abx for ear or sinus infection
99232 “responding inadequately to therapy or has developed minor complication”
Unstable asthma complicated by pneumonia
Bacterial meningitis on IV abx now with fever
99233 “unstable or has developed significant complication or new problem”
Electrical burns to arm with ascending infection
Pan sinusitis complicated by brain abscess and asthma not responding to current treatment.
44. 44 Show MeSub Hospital Care (99231-99233)
SHC History Exam MDM (Time)
231 P. Focused P. Focused Straight/Low (15 min)
232 Exp. P.F Exp P.F. Moderate (25 min)
233 Detailed Detailed High (35 min)
Must meet two of three for given level
Inpatient F/U consult (99261-99265) uses same criteria
45. 45 Show MeSub Hospital Care (99231-99233) History/Exam
HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic
Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations
Family – health of parents/sibs/children, family members with disease realted to CC
Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education
Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic
HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic
Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations
Family – health of parents/sibs/children, family members with disease realted to CC
Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education
Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic
46. 46 MISSSub Hospital Care (99231-99233) MDM
# of Diagnosis or Treatment options
Est. Problem, stable or improves 1 point
Complexity
Review and/or order lab tests 1 point
Risk
IV ABX therapy Moderate
47. 47 Show MeSub Hospital Care (99231-99233) MDM #of Dx/TX Complexity Risk
(2 of 3)
48. 48 Show MeSub Hospital Care (99231-99233) 4 wk old with fever.
IHC 99222 (2.97) or 99223 (4.13)
SHC 99231 (0.89) or 99232 (1.47)
How can it be 99232?
“Responding inadequately”
Persistent fever
Level based on two of three
49. 49 $$$$Sub Hospital Care (99231-99233) Don’t abuse 99233 (2.09)
Keep track of time with multiple visits on same day
May be able to up code based on time
Document properly
50. 50 $$$$Sub Hospital Care (99231-99233) Use benchmarks for comparison
99231 (0.89) 99232 (1.47) 99233 (2.09)
Seattle 25% 66% 9%
SOHM Survey
10% 67% 23%
TCH/BCM 34% 59% 7%
MD1 9% 87% 4%
MD2 16% 22% 62%
MD3 79% 20% 1%
Melzer et al Pediatrics July 2001;108:79-84
51. 51 Show MeDischarge (99238, 99239) Time based
99238 (1.47, 30 minutes or less) 99239 (2.09, >30 minutes)
Includes PE, coordination of discharge, and discharge paperwork
Speaking with referring PCP
Prescriptions, written d/c summaries, referrals forms etc….
Discussion of care plans with patient/parent/caregiver etc….
DOES include time spent on dictations
Mclam Today’s Hospitalist May 2004 p 2 (amended August 2005)
52. 52 4 wk old with fever.
IHC 99222 (2.97) or 99223 (4.13)
SHC 99231 (0.89) or 99232 (1.47)
Discharge 99238 (1.47) or 99239 (2.09) Show Me
53. 53 Show MePATH PATH – Physicians at Teaching Hospital
Teaching physicians (TP) may bill for residents
Personally provided the service
Present during key or critical portions of the service that the resident performs
Independently sees the patient and reviews the management plan with the resident
Level of E/M derived by combining the residents and TP’s note.
www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf
54. 54 Show MePATH PATH
Scenario One
TP sees patient without the resident.
E/M guidelines as previously.
Scenario Two
Resident and TP sees the patient together
“I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.” (IHC)
“I saw the patient with the resident and agree with the residents’ findings and plan.” (SHC) Scenario one
Why bother having the resident there anywayScenario one
Why bother having the resident there anyway
55. 55 Show MePATH PATH
Scenario Three
Resident sees the patient then TP follows.
“I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.” (IHC)
“See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.” (SHC)
56. 56 $$$$PATH Scenario One
IF TP sees patient first and then the resident writes note
“I performed a history and physical exam of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.” (IHC)
“Hospital Day #__. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note. (SHC)
If TP sees patient first
“I performed a history and physical exam of the patient and discussed the management with the resident.”
After the note is written by the resident
“I have reviewed the resident’s note and agree with the documented findings and plan of care.”
57. 57 $$$$PATH TP must review notes written by resident and if disagrees then must document
Pre-printed templates NOT ACCEPTABLE
Not acceptable documentation
“Agree with above”
“Rounded, Reviewed, Agree”
“Discussed with resident. Agree”
“Seen and Agree”
Etc….
Medical Students work – “worth slightly more than the paper its written on”
Only limited to PFSH/ROS
TP must document HPI/Exam/MDM
58. 58 Show MePATH Procedures
TP must be present during “all critical and key portions of the procedure and be immediately available...”
If procedure is < 5 minutes, must be present for the entire procedure
What is the key portion for the LP
Judgment call
59. 59 Show MeNPP NPP (Non physician provider) Billing
Same group practice
Physician “provides ANY face to face portion of E/M encounter” in inpatient/outpatient/ED setting
Physician or NPP UPIN/PIN number
No face to face encounter
Bill NPP UPIN/PIN number
www.cms.hhs.gov/manuals/pm_trans/r178co.pdf
60. 60 Show MeProlonged Service Care Provisions for billing for time in excess for given E/M
Face to Face
99354, 99355 (outpatient)
99356, 99357 (inpatient)
Non Face to Face (reviewing chart, calling PMD etc…)
99358, 99359
May NOT be reimbursed
1st hour then subsequent 30 min increments
Must use with other E/M codes
Does not have to be continuous
Must be documented
No additional documentation accompanying bill required
61. 61 Show MeProlonged Service Care Example (time beyond defined E/M code)
SHC 99232 (25 minutes)
If total time spent - 25min =
<30 min None
30-74 min 99354/356/358
75-104 min above + 99355/357/359
105-134 min above +
99355/357/359 x 2
62. 62 $$$$Prolonged Service Codes HD #2
4 wk old with fever. Spent 45 minutes
explaining the plan of care to parents. On
f/u visit, explained to GM same plan.
Total time 80 minutes
E/M code?
63. 63 $$$$Prolonged Service Codes
Which SHC based on documentation?
99232 (25min)
64. 64 $$$$Prolonged Service Codes Did >50% occur face to face and used for
coordination of care/counseling?
YES – Then 99233 (35min) + then rest of 45 minutes use either 99356 (if face to face) or 99358 (if not face to face)
NO – 99232 (25min) + 99358 (55 minutes)
65. 65 Show MeMedical Team Conference Team Conference 99367
Time base 30 min or more
Multidisciplinary
Non face to face contact with patient/family
May NOT be reimbursed
Baylor compliance states “no dinero”
66. 66 Show MeConsultations Family Physician asks you to consult on
4 wk old with fever to 101 admitted to his
service for advice on treatment.
E/M code?
67. 67 Show MeConsultations Three types of consult
Inpatient Consult (99251-99255)
Outpatient Consult (99241-99245)
Obs, ER, Clinic
Confirmatory Consult (99271-99275)
Family/patient request second opinion
68. 68 Show MeConsultations Three Rs of consultation
Request
MD requesting consult must be documented
Verbal or written but must be documented
Reason
Report
Written or dictated
69. 69 Show MeInpatient Consult
IC History Exam MDM (Time)
251 Prob. F. Prob. F. Straight (20 min)
252 Exp. P.F. Exp. P.F. Straight (40 min)
253 Detailed Detailed Low (55 min)
254 Compre Compre Moderate (80 min)
255 Compre Compre High (110 min)
Must meet all three for given level
Outpt consult (99241-99245) uses same criteria
70. 70 Show MeInpatient Consult
HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic
Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations
Family – health of parents/sibs/children, family members with disease realted to CC
Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education
Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic
HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms
ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic
Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations
Family – health of parents/sibs/children, family members with disease realted to CC
Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education
Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic
71. 71 $$$$Inpatient Consult Inpatient consult on 4 wk old with fever.
E/M code?
MDM = Mod or High
99254 or 99255
72. 72 $$$$Consultations Family MD asks you to assume care of the
patient after the consult.
E/M code?
SHC 99231-99233
73. 73 $$$$Consultations Time may be factor if >50% face to face time is used for counseling/coordination of care
Make MDM be the driver
Four D’s (Document, Develop, Discover, Discuss)
74. 74 $$$$Consultations EC MD asks for consult for 4 wk old with
fever to 101 after full SBI w/u is done.
E/M code?
MDM = Mod or High
99244 (3.65) or 99245 (4.83) if admitted to different MD or discharged by ED MD (OUTPT)
75. 75 $$$$Consultations EC MD sees same patient then ask for your
consult. You subsequently admit to your
service.
E/M code?
MDM = Mod or High
IHC 99222-99223 (combine consult/admit)
76. 76 $$$$Consultations EC MD sees patient. Ask for your consult
and you discharge the patient from the ER
(Spanish speaking 100.1 not 101).
E/M code?
MDM = Mod or High
99204 or 99205 (outpt visit 3.59, 4.58)
Scott Pediatric Coding Companion Issue 1 2004
99244 or 99245 (outpt consult 4.51, 5.85) Baylor Compliance
77. 77 $$$$Consultations Follow up visits on Consult
Use SHC
May not get billed if use same diagnosis as Primary MD
78. 78 Show MeObservation To Obs or not to Obs, that is the question
Doesn’t meet inpatient criteria
“tweeners”
Not sick enough to be admitted but too sick to be d/c’d from the EC
Extended prolonged therapy from the EC
Asthmatic on frequent b-agonist therapy
Gastro with dehydration
Diagnostic uncertainty
Abd pain with negative U/S but persistent RLQ pain
79. 79 Show MeObservation Two sets of E/M codes (classified as outpt)
99218-99220
Use if in Obs status on different calendar day from d/c
Use 99217 for discharge on the second day
99234-99236
Use if Obs and d/c on the same calendar day
Also used for same day admit/discharge
Uses exact same E/M guidelines as IHC (99221-99223)
80. 80 $$$$Observation Status not a location
Can be anywhere
Must document Observation status
Pre-printed forms (see handout)
Time of admit to obs
Observation note
Diagnostic tests ordered
Discharge criteria
Ideally, have some hospital policy for which patient can be placed in Obs or admitted
81. 81 $$$$Observation EC MD sees patient in the ER. Hospitalist sees
patient in Obs status and then d/c that day.
E/M codes?
Different group
EC MD 99281-99285
Hospitalist 99234-99236
Same group
Use 99234-99236 (EC/Obs combined)
If D/C on different day then use 99218-99220 for Obs Day #1 and 99217 on Day #2
82. 82 $$$$Observation Hospitalist sees in EC and admits to Obs and then d/c.
If same calendar day then 99234-99236 (EC/Obs combined)
If different calendar day then 99218-99220 Day 1 (EC/Obs combined) and 99217
If from Obs to Admit on different day
Then use 99218-99220 on day 1 and 99221-99223 (IHC) on the day of admit
If same day, use only 99221-99223 (Obs/IHC combined)
WWW.ACEP.org
83. 83 $$$$Observation Medicare
If < 8 hours and same calendar day
Only 99218-99220
If >8 but <24 and same calendar day
99234-99236
If two calendar day (no time restriction)
Then both 99218-99220 and 99217
Same rules apply for inpatient admit
84. 84 Show MeER (99281-99285) 4 wk old with fever in the ER
EC History Exam MDM
99281 (0.44) Prob. F. Prob. F. Straight
99282 (0.73) Exp. P.F. Exp. P.F. Low
99283 (1.64) Exp P.F. Exp P.F. Moderate
99284 (2.56) Detailed Detailed Moderate
99285 (4.0) Compre Compre High
85. 85 Show MeEC (99281-99285) 4 wk old with fever in the ER
86. 86 Show MeEC (99281-99285) MDM #of Dx/TX Complexity Risk
(2 of 3)
87. 87 Show MeEC (99281-99285) MDM
# of Diagnosis or Treatment options
New problem, additional w/u 4 points
Complexity
Review and/or order lab tests 1 point
Review and/or order radiology test 1 point
88. 88 Show MeEC (99281-99285) Risk (from table)
Presenting Problem
Mod (Acute illness with systemic symptoms…)
High (Acute illness that pose a threat to life…)
Diagnostic Procedure
Mod (Fluid from body cavity…)
Management Options
Mod (IV fluids with additives)
Case =Mod or High
89. 89 Show MeEC (99281-99285) MDM #of Dx/TX Complexity Risk
(2 of 3)
90. 90 $$$$EC (99281-99285) 4 wk old with Fever to 101 in ER.
E/M Code?
99284 (2.56) or 99285 (4.0)
Plus LP 62270 (4.97)
91. 91 $$$$EC (99281-99285) 4 wk old with fever in EC after evaluations
by you is then admitted.
E/M code?
Admitted to you.
IHC 99223 (4.13) + LP 62270 (4.97)
(combine EC/IHC)
Admitted to someone else (not your group)
EC 99285 (4.0) + LP 62270 (4.97)
92. 92 $$$$EC (99281-99285) Admitted to Observation to you/group.
IOC 99220 (4.13) + LP 62270 (4.97)
Remember Four D’s (Document, Develop, Discover, Discuss)
93. 93 Show MeCritical Care 4wk old with fever. Becomes septic after sign out and requires transfer to ICU after prolonged resuscitation. What do I bill?
94. 94 Show MeCritical Care Delivery of Critical Care Service
Injury/illness that impairs one or more vital organ with high probability of imminent or life threatening deterioration…
Complex decision
Not Location dependent (EC, ACU, ICU…)
Time based
Direct care
Counseling and coordination of Care
95. 95 Show MeCritical Care Critical Care Code
99291 1st Hour
99292 Subsequent 30 minutes
96. 96 Show MeCritical Care
97. 97 Show MeCritical Care 4wk old with fever. Becomes septic after sign out and requires transfer to ICU after prolonged resuscitation. What do I bill?
How long did you spend?
2 hours total (99291 + 99292 x2)
98. 98 $$$$Critical Care Examples
Asthmatics
Bronchiolitis
Gastro
Document with time specified and what exactly was done.
In addition to E/M code
Can be multiple MDs (document properly)
99. 99 $$$$Critical Care Patient is now transferred from the ICU to your service. E/M code?
IHC (99221 - 99223) plus prolonged service if applicable
(Molteni Pediatric Coding Companion Issue 3 2004)
SHC (99231 - 99233) with prolonged service codes (99356,99357)
Baylor Compliance
100. 100 Show MeMiscellaneous E/M Codes Sedation
Same Physician
99143 (<5 yrs) first 30 min
99144 (>5 yrs) first 30 min
99145 additional 15 min
Different Physician
99148 (<5yrs) first 30 min
99149 (>5 yrs) first 30 min
99150 additional 15 min
101. 101 Summary Four D’s
Document
Coders/Auditors = Lawyers
Write everything down
Make it legible
Develop
Hx/Exam sheet
Pt/parent questionnaire
Super bill
Discover
Periodic audits/distribution
Discuss
Coders/compliance dept
“Gray areas”
102. 102 Resources CPT 2009
Your Billing/Coding Compliance officer
CMS
www.cms.hhs.gov
AAP
Coding for Pediatrics
Pediatric Coding Companion
Coding hotline (800-433-9016) or aapcoding@aap.org
103. 103 Resources Society of Hospital Medicine
www.hospitalmedicine.org
American College of Emergency Physician
www.acep.org
Physician Practice
www.physicianspractice.com
Today’s Hospitalist
www.todayshospital.com