My Little Book of Inpatient Billing & Coding

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II

Read this carefully before you proceed

Medical necessity should always guide your level of coding

Disclaimer

Read and use at your own risk, I am a family physician with special interest in Hospital Medicine. I am the inpatient chief for our Family Medicine Residency Program. I am not a licensed billing or coding compliance officer. My interpretations are based on the 1997 CMS E/M guidelines, The Hospitalist section on medical coding and a series of lectures by our billing and coding department. Every physician responsible for coding should have a copy of the AMAs most recent CPT Standard Edition 2013 the authority on CPT coding.

Waiver, Release of Liability

By using this tool you release me, Carlos F Dumois, MD, Florida Hospital, Centre for Family Medicine, The Family medicine residency program, all the Family Medicine Residency faculty from any liability relating to your use of this tool. You waive any claims for sustained losses or damages from use of this Tool.

I would appreciate feedback regarding any errors discovered while using this tool or any

general comments on how to improve this billing and coding tool. Send comments or errors to

fmiroundingtool@gmail.com

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III A Word About Documentation

“If it isn’t documented, it hasn’t been done”

Please note that the examples of documentation for each level of coding is the bear minimum required by medicare to validate that level of coding. Additional

documentation maybe required for proper patient care and medical legal reasons.  “GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record”

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IV

Code History Physical MDM Time RVU

A

d

missio

n

N ee d 3 of

3 99221 Detailed Detailed SF / Low

30

min 1.92

99222 Comprehensive Comprehensive Moderate 50

min 2.61

99223 Comprehensive Comprehensive High 70

min 3.86

Sub

seq

u

en

t

Vi

sit

N ee d 2 of 3 99231 PF PF Low 15 min 0.76

99232 EPF EPF Moderate 25

min 1.39

99233 Detailed Detailed High 35

min 2.0 Obs Adm is si o n N ee d 3 of

3 99218 Detailed Detailed SF / Low

30

min 1.92

99219 Comprehensive Comprehensive Moderate 50

min 2.60

99220 Comprehensive Comprehensive High 70

min 3.56

Obs

fo

llo

w

-up

N ee d 2 of 3 99224 PF PF Low 15 min 0.76

99225 EPF EPF Moderate 25

min 1.39

99226 Detailed Detailed High 35

min 2.0

Obs

A

d

mit &

D/C Sam

e Da

y

N ee d 3 of

3 99234 Detailed Detailed SF / Low

40

min 2.56

99235 Comprehensive Comprehensive Moderate 50

min 3.24

99236 Comprehensive Comprehensive High 55

min 4.20

Billing and Coding

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V

 Medicare requires a patient to be in the hospital for a minimum of 8 hours before they

will consider an observation stay as medically necessary Medicare allows up to 48 hours of observation care

Di sc ha rg e Admi tt

ed 99238 D/C Less Than 30 Minutes

Document time on note only the time an attending spent

on discharge counts towards the Time allocation

99239 D/C More Than 30 Min

Obs 99217 Discharge (D/C)

Add on codes

Medicare will pay smoking cessation counseling codes up to eight times a year

Smokin g Ce ss at ion Sy mpt oma

tic 99406 counseling 3-10 min

99407 counseling > 10 min

As

ymp

toma

tic G0436 counseling 3-10 min

G0437 counseling > 10 min

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VI Add on Codes

Teaching time may not count towards Critical Care or Prolonged Service codes.

 However, the attending may bill for time spent supervising the resident so long as the

attending is physically in the room with the patient while the services are being provided, and documents:

 The time the teaching physician spent providing critical care

 That the patient was critically ill during the time the teaching physician saw the patient

 What made the patient critically ill

 The nature of the treatment and management provided by the teaching physician.

 The attending may reference the resident's documentation for details.

Cr it ic al Ca re 99291 Initial 30 – 60 min

3 key elements must be met for critical care (and documented):

Time: This is a time-based code; You must document the total time spent in the care of the patient. The time requirement is cumulative

Medical Necessity/Criticality: Defined as "A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition."

Interventions:CPT definition includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention that was performed which can be said to have averted or treated the patient's actual or potential

deterioration. (IVF, blood, pressors)

99292 Additional 30 min Prol o nged Servi ce code s 99356

Minimum of 30 min up to 60 min of additional time past the

threshold time of the original code

You must document the total time spent during the face-to-fact portion of the encounter, and the additional unit or floor time in an additional note or one cumulative note 99357

Every additional 30 minutes (minimum of 15 minutes)

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VII

HIS

TORY

Type of History determined by column with 3 selected areas or column with selected area farthest to the left

HPI: Status of chronic conditions:

 1 condition  2 conditions  3 conditions

OR Status of 1-2 conditions Status of 1-2 conditions Status of 3 conditions Status of 3 conditions

HPI (history of present illness) elements:

 Location  Severity  Timing

 Quality  Duration  Context

 Associated signs and symptoms

 Modifying factors Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more)

ROS (review of systems):

 Constitutional  Eyes  Ent  Cardiac

 Pulm  GI  Gyn  GU  MS

 Skin  Neuro  Psych  Endo

 Hem/Lymph  Allergy

 All others negative

None Pertinent (1 system) Extended (2-9 systems) Extended (2-9 systems) PFSH areas:

 medical  family  social history None None

Pertinent (1 history) Complete (3 of 3) PROBLEM FOCUSED EXP.PROB FOCUSED DETAILED COMPRE- HENSIVE PHYSI CA

L Elements Identified by Bullets

1 to 5 elemnts At least 6 elemnts 2+ elemnts frm 6 systms OR 12 + elemnts in 2+ systems 2+ elemnts from 9+ systems Organ systems:

 Constitutional  Eyes  ENT  Resp

 CV  GI  GU  MS  Neuro

 Psych  Skin  Hem/lymph/imm

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VIII

MDM

Final Result for Medical Decision Making 2 of 3 needed

Number diagnoses/ treatment 1 = Minimal 2 = Limited 3 = Multiple 4 = Extensive

Amount &/or complexity of data

1 = Minimal or

low 2 = Limited 3 =Multiple 4 = Extensive

Risk Minimal Low Moderate High

Medical Decision Making score Straight Forward Low Complex Moderate Complex High Complex MDM

Number of Diagnoses or Treatment

Problem(s) Status Number Points

Self-limited or minor (stable, improved or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1 Est. problem (to examiner); worsening 2 New problem (to examiner); no additional workup planned Max = 1 3 New prob. (to examiner); add. workup planned 4

TOTAL

MDM

Amount and/or Complexity of Data Reviewed Points

Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarize of old records and/or discussion of case with another health care pro 2 Independent visualization of image, tracing or specimen itself (not simply review of report) 2

TOTAL

Back Back

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IX

mdm

RISK (circle one in each category, highest category = level of risk)

Level of

Risk Presenting Problem(s)

Diagnostic Procedure

Ordered Management Options

Minimal

1 self-limited or minor problem

Laboratory tests requiring Venipuncture

Chest x-rays, EKG/EEG

Ultrasound Echo KOH prep , Urinalysis

Rest Gargles Elastic bandages Superficial dressings

Low

2 + self-limited or minor problems.

One stable chronic illness Acute illness /injury uncomplicated (cystitis, AR, sprain)

Physiologic tests not under stress, eg, PFT’s

Non-CV imaging with contrast, eg, barium enema Superficial needle biopsies

laboratory tests requiring arterial puncture

Skin biopsies

Over-the-counter drugs Minor surgery with no identified risk factors

Physical therapy Occupational therapy IV fluids without additives

Moderate

1 + chronic illnesses with mild excerbtn

Two or more stable chronic illnesses

Undiagnosed new problem Acute illness with systemic symptoms

Acute complicated injury

Physiologic tests under stress, eg, cardiac stress test

Dx endoscopies no risk factors

Deep needle or incisional bx CV imaging studies with contrast

Obtain fluid from body cavity

Prescription drugs IV fluids with additives

Closed treatmnt of fracture or dislocation w/out manipulation Minor surgery with risk factors Elective major surgery with no identified risk factors

High

1 + chronic illnesses w/ severe excerbtn,

Acute or chronic illnesses or injuries that pose a threat to life or bodily function

psychiatric illness with potential threat to self or others,

acute renal failure

Cardiovascular imaging studies with contrast with identified risk factors

Cardiac electrophysiological tests

Diagnostic Endoscopies with identified risk factors

Discography

Parenteral controlled Substances

Drug therapy requiring

intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

An abrupt change in neuro status, eg, seizure, TIA, weakness, sensory loss

Elective major surgery with risk factors

Emergency major surgery

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X REFERENCES

1. Lecture on Coding and Billing by Carol Miller at Centre for Family Medicine November 2012 2. The Hospitalist a publication of the society of Hospital Medicine. Accessed Jan and Feb 2013.

3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 2013.

4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Jan 2013.

5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at:

http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Jan 2013

6. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed Jan 2013 7. E/M University. http://emuniversity.com/Curriculum_Free.html. Accessed Jan 2013

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I

RESOURCES

My Little Book of Inpatient Billing and Coding

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II Critical Care Codes

Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Teaching time may not count towards Critical Care. However, the attending may bill for time spent supervising the resident so long as the attending is physically in the room with thepatient while the services are being provided, and documents: "(1) the time the

teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching

physician." The attending may reference the resident's documentation for details.

There are a three key requirements which must be met for critical care: Time:

 This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful

documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.

 The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.

 A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time.

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III Medical Necessity/Criticality.

 This is the huge subjective element in Critical care today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleed requiring fluids resuscitation and transfusion. For that matter, the current definition of

sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."

The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.

 Auditors generally give a fair amount of latitude to the judgment of the provider, so long as you explain your thoughts.

Supporting evidence of criticality which is helpful to highlight in your documentation might include:

 Obvious problems like respiratory failure or circulatory failure.

 Any organ system which has acutely failed (or may fail).

 Significantly abnormal vital signs.

 Shock, even early shock.

 Acidosis.

 Need for interventions such as central venous access, thoracostomy,

cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.

 Multi-system diagnoses (aka, your "Train wrecks") requiring highly complex medical decision-making.

 Trauma patients with serious injuries.

 Patients requiring ICU admission.

 ICU admission may support the criticality of the patient, but is alone not sufficient, especially if the patient is admitted as an overflow patient, or as a chronic ventilator patient.

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IV Intervention:

In order to fully justify the service you are claiming, it is necessary to have done

something for the patient. That may include anything from heroic life-sustaining

measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met.

 The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.

Documentation:

What's not required for critical care is almost as important as what is required. The standard E/M components of HPI, ROS, Past/Family/Social History, etc are not required. While you omit them at your peril (from a medical liability point of view), these are not required elements of a critical care chart from a coding and billing perspective.

It is important to understand that a variety of procedures are included, or "bundled" into CC. These are: blood draws, peripheral IV placement, blood gas interpretation, NG

placement, Pulse oximeter interpretation, ventilator management, transcutaneous pacing, and CXR interpretation. You may not bill separately for these items on a critical care

patient. However, all other procedures still may be billed separately, including but not limited to: intubation, central line placement, EKG interpretation, cardioversion, tube thoracostomy, laceration repair, fracture care, lumbar puncture, etc etc etc. Be aware that CPR supervision is a separately billed service, and CPR time bust therefore be subtracted from your total Critical Care time. It is very important to explicitly note that the time you spent providing critical care services was "exclusive of all other separately billed services." Memorize that phrase and be certain to use it in every critical care dictation you do!

You can bill an E&M code followed by a critical care code on the same calendar day (from midnight to midnight) because a stable patient can become unstable, However, you

cannot bill a critical care code followed by an E&M code. You would instead bill the follow up critical care codes 99292 if you meet the 30 minute targets.

 Example: If you bill a critical care code on admission at 1am-3am, and you come back for daily rounds at 7:30 am, you can not bill a hospital follow up code. You would have to bill the add on critical care codes 99292 if you meet the 30 minute time levels for each 99292.

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V Family Discussions

In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

The patient is unable or clinically incompetent to participate in discussions;

The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a

 medical history

 reviewing the patient’s condition or prognosis  discussing treatment or limitation(s) of treatment

 The conversation bears directly on the management of the patient. The medical record should reflect these criteria.

Do not consider the time if

 the discussion takes place in an area outside of the patient’s unit/floor

 if the time is spent counseling family members through their grieving process. It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan

review/revision), this second encounter might be regarded as a prolonged care service. Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.

Query payors for coverage, because some non-Medicare insurers do not recognize these codes.

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VI The Low Level Initial Hospital Visit

Admit Code: 99221

Observation Code: 99218

The Admit / Discharge Same Day Code: 99234 99221 accounted for only 2.8% of admissions.

The reimbursement for this level of care is approximately $97. CPT Definition

Initial hospital care (or observation), for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or

comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit (40 minutes for 99234).

Example of Minimal documentation needed for a level one admission 99221 CC: “My right foot hurts”

HPI: 45 year old homeless man who cut his right foot on a piece of glass about three days ago. He has noted increasing pain and swelling as well as stiffness in his right foot over the past 24 hours. The pain is described as a “burning” sensation (4 HPI)

PMH: Smoker (1 PMH)

ROS: No CP or SOB (2 ROS)

Exam

120/80, 85 102.7 temp (3 VS = 1 bullet)

Well appearing

Heart: RRR without murmur, good femoral pulses Lungs: clear to auscultation, normal effort

Abdomen: soft, no palpable liver (12 bullets)

Skin: erythema lines marked and noted, Induration present

Musculoskeletal: normal ROM knee, no clubbing, Cyanosis

Labs: WBC 17,000 HGB 11.5 (1 Data)

Assessment

Right lower extremity cellulitis ( 1 Dx)

Plan

Admit for IV antibiotics (mod risk – not needed for 99221)

HISTORY

4 elements of the HPI or the status of 3 chronic medical conditions. 2 ROS

1 area from Past Medical, Medications, Allergies, Family, Social history

EXAM

6 areas (2 bullets each) or 2+ areas (12 bullets total).

MEDICAL DECISION MAKING

One diagnosis is all you need. No data and minimal risk

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VII The Mid Level Initial Hospital Visit

Admit Code: 99222

Observation Code: 99219

The Admit / Discharge Same Day Code: 99235 99222 accounted for only 28% of admissions.

The reimbursement for this level of care is approximately $132. CPT Definition

Initial hospital care (or observation care), per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and /or

coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

Example of Minimal documentation needed for a mid level 99222 CC: “My right foot hurts”

HPI: 45 year old homeless man who cut his right foot on a piece of glass about three days ago. He has noted increasing pain and swelling as well as stiffness in his right foot over the past 24 hours. The pain is described as a “burning” sensation

Medications: On no meds. PMH: Smoker

FHX: Mother with eczema

ROS: pertinent positives as above, otherwise all other systems were reviewed and are negative (10+ROS)

Exam

120/80 85 102.7 temp, well appearing

(3 vitals = one bullet)

(HENT): 2 bullets Eyes: 2 bullets Neck: 2 bullets CV: 2 bullets Respiratory: 2 bullets GI: 2 bullets Neuro: 2 bullets Psychiatric: 2 bullets

Skin: Edema, warmth, redness right leg,

3/3 Needed .

History

4 elements of the HPI OR status of 3 chronic medical conditions. 10+ review of systems

3 areas documented: Past History (things like medical, medications, allergies) and Family History and Social History

Exam

1997 Guidelines: 9 areas with two bullets each

Medical Decision Making (moderate decision

making)

Number of diagnoses and management options: 3 points

Amount and complexity of data to be reviewed: 3 points

Table of risk: Moderate risk.

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VIII lines consistent with cellulitis

Labs: WBC 17,000 HGB 11.5 Assessment

Right lower extremity cellulitis Plan

Admit for IV antibiotics. Antibiotics reviewed with ER physician.

High Level Initial Hospital Visit Admit Code: 99223

Observation Code: 99220

The Admit / Discharge Same Day Code: 99236 99223 accounted for only 69%of admissions.

The reimbursement for this level of care is approximately $194. CPT Definition

Initial hospital care (or observation care), per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and /or coordination of care with other providers or agencies are provided consistent with the nature of the

problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 70 minutes at the bedside and on the

patient's hospital floor or unit (55 minutes for 99236).

Example of Minimal documentation needed for a high level 99223 CC: “My right foot hurts”

HPI: 45 year old homeless man who cut his right foot on a piece of glass about three days ago. He has noted increasing pain and swelling as well as stiffness in his right foot over the past 24 hours. The pain is described as a “burning” sensation

Medications: On no meds. PMH: Smoker

FHX: Mother with eczema

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IX Exam

120/80 85 102.7 temp, well appearing (3 vitals equals one bullet)

(HENT): 2 bullets Eyes: 2 bullets Neck: 2 bullets CV: 2 bullets Respiratory: 2 bullets GI: 2 bullets Neuro: 2 bullets Psychiatric: 2 bullets

Skin: Edema, warmth, redness right leg, lines consistent with cellulitis Labs: WBC 17,000 HGB 11.5

Venous doppler report reviewed. No clot.

Assessment

Right lower extremity cellulitis Plan

Admit for IV antibiotics. Antibiotics reviewed with ER physician.

The only difference between a high level admission code and a mid level admission code lies in the decision making component.

3/3 Needed .

History

4 elements of the HPI OR status of 3 chronic medical conditions.

10+ review of systems

3 areas documented: Past History (things like medical, medications, allergies) and Family History and Social History

Exam

1997 Guidelines: 9 areas with two bullets each

Medical Decision Making (moderate decision making)

Number of diagnoses and management options: 4 points amount and complexity of data to be reviewed: 4 points Table of risk: High risk.

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X Low Level Hospital Follow-Up

Admit Code: 99231

Observation Code: 99224

99231 accounted for 12% of follow up visit

The reimbursement for this level of care is approximately $38. CPT Definition

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided

consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.

Most doctors over-document this encounter and over-use this code

Example of Minimal documentation needed for a level one follow up 99231 S: No pain, no SOB (1 HPI)

O: 120/80, 88 Tmax 98 (three vitals is one bullet/ elements)

A: Right lower extremity cellulitis – stable (not needed for level 1)

P: Continue IV antibiotic (not needed for level 1)

Another example

S: No pain, (not needed for level 1)

s/p hip replacement

O: 120/80, 88 Tmax 98 (3 vitals = one bullet)

A: Hip replacement – stable

HTN – stable (1 Dx low risk)

P: Continue BP meds

History, 1 component for HPI.

Physical, you only need one organ system,

and documenting three vitals counts as one organ system. You don't need to document anything else to get paid appropriately for a 99231,

You can also document history and status of one medical condition to comply with the documentation for a 99231

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XI Mid Level Hospital Follow-Up

Admit Code: 99232

Observation Code: 99225

99231 accounted for 61% of follow up visit

The reimbursement for this level of care is approximately $69. CPT Definition

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided

consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.

It's almost impossible not to meet the criteria of a 99232 at a minimum, every time. Example of Minimal documentation needed for a mid level follow up 99232

S) sharp pain in leg (1 HPI), no fever (1 ROS)

O) 120/80, 88 Tm 98 (three vitals is one bullet/ elements)

Alert, RRR, no wheezing, mild leg edema, good pulses (6 bullets/elements)

A) Right lower extremity cellulitis

P) Continue antibiotic, WBC reviewed 12.6, case discussed with ID OR

you can document the status of three chronic medical conditions to substitute for your HPI

S: No SOB at rest, but worsens when laying down (1 ROS)

O: 120/80 70 Tm 98.6

Alert, RRR, no wheezing, no leg edema, no rash A: CHF, stable

HTN, stable (HPI, 3 chronic medical condition),

CAD, stable

P: Check pBNP, check CXR, continue current BP meds.

2 out of 3 needed

HISTORY

One HPI OR the status of 3 chronic medical condition

One ROS PHYSICAL

1997 guidelines require 6 bullets. DECISION MAKING 2/3

Diagnosis: 3 points Data: 3 points Risk: Moderate

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XII High Level Hospital Follow-Up

Admit Code: 99233

Observation Code: 99226

99233 accounted for 27% of follow up visit

The reimbursement for this level of care is approximately $100. CPT Definition

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed

examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

As a general rule when billing a patient for a high level code 99233 they should almost always have to have some sort of new issue going on and your documentation should support a high level history and a high level decision making component. While the rules state that you only need two out of three (history and physical, history and decision making, or physical and decision making), I would recommend to always limit yourself to history and decision when coding a level 99233, but, that's not necessary if the physical exam meets 99233 coding documentation requirements.

Examples of minimal documentation needed a high level one follow up (99233)

S: Chest pain, sharp, started last night, constant, associated with shortness of breath (5 HPI)

+leg swelling, no wheezing (2 ROS)

O: 120/80, 118, 98.8. pulse ox 89% on RA

(nothing needed for billing 99233 if high level History and MDM)

A: 1. Chest pain, shortness of breath, New problem

(4 points in diagnosis section with further workup planned )

2. Rt lower extremity cellulitis

P: Check ECG, cardiac enzymes x 3, Start O2, start Lovenox, check CCTA , if positive start Lovenox (high risk = Acute illnesses that pose a threat to life)

HISTORY

4 elements of the HPI OR the status of 3 chronic medical conditions 2 ROS

PHYSICAL EXAM

1997 guidelines state more clearly 6 areas with 2 bullets each, or 2+areas with 12 bullets total.

MEDICAL DECISION MAKING You need 2 /3

1. Diagnosis (4 points) 2. Data (4 points) 3. High Risk

(24)

XIII Another Example S: Shortness of breath no CP, no wheezing (2 ROS) O: Nothing needed A: 1. DM-stable

2. HTN-stable status of 3 chronic medical conditions substitutes for the 4 HPI

3. chronic afib-stable

4. hypoxemia- New problem (4 points in diagnosis section with further workup planned )

P: Discussed code status today. Patient wishes to be a DNR due to poor prognosis. Check CXR

(decision making is high risk,writing DNR)

(25)

XIV What are RVUs

RVU = Relative value units

RVUs reflect the relative level of time, skill, training and intensity required of a physician to provide a given service. RVUs therefore are a method for calculating the volume of work or effort expended by a physician in treating patients.

Medicare Reimbursement is calculated using RVUs.

Medicare pays physicians for services based on submission of a claim using CPT codes. Each CPT code has a Relative Value Unit (RVU) assigned to it. This is multiplied by a conversion factor (CF) and a Geographic Practice Cost Indices (GPCI), to create the compensation level for a particular service.

Relative value units (RVUs) – RVUs capture the three following components of patient care.

Physician work RVU – The relative level of time, skill, training and intensity to provide a given service. A code with a higher RVU work takes more time, more intensity or some

combination of these two.

Practice Expense RVU – This component addresses the costs of maintaining a practice including rent, equipment, supplies and nonphysician staff costs.

Malpractice RVUs - These are generally the smallest component of the RVU values and represent payment for the professional liability expenses.

Geographic Practice Cost Indices (GPCI) - accounts for the geographic differences in the cost of practice across the country. CMS calculates an individual GPCI for each of the RVU components -- physician work, practice expense and malpractice.

Conversion Factor (CF) – The conversion factor converts the relative value units into an actual dollar amount.

(26)

XV Problem Focused

HIS

TORY

Type of History determined by column with 3 selected areas or column with selected area farthest to the left

HPI: Status of chronic conditions:

 1 condition  2 conditions  3 conditions

OR Status of 1-2 conditions Status of 1-2 conditions Status of 3 conditions Status of 3 conditions

HPI (history of present illness) elements:

 Location  Severity  Timing

 Quality  Duration  Context

 Associated signs and symptoms

 Modifying factors Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more)

ROS (review of systems):

 Constitutional  Eyes  Ent  Cardiac

 Pulm  GI  Gyn  GU  MS

 Skin  Neuro  Psych  Endo

 Hem/Lymph  Allergy

 All others negative

None Pertinent (1 system) Extended (2-9 systems) Extended (2-9 systems) PFSH areas:

 medical  family  social history None None

Pertinent (1 history) Complete (3 of 3) PROBLEM FOCUSED EXP.PROB FOCUSED DETAILED COMPRE- HENSIVE Physical Exam PHYSI CA

L Elements Identified by Bullets

1 to 5 elemnts At least 6 elemnts 2+ elemnts frm 6 systms OR 12 + elemnts in 2+ systems 2+ elemnts from 9+ systems Organ systems:

 Constitutional  Eyes  ENT  Resp

 CV  GI  GU  MS  Neuro

 Psych  Skin  Hem/lymph/imm

(27)

XVI Expanded Problem Focused

HIS

TORY

Type of History determined by column with 3 selected areas or column with selected area farthest to the left

HPI: Status of chronic conditions:

 1 condition  2 conditions  3 conditions

OR Status of 1-2 conditions Status of 1-2 conditions Status of 3 conditions Status of 3 conditions

HPI (history of present illness) elements:

 Location  Severity  Timing

 Quality  Duration  Context

 Associated signs and symptoms

 Modifying factors Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more)

ROS (review of systems):

 Constitutional  Eyes  Ent  Cardiac

 Pulm  GI  Gyn  GU  MS

 Skin  Neuro  Psych  Endo

 Hem/Lymph  Allergy

 All others negative

None Pertinent (1 system) Extended (2-9 systems) Extended (2-9 systems) PFSH areas:

 medical  family  social history None None

Pertinent (1 history) Complete (3 of 3) PROBLEM FOCUSED EXP.PROB FOCUSED DETAILED COMPRE- HENSIVE Physical Exam PHYSI CA

L Elements Identified by Bullets

1 to 5 elemnts At least 6 elemnts 2+ elemnts frm 6 systms OR 12 + elemnts in 2+ systems 2+ elemnts from 9+ systems Organ systems:

 Constitutional  Eyes  ENT  Resp

 CV  GI  GU  MS  Neuro

 Psych  Skin  Hem/lymph/imm

(28)

XVII Detailed

HIS

TORY

Type of History determined by column with 3 selected areas or column with selected area farthest to the left

HPI: Status of chronic conditions:

 1 condition  2 conditions  3 conditions

OR Status of 1-2 conditions Status of 1-2 conditions Status of 3 conditions Status of 3 conditions

HPI (history of present illness) elements:

 Location  Severity  Timing

 Quality  Duration  Context

 Associated signs and symptoms

 Modifying factors Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more)

ROS (review of systems):

 Constitutional  Eyes  Ent  Cardiac

 Pulm  GI  Gyn  GU  MS

 Skin  Neuro  Psych  Endo

 Hem/Lymph  Allergy

 All others negative

None Pertinent (1 system) Extended (2-9 systems) Extended (2-9 systems) PFSH areas:

 medical  family  social history None None

Pertinent (1 history) Complete (3 of 3) PROBLEM FOCUSED EXP.PROB FOCUSED DETAILED COMPRE- HENSIVE Physical Exam PHYSI CA

L Elements Identified by Bullets

1 to 5 elemnts At least 6 elemnts 2+ elemnts frm 6 systms OR 12 + elemnts in 2+ systems 2+ elemnts from 9+ systems Organ systems:

 Constitutional  Eyes  ENT  Resp

 CV  GI  GU  MS  Neuro

 Psych  Skin  Hem/lymph/imm

(29)

XVIII Comprehensive

HIS

TORY

Type of History determined by column with 3 selected areas or column with selected area farthest to the left

HPI: Status of chronic conditions:

 1 condition  2 conditions  3 conditions

OR Status of 1-2 conditions Status of 1-2 conditions Status of 3 conditions Status of 3 conditions

HPI (history of present illness) elements:

 Location  Severity  Timing

 Quality  Duration  Context

 Associated signs and symptoms

 Modifying factors Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more)

ROS (review of systems):

 Constitutional  Eyes  Ent  Cardiac

 Pulm  GI  Gyn  GU  MS

 Skin  Neuro  Psych  Endo

 Hem/Lymph  Allergy

 All others negative

None Pertinent (1 system) Extended (2-9 systems) Extended (2-9 systems) PFSH areas:

 medical  family  social history None None

Pertinent (1 history) Complete (3 of 3) PROBLEM FOCUSED EXP.PROB FOCUSED DETAILED COMPRE- HENSIVE Physical Exam PHYSI CA

L Elements Identified by Bullets

1 to 5 elemnts At least 6 elemnts 2+ elemnts frm 6 systms OR 12 + elemnts in 2+ systems 2+ elemnts from 9+ systems Organ systems:

 Constitutional  Eyes  ENT  Resp

 CV  GI  GU  MS  Neuro

 Psych  Skin  Hem/lymph/imm

(30)

XIX MDM Straight Forward Or Low Complexity

MDM

Final Result for Medical Decision Making 2 of 3 needed

Number diagnoses/ treatment 1 = Minimal 2 = Limited 3 = Multiple 4 = Extensive

Amount &/or complexity of data

1 = Minimal or

low 2 = Limited 3 =Multiple 4 = Extensive

Risk Minimal Low Moderate High

Medical Decision Making score Straight Forward Low Complex Moderate Complex High Complex MDM Moderate Complexity MDM

Final Result for Medical Decision Making 2 of 3 needed

Number diagnoses/ treatment 1 = Minimal 2 = Limited 3 = Multiple 4 = Extensive

Amount &/or complexity of data

1 = Minimal or

low 2 = Limited 3 =Multiple 4 = Extensive

Risk Minimal Low Moderate High

Medical Decision Making score Straight Forward Low Complex Moderate Complex High Complex MDM High Complexity MDM

Final Result for Medical Decision Making 2 of 3 needed

Number diagnoses/ treatment 1 = Minimal 2 = Limited 3 = Multiple 4 = Extensive

Amount &/or complexity of data

1 = Minimal or

low 2 = Limited 3 =Multiple 4 = Extensive

Risk Minimal Low Moderate High

(31)

Figure

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