Unlock the Secret to E/M Coding: Medical Necessity Skills

Transcription

AAPC Workshops
Unlock the Secret to E/M Coding:
Medical Necessity Skills for Coders
AAPC
2480 South 3850 West, Suite B
Salt Lake City, Utah 84120
800-626-CODE (2633), Fax 801-236-2258
www.aapc.com
2014
Medical Necessity Skills for Coders
By Stephanie Cecchini, CPC, CEMC, CHISP, Approved ICD-10 Trainer
Introduction
AAPC Disclaimer
This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding the concepts of Medical Necessity in Evaluation and Management (E/M) coding and is not intended to grant
rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information
within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice
lies with the provider of services.
AAPC agents, writers, contributors, contractors, employees and staff make no representation, warranty, or guarantee that
this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the
use of this course. This guide is a general summary that explains commonly accepted aspects of selecting E/M codes, but it
is not a legal document.
Viewpoints are discussed from the standpoint of the 1995 and 1997 Centers for Medicare and Medicaid Services (CMS)
Evaluation and Management Documentation Guidelines with Medical Necessity and the nature of the presenting problem
as the primary criterion of code selection (Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician
Practitioners, 30.6.1 - Selection of Level of Evaluation and Management Service, A. Use of CPT® Codes.)
For the purpose of objective consistency, specific logics are primarily based on the same used by the E/M Documentation Auditors’ Worksheet, Marshfield Clinic, available through the Medical Group Management Association (MGMA).
Specific payers, including Medicare Carriers, may use different and sometimes varied audit tools logics to gain objective
consistency around the 1995 and 1997 Documentation Guidelines. Official provisions are contained in the relevant laws,
regulations, rulings and contractual agreements of providers.
US Government Rights
This product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at
private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government
rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/
or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS
252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights
restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987)
and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of
Defense Federal procurements.
AMA Disclaimer
CPT® copyright 2013 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part
of CPT®, and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not
directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or
not contained herein.
CPT® is a registered trademark of the American Medical Association.
The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for
Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims
responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information
contained in this product.
It is recommended that the participant of this course will familiar with:
CMS 1995 Documentation Guidelines for Evaluation and Management Services
zz CMS 1997 Documentation Guidelines for Evaluation and Management Services
zz
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AAPC 1-800-626-CODE (2633)
Introduction
About the Author:
Stephanie Cecchini, CPC, CEMC, CHISP, Approved ICD-10 Trainer, VP Coding Operations joined Aviacode in 2012
where she continues her commitment to best serve the revenue cycle management needs of physicians and the healthcare
community. She is an executive Level consultant with significant healthcare business experience. Stephanie is an expert in
clinical documentation requirements for coding and billing to Medicare, Medicaid and all lines of commercial payer business. She brings to her position more than 18 years’ involvement in healthcare regulations including: coding and billing
compliance, HIPAA privacy, security, and transactions, and HITECH “meaningful use” compliance. Previously, Stephanie
served as SVP at the American Society of Health Informatics Managers, working to fill the needs of physicians adopting Health IT and at its sister organization, AAPC as VP, Product Management. In prior roles she served as Chief Audit
Officer for Parses, Inc., designing audit programs for payers and managing overpayment recovery. As a public speaker and
published writer, she is a nationally respected advocate of fair and proper payment for medical services. Stephanie lives in
Salt Lake City, Utah with her husband Jim and their three children. Stephanie is LION (Linked In Open Network). Please
feel free to connect with her at: http://www.linkedin.com/in/stephaniececchini
Notice Regarding Clinical Examples Used in this Book
AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and
examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members.
To preserve the real world quality of these notes for educational purposes, we have not rewritten or edited the notes to the
stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity
or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.
© 2014 AAPC
2480 South 3850 West, Suite B, Salt Lake City, Utah 84120
800-626-CODE (2633), Fax 801-236-2258, www.aapc.com
All rights reserved.
CPC®, CPC-H®, CPC-P®, CIRCC®, CPCOTM, and CPMATM are trademarks of AAPC.
Unlock the Secret to E/M Coding
www.aapc.comiii
Contents
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1: Refresher—Code Selection by Documentation Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
History of Present Illness: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Past, Family & Social History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The CMS 1995 Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The CMS 1997 Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Medical Decision Making (MDM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Number of Diagnoses and Management Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Amount and/or Complexity of Data to be Reviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Risk Significant Complications, Morbidity, and/or Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapter 2: Medical Necessity—What is it? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Chapter 3: How Sick is Sick? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Nature of the Presenting Problem and Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
MDM and Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Example: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chapter 4: Who Says How Sick Is Sick? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Relating Medical Necessity to Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Medical Necessity “Faces” E/M Coding Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Sick: Level Three Outpatient (Level One Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Sicker: Level Four Outpatient (Level Two Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Sickest: Level Five Outpatient (Level Three Inpatient) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Communicating Effectively with Documenting Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Chapter 5: Combining ICD-10 CDI Training Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Chapter 6: Mastering a Good Coder-Physician Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Let’s Help! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References Cited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Appendix A: E/M Code Selection (Reference Sheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
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Contents
Appendix B: Medical Necessity Flow Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Appendix C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Slide Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
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AAPC 1-800-626-CODE (2633)
Summary
Evaluation and management (E/M) codes are the most
commonly billed codes. Although there are guidelines to
proper E/M code selection, Medical Necessity is the primary driver of correct coding. We are told that a physician
may take a full history and provide a full physical, but
without medical need to back it up…we should select a
lesser code. For example, a resolved contact dermatitis with
no other problem or complaint, is not a Level Five service
because there is no need for a full Level Five service. It is
a coder’s responsibility to verify that the diagnosis in the
chart supports the procedure being billed. The question
becomes: How does a coder, who is not medical peer, challenge the questions of Medical Necessity when the reason
for the services are NOT so black and white? And, the
largest shade of grey, what supports a Level Three versus
a Four? This workshop will provide you with the insights
necessary to unlock the secret of accurate E/M coding by
introducing the skills needed to accurately identify and
effectively address Medical Necessity concerns.
Introduction
E/M codes, the codes that bill for patient visits, are subjective in nature. One of the biggest conundrums faced by
coders is Medical Necessity in E/M coding. Legally, the
CMS 1995 and 1997 Documentation Guidelines are not
statutes, and they are interpretive and arguable. Medical
need for services rendered is the authoritative and winning
factor.
From the aspect of Medical Necessity, the correct level
of service is determined simply by how sick a patient is.
Conditions that pose an immediate threat to life or bodily
function qualify for the highest code Level, whereas
patients with minor or well controlled problems are at the
lowest.
A coder may review a document and establish that a comprehensive service was rendered; however, a medical review
may find the same service lacking in necessity. A comprehensive service may be a physician’s personal art and style
of practice but may not be considered necessary and billable by a majority of his or her peers. For example, a comprehensive history and physical may not be necessary to
repeat on a two week follow-up visit to check the patient’s
normal blood pressure.
This is a problem that only asserts itself in the healthcare
industry, but it is rather like pulling in for an oil change…
and then also being charged for new wiper blades, fans,
and a transmission flush – all before manufacturer recommendation - and without being asked first. Although the
services were rendered, and might even be superior to the
services by the mechanic down the street…but they were
unnecessary per industry standards. The customer might
complain and feel cheated. In the world of healthcare,
payers are required to guard against medically unnecessary
services.
In its annual financial report, the Department of Health
and Human Services disclosed Medicare fee-for-service
improper payments increased by 18 percent to total some
$36 billion during the 2013 fiscal year, which ended in
September . The report finds that the primary cause of
improper Medicare Fee for Service (FFS) payments is
Administrative and Documentation errors (63 percent), in
large part due to insufficient documentation. The other
cause of improper payments is classified as Medical Necessity errors (37 percent), caused by medically unnecessary
services.
Accurate E/M coding requires interpretation of documented medical records---followed by code look up and
knowledge of coding rules. Certified coders are well
equipped to define clinical documentation insufficiency
errors and to educate our physicians to improve. However,
Medical Necessity issues are a different story. A coder
might code correctly per the rules of documentation
requirements …however, still miscode the service if they
incorrectly interpret the severity of the patient’s problem as
compared to proper payment.
The problem many coders have is that they are not medical peers to physicians. Challenging the medical need for
services is not appropriate, even though they are often
required to make decisions that involve it. Coding auditors
without access to a Medical Director or other peer are even
more disadvantaged.
Although many coders are good at identifying a Medical
Necessity concern, they are often uncertain about how to
respond to it. Because the vast majority of medical coders
are not physicians or qualified to act as a medical peer in
making Medical Necessity determinations -and may be
worried about the implications of querying the physician.
A wrong step can lead to significant barriers in the coderphysician relationship.
Yet coder silence can be damaging. Concerns left unvoiced
may lead to over-payments and risk of negative payer
audits, which are projected to rise in 2014. In fiscal year
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(FY) 2013, CMS reported an error rate of 10.1 percent
for Medicare Fee-for-Service. This exceeds the 10 percent
threshold set by the Improper Payments Elimination and
Recovery Act of 2010 (IPERA) and is an increase from FY
2012. Exacerbating the problem, EHR templates are in
growing use. These templates are known to increase the
likelihood of artificially inflated codes due to expanded
documentation that is not supported by Medical Necessity.
This type of “false positive” code can be costly on payer
audit. The bottom line is: no one can afford to make a
mistake.
This workshop is designed to make the topic of Medical
Necessity less intimidating for coders. It also teaches you
how to connect with documenting physicians to make
E/M coding easier, audit ready, and accurate for fair payment. Maybe even...fun!
In this workshop, you will learn:
Three little known secrets to accurate E/M coding
zz The definitions of Medical Necessity for purposes of
accurate coding
zz How to clinically differentiate E/M service Levels
zz Effective techniques for communication with physicians regarding Medical Necessity
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AAPC 1-800-626-CODE (2633)
Chapter 1: Refresher—
Code Selection by
Documentation Markers
This workshop will first review the documentation requirements to ensure that this foundation is addressed. If you
are an E/M documentation requirements expert, skip to
Chapter 2: Medical Necessity – What is it?
The CMS 1995 and 1997 Documentation Guidelines
are defined methods to determine the correct code for a
patient visit. If all work that is documented is Medically
Necessary, these guidelines serve to select a correct Level of
service. In most cases, the E/M code is calculated by following relational rules from three parent tables (together
called the “Key Components”). Each of these three tables
has child variables that are considered by themselves and
then together before selecting the final E/M code.
The Key Components
1. History
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family and Social History (PFS)
2. Exam
3. Medical Decision Making
Number of Diagnoses and Treatment Options
Amount and Complexity of Data
Overall Risk
History
There are sub components, which could be thought of as
“child variables” to measuring the amount of physician’s
work in taking a patient’s medical history. These are: History of Present Illness (HPI), Review of Systems (ROS),
and Past, Family Social History (PFS).
History of Present Illness:
The patient’s EXPLANATION of what brought them to
the PHYSICIAN
LOCATION: For example “chest” pain, sore “knee”, etc.
zz SEVERITY: A statement of degree or measurement
regarding how “bad” it is… that it is improved, it is
extreme pain, “Blood Sugar is 200,” feeling “better,”
pain is bad enough “that the patient can’t sleep” etc.
zz
TIMING: A measurement of when or at what frequency; i.e. “intermittent,” “constant,” in the “morning,” lasted “5 minutes,” “occasional,” “on and off,” etc.
zz ASSOCIATED SIGNS AND SYMPTOMS: Any
associated or secondary complaints.
zz MODIFYING FACTORS: Anything that makes
the problem better or worse, a factor that changes,
improves, or alters the problem. For example,
improved “with Tylenol,” worse “when standing,”
better “when resting,” “calms down when mother
feeds her”
zz CONTEXT: What the patient was doing, the environmental factors/circumstances surrounding the complaint, for example, “while sleeping,” “MVA,” “slipped
and fell,” after “eating peanuts,” “while dusting,”
“when arguing with his wife,” etc.
zz DURATION: A measurement of time regarding when
the complaint first occurred. For example, began “in
childhood,” “since 1995,” first noticed “2 weeks” ago,
“symptoms x 3d,” etc.
zz QUALITY: Any characteristic about the problem and/
or expresses an attribute. For example: how it looks
or feels; for example. “green” phlegm, “popping” knee,
“dull” ache, “sharp” pain, “metallic” taste, etc.
zz
Review of Systems
The review of system (ROS) is an account of body systems
obtained through a series of questions seeking to spot signs
and/or symptoms that the patient may be experiencing or
has experienced. This query is made by the physician and/
or the staff (verbally or via patient intake forms) in order
to best define the patient’s total problem. It includes defining the need for expanded examination, testing, possible
affected management options, etc. The review may be
about the system(s) directly related to the problem(s) identified in the HPI and/or additional body systems.
CONSTITUTIONAL: Patient answers about general
constitutional signs or symptoms: Examples - fatigue,
general appearance, exercise tolerance, fever, weakness,
impaired ability to carry out functions of daily living, etc.
zz RESPIRATORY: Patient answers about signs or symptoms of the respiratory system: Examples - cough,
phlegm, wheeze, SOB, rapid or difficult breathing,
chest pain on deep inhalation, etc.
zz INTEGUMENTARY: Patient answers about signs or
symptoms of the skin or breast: Examples - skin reactions to hot or cold, itching, rash, changes in scars,
zz
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moles, sores, lesions, nail color or texture, changes in
the color of the skin, bruising, breast pain, tenderness,
swelling, lumps, nipple discharge or changes, etc.
zz PSYCHIATRIC: Patient answers about signs or symptoms of the psychiatric condition: Examples - depression, stress, excessive worrying, suicidal thoughts,
persistent sadness, anxiety, lost pleasure from usual
activities, energy loss, physical problems not responding to treatment, restlessness, irritability, excessive
mood swings, etc.
zz EYES: Patient answers about signs or symptoms of the
eye: Examples - use of glasses, discharge, itching, tearing or pain, spots or floaters, blurred or double vision,
twitching, light sensitivity, visual disturbances, swelling around eyes or lids, etc.
zz GASTROINTESTINAL: Patient answers about signs
or symptoms of the GI system: Examples – heart
burn, indigestion or pain with eating, burning sensation in the esophagus, frequent nausea and/or vomiting, changes in bowel habits or stool characteristics,
abdominal swelling, diarrhea or constipation, use of
digestive aids or laxatives, etc.
zz NEUROLOGICAL: Patient answers about signs or
symptoms of the neurologic system: Examples - numbness, tingling, dizziness, syncope or unconsciousness,
seizures, convulsions, attention difficulties, memory
gaps, hallucinations, disorientation, speech or language dysfunction, tremor or paralysis, inability to
concentrate, sensory disturbances, motor disturbances
including gait, balance, coordination, etc.
zz ALLERGIC/IMMUNOLOGIC: Patient answers
about signs or symptoms of the allergic/immunologic
system: Examples - allergies to medicine, foods, environmental or other substances, frequent sneezing,
hives and/or itching, chronic clear PND, conjunctivitis, chronic infections, etc.
zz ENT: Patient answers about signs or symptoms of
the ears, nose of throat: Examples - Ears: sensitivity
to noise, ear pain, vertigo, ringing in the ears, “fullness” in the ears, ear wax abnormalities, etc. Nose:
nosebleeds, post nasal drip, nasal drainage, impaired
ability to smell, sinus pain, snoring, difficulty breathing, sinus infections, etc. Throat/Mouth: sore throats,
mouth lesions, teeth sensitivity, bleeding gums,
hoarseness, change in voice, difficulties swallowing,
changed ability to taste, etc.
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AAPC 1-800-626-CODE (2633)
GENITOURINARY: Patient answers about signs
or symptoms of the GU system: Examples - painful
urination, urine color, urinary patterns, hesitance,
flank pain, decreased or increased output, dribbling,
incontinence, frequency at night, genital sores, erectile
dysfunction, irregular menses, toilet training or bedwetting, etc.
zz ENDOCRINE: Patient answers about signs or symptoms of the endocrine system: Examples – Blood
Sugar readings at home, changes in height and/or
weight, increased appetite or thirst, intolerance to heat
or cold, etc.
zz CARDIOVASCULAR: Patient answers about signs
or symptoms of the cardiovascular system: Examples
– heart rate, chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in
fingers or toes, edema, leg pain when walking, etc.
zz MUSCULOSKELETAL: Patient answers about signs
or symptoms of the MS system: Examples - cramps,
twitching or pain, difficulty walking, running or participation in sports, joint swelling, redness or pain, joint
deformities, stiffness, noise with joint movement, etc.
zz HEMATOLOGIC/LYMPHATIC: Patient answers
about signs or symptoms of the hematologic/lymphatic
systems: Examples - easy bruising, fevers which can
come and go, swollen glands, night sweats, itching
without rash, excessive bleeding, unusual bleeding, etc.
zz
Past, Family & Social History
When it is medical necessity to perform the ROS and
PFSH again at a second encounter, it does not have to be
completely re-documented. It may be updated by including
the original history date and describing any new ROS and/
or PFSH information or noting there has been no change.
PAST HISTORY: The patient’s past experiences with
illnesses, operations, injuries and treatments, and
medications; If a patient presents for follow up on a
chronic condition both HPI and Past History would
be considered. Positive findings of past diagnoses and
current medication discovered on ROS would be considered.
zz FAMILY HISTORY: A review of medical events in
the patient’s family, including age at death, diseases
which may be hereditary or place the patient at risk.
zz SOCIAL HISTORY: An age-appropriate review of
past and current activities, for example occupation,
smoking, alcohol use (EtOH), sexual activity, marital
status, etc.
zz
Physical Exam
There are sub components, which could be thought of as
“child variables” to measuring the amount of physician’s
work in performing a patient exam. These are defined by
two different rule tables: The 1995 Documentation Guidelines and the 1997 Documentation Guidelines. Physicians
are allowed to choose which set of rule tables to use.
The CMS 1995 Documentation Guidelines
Body Areas:
zz Head/Face
zz Neck
zz Back
zz Abdomen
zz Genitalia
zz Chest/axillae/breast
Systems:
zz Constitutional
zz Eyes
zz Ears, nose, mouth and throat
zz Cardiovascular
zz Respiratory
zz Gastrointestinal
zz Genitourinary
zz Musculoskeletal
zz Skin
zz Neurologic
zz Psychiatric
zz Hematologic, lymphatic immunologic
The CMS 1997 Documentation Guidelines
The guidelines use the same body areas and systems but
expand them for specialty specific use. Please review the
official guidelines for details.
Problems that are new to the patient or that the physician is seeing in this patient for the first time
zz Seeking additional work-up such as a consultant’s
opinion
zz Ordering additional work-up such as diagnostic tests
to confirm or to rule out the suspected diagnoses and/
or differential diagnoses for the patient
zz
Amount and/or Complexity
of Data to be Reviewed
The Amount and Complexity of Data to Be Reviewed is
measured by the need to order and review tests and the
need to gather information and data. Planning, scheduling, and performing clinical labs and tests from the CPT®
Medicine and Radiology sections are indicators. The
need to request old records or to obtain additional history
from someone other than the patient (for example. family
member, care giver, teacher, etc.) is credited in this section.
Also documented are discussions with the performing physician about unusual or unexpected patient results.
If a physician needs to make an independent visualization
and interpretation (for example, MRI film, gram stain,
etc.) and he or she is not billing separately for this service,
it too is credited to this component of code selection.
Risk Significant Complications,
Morbidity, and/or Mortality
Risk is measured based on the physician’s determination
of the patient’s probability of becoming ill or diseased,
having complications, or dying between this encounter and
the next planned encounter. The nature of the presenting
problem and the urgency of the visit, comorbid conditions,
as well as the need for diagnostic tests or surgery, are indicators of risk.
Putting It Together
View the form in Appendix A to visualize typical code
selection for Outpatient visits (based on combining each of
the key components).
Medical Decision Making (MDM)
The Number of Diagnoses
and Management Options
The Number of Diagnoses and Management Options is
based on the relative level of difficulty in making a diagnosis and by the status of the problem (controlled versus
worsening.) Usual indicators include the following:
www.aapc.com5
Chapter 2:
Medical Necessity—What is it?
Medical Necessity determines the correct code Level. Fulfilling documentation requirements is secondarily required
to support correct code use. Although each payer might
have its own definition of “Medical Necessity,” most
follow Medicare’s example of using Medical Necessity as
the “overarching criterion for payment in addition to the
individual requirements of a CPT® code”. However, before
we can address the problem of Medical Necessity, we must
first fully define what Medical Necessity means.
Medicare (and many other insurance plans) may deny payment for a service that the physician believes is clinically
appropriate, but which is not reasonable and necessary. To
distinguish between “clinically appropriate” and “medically
necessary” is a fine line. There are many definitions:
Per the Social Security Act 42 U.S.C. § 1395y(a)(1)(A),
Medicare only pays for medical items and services that are
“reasonable and necessary for the diagnosis or treatment
of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory
authorization for payment.
Medicare has a number of policies, including National
Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Section 522 of the Benefits
Improvement and Protection Act (BIPA) defines an LCD
as a decision by a Medicare carrier whether to cover a particular service in accordance with the Social Security Act.
The AMA definition of “Medical Necessity” is: “Healthcare services or products that a prudent physician would
provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally
accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration;
and (c) not primarily for the convenience of the patient,
physician, or other healthcare provider.”
What is common acknowledged as “generally accepted”?
Standards that are based on credible scientific evidence
published in peer-reviewed, medical literature generally recognized by the relevant medical community;
zz Physician specialty society recommendations;
zz The views of physicians practicing in the relevant
clinical area.
zz
6
AAPC 1-800-626-CODE (2633)
When dealing with E/M codes, there are few diagnoses
that concretely fall into any of the five levels of care (Outpatient) or three levels of care (Inpatient). There are no
NCDs or LCDs to direct a coder to an ICD-9-CM code
that is unarguably correct.
This leaves a coder with two distinct questions:
1. How sick does a patient have to be to fall into one of
the five levels of care (Outpatient) or three levels of
care (Inpatient);
How sick is sick?
2. Who can authoritatively say how sick a patient is;
Who can say how sick is sick?
Chapter 3: How Sick is Sick?
Let’s begin with the question of: How sick does a patient
have to be in order to fall into one of the five levels of care
(Outpatient) or three levels of care (Inpatient)? We know it
is imperative to answer this correctly. Medicare contractors
and carriers may identify fraud or abuse in situations where
they determine Medical Necessity is not met…yet the definitions are broad, subjective, and ambiguous.
There are two references that are commonly employed as a
“best practice” in an effort to provide reproducible coding
and auditing results. They include the Nature of the Presenting Problem as defined by the CPT®, and the Medical Decision Making (MDM) component of the CMS
1995 and 1997 Documentation Guidelines. Both of these
approaches have benefits and challenges.
Nature of the Presenting
Problem and Medical Necessity
The CPT® describes the nature of the presenting problem
to assist the physician in determining the appropriate Level
of E/M service. It prompts the reader that the extent of the
examination is dependent on clinical judgment per on the
nature of the presenting problem(s). It describes five types
of presenting problems:
1. Minimal: A
2. Self-limited or minor: A problem that runs a definite
and prescribed course, is transient in nature, and is
not likely to permanently alter health status OR has
a good prognosis with management/compliance.
3. Low severity: A problem where the risk of morbidity
without treatment is low; there is little to no risk of
mortality without treatment; full recovery without
functional impairment is expected.
4. Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain
prognosis OR increased probability of prolonged
functional impairment.
5. High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a
moderate to high risk of mortality without treatment
OR high probability of severe, prolonged functional
impairment.
CPT® provides clinical examples in its Appendix C to
describe presenting problems that are frequently seen with
a level of service with a given specialty. The language is
broad, interpretive, and warns: “Of utmost importance
is that these clinical examples are just that: examples. A
particular patient encounter, depending on the specific
circumstances, must be judged by the services provided by
the physician…”
This approach is not wholly objective or unfailingly reproducible. Therefore, even after typically 12 years of school,
four years of college, four years of medical school, residency, fellowship, licensing, and certification—many physicians are not able to use these definitionscomparatively
with the patient’s condition to confidently determine the
correct level of service.
MDM and Medical Necessity
To solve this problem, some physician practices have
adopted the MDM component to classify Medical Necessity. Does this work better?
Let’s take a closer look to determine this by reviewing
the form referenced in this workbook under Appendix
A. This form is an audit tool based on the “Marshfield
Clinic model”. It is an industry accepted standard that was
developed jointly between the Marshfield Clinic and CMS
in the 1990s as a method for Medicare carriers to create
reproducible audit results across many reviewers by better
defining the key components. The form has three components displayed as tables. The component on the bottom
of the page is referenced as MDM -Medical Decision
Making. The MDM table requires two of three columns to
line up with the row that classifies the MDM. If all three
columns don’t line up, the column in the middle of the
three rows is selected.
1. In the header of the first column, called “Number of
Diagnoses and Management Options”, we see that
not all diagnoses are “equal” - some require more
work than others based on the type of diagnosis, not
just the number of diagnoses. All diagnosis values
are summed together to select a row in that column
on the table.
2. The second column captures the work associated
with compiling and analyzing outside information,
from various sources, to obtain relevant facts about
the patient and his or her condition. These values
are summed to select a row in that column on the
table.
3. The last column works to qualify the medical risk
that the patient faces of complications, morbidity,
and/or mortality. It is an abbreviated version of the
CMS Table of Risk.
Because the determination of risk is complex and not
readily quantifiable, the table includes common clinical
examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the
risk related to the disease process anticipated between the
present encounter and the next one. The row containing
the highest value, by example, is selected in that column
on the table.
Example:
1. Number of Diagnoses and Management Options:
A patient with a new problem is diagnosed during the same
encounter with a problem that is more severe than a minor
problem. This is worth “3” on the MDM scale of Number
of Diagnoses and Management Options.
2. Amount/Complexity of Data:
The physician ordered and reviewed a medical test in his
office. This is worth “1” on the Amount and Complexity
of Data
3. Overall Risk:
The problem requires a prescription medication, which the
physician orders.
www.aapc.com7
MDM - Medical Decision Making
Number of Diagnoses and
Management Options
( 2 of 3)
Amount/Complexity of
Data:
Overall Risk:
1
3
Stated as a clinically illustrated example:
The patient has sudden central vision loss and is sent to a
retina specialist for diagnosis and treatment. A history is
obtained and both eyes are thoroughly examined. Several optic
tests are used, including an Amsler grid and optical coherence tomography. A new diagnosis is made by the physician of
sub choroidal neovascularization for which he recommends a
monthly injection of Avastin. He explains the risk of the injections, and shares with the patient the risk of continued vision
loss with or without the injection. The patient elects to have
the injection the same day. Follow up in 3 weeks for evaluation and repeat injection.
In this clinically illustrated example, the patient was given
the classification of a Moderate Level of MDM. If you are
using the MDM as a driver In terms of code selection, this
is a Level Four new or established Outpatient patient visit.
So the answer is a Level Four, right? Perhaps, but let’s take
a deeper look…
1. What if the patient was sent by the physician to be
worked up at an outside facility, and the patient
returned with the test results for final diagnosis with
the results on the same day? The patient’s medical
need is not different, but this would now be a “4”,
not a “3”, on the MDM scale of Number of Diagnoses and Management Options.
2. What if the provider decides that the risk of the
problem is not classifiable as that associated with
prescription drug management, but rather with
the risk associated with an acute illness or injury
that poses a threat to bodily function (in this case
vision)? This would bump the office visit classification to a High Level of MDM.
In terms of code selection, this would now support a Level
Five new or established Outpatient patient.
8
AAPC 1-800-626-CODE (2633)
Rx drug management
Type
Level
(X)
SF
1&2
L
3
M
4
H
5
The clinical example below further demonstrates the subjectivity (and possible lack of reproducibility among coders)
associated with the MDM method of code selection:
45-year-old, otherwise healthy male returns for a non-resolved
problem first seen 5 days ago ….a cough x 7 days which is
now productive. This patient is also under the physician’s care
for well controlled hypertension and hypercholesterolemia.
The diagnosis today is URI. She reviews all the patient’s current medications and adds to it by ordering an antibiotic. No
follow up requested.
Under this case, the MDM still objectively measures by
documentation to a Moderate Level, which is what is
needed for a visit Level Four. Some medical peers would
argue that a patient seen in follow up for an antibiotic is
medically indicated as Low or Straightforward, and that a
Detailed History and Examination would not be needed.
Therefore the coding would more accurately support a visit
Level Two or Three. The code values require a combination of the coding component tables, therefore reviewing
the MDM alone may not be fully conclusive. Like the
Nature of the Presenting Problem, the MDM component,
used to classify Medical Necessity, is not wholly objective
or unfailingly reproducible. While both of these are helpful, they are not the silver bullet of proper code selection.
Chapter 4:
Who Says How Sick Is Sick?
The best way to stay within the boundaries of Medical
Necessity is to think of each element of the history and
physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. A
coder, while better educated than most non-clinicians,
is not able to make that judgment with the certainty of
a medical peer. Only a medical peer has the authority to
define the medical need of the patient. Due to the repetitive nature of documentation review in coding, a coder is
well practiced in the analysis of the Levels of service compared to the documented diagnoses. They are often able to
identify possible outliers and cases when Medical Necessity might be questioned. Responding to that concern by
reviewing it with the treating physician, or a medical peer
of the treating physician, is an important part of correct
coding.
We know it is the necessity of the work versus the actual
volume of work and documentation that should be coded
and billed. But, in today’s world of EHR, more documentation is produced than ever. Many EHRs have the ability
to carry forward old clinical information into the latest
note, which is could be seen as “cloning.” Cloning is the
billing for services not provided on the actual date of service billed, but rather provides on a previous already billed
date. The problem lies in copying forward old information,
such as patient complaints from an earlier visit that have
resolved themselves. It can create confusion about what the
patient is presenting for on the actual date of service.
Secret #1: Medical Necessity criteria is best
explained in laymen’s terms that allows the
physician to define the detail using their own
advanced knowledge.
For example, in the subsequent visit hospital setting, it is
reasonable to expect higher Levels of history and physical
exam to be needed in the days immediately following a
hospital admission. These higher levels most likely would
not be medically necessary when the patient is stable and
improving, particularly in the visits on days preceding
discharge from the hospital. Simply stated, the provider
needs to understand that a Level One hospital visit is for
a patient who is getting better, a Level Two hospital visit
is for a patient who isn’t getting better, and a Level Three
for a patient who is rapidly declining. Once the provider
is able to classify the patient into one of these Levels, the
only thing left to ensure is that the documentation requirements are met for the appropriate level. If a provider feels
confident that a non-friendly peer would have to agree
with him or her, the code is correct.
Effective documentation is clinically relevant, easy to navigate, and provides a solid record of the patient problem
and care. The best defense for correct coding is to provide
the physician with insight on the clinical relationships
in proper code selection. The silver bullet to proper code
selection is to empower the physician with the knowledge
of that medical need is supported by each Level of service.
And, to document what is relevant only to support the
patient care and the subsequent coding. No more. No less.
Likening the five base levels of service to the same logic
in the Wong-Baker children’s pain chart can be helpful
to start the conversation. Many will laugh when you say:
“Doctor, this is to represent the patient’s pain…not yours
in the documentation process!” Levity aside, most physicians readily understand that Levels Three to Five are
reserved for actively “sick” patients (Levels One to Three
in the hospital setting) and that the lower levels of service
are reserved for patients with minor and/or well controlled
conditions.
Relating Medical
Necessity to Coding
The approach here is to ask the physician about a common
patient problem that he or she treats, and then to ask him
or her what factors would make them more concerned
about the patient or less concerned about the patient.
Typically, the greater the concern, the higher the level of
service.
One of the most important jobs of a coder is to teach the
provider what is medically relevant to each of the levels
of service in E/M coding. Provide the documenting provider with a clear understanding of code selection related
to Medical Necessity and the rest is…as they say: History
(and Exam and MDM and the documentation requirements thereof).
When a provider is confident that their coding is for services that are consistent with medically-accepted standards
of practice compared to a Level of service, subjectivity is
shored up. The chart in Appendix B is a visual tool that
can help facilitate communication. It not all-inclusive and
should be used for discussion purposed only.
Medical Necessity “Faces” E/M Coding Scale
Preventive
12345
**Adapted from Wong-Baker “Faces” Pain Rating Scale
www.aapc.com9
Sick: Level Three
Outpatient (Level One Inpatient)
The lower level of service represented by a “sick” patient
usually consists of a presenting problem that may be 2
minor, 1-2 stable chronic, 1-2 acute uncomplicated conditions. Typically the diagnosis is known and/or made
during the encounter and future follow up is often classifiable as routine. Usually, the patient is clinically responding
as expected to treatment or is following a defined course.
Patient returns with productive cough x 10 days for
antibiotic
zz Patient with choroidal revascularization to assess
efficacy of anti-VEGF
zz Patient with cystocele not requiring treatment
zz Return visit for patient with worsening plantar fasciitis
zz Patient with URI
zz Patient with well controlled hypertension and
hypercholesterolemia
zz
Sicker: Level Four Outpatient
(Level Two Inpatient)
The moderately high level codes represented by a “sicker”
patient that has the physician concerned. It might be a
comorbid problem or complication that is causing the
additional concern. It might be that the patient is failing
to respond as expected to treatment. The presenting problem may be 2-3 stable chronic, chronic exacerbated, acute
with systemic symptoms or injury. Typically the diagnosis
is known but worsening/complicated or yet unknown and
further testing is required to make a final diagnosis. A key
clue to Level Four is the concern of the provider – which
often results in future follow up that is classifiable as routine or sooner.
Patient with cough and chest pain x 2 weeks sent out
for CXR
zz Patient with choroidal revascularization on anti-VEGF
but with new central vision loss
zz Patient with cystocele and stress incontinence and to
discuss options
zz Patient in follow-up with stable angina, not tolerating
medication
zz Patient requiring closed treatment of new metatarsal
fracture
zz Patient with back pain and new vaginal discharge for
STD testing
zz
10
AAPC 1-800-626-CODE (2633)
zz
Patient with well controlled asthma, hypertension, and
hypercholesterolemia
Sickest: Level Five Outpatient
(Level Three Inpatient)
The highest level of service represents a patient with a
worst-case prognosis. The presenting problem may be an
illness or injury that poses a threat to life or bodily function. Typically the patient’s situation is serious, imminent,
and uncertain.
Examples:
Severe exacerbation of CHF
zz Hospice patient with death imminent
zz Patient presents confused in diabetic ketoacidosis
zz Morphine Sulfate IVP ordered for chest pain not
controlled by Nitro
zz Patient brought by parents after a failed suicide
attempt
zz Patient post fall on ski slopes with extradural hematoma
zz
Communicating Effectively with
Documenting Providers
“Clinical Documentation Improvement” (CDI) is a term
being dropped with growing frequently---especially as we
gear up to ICD-10. It refers to the process of physicians
and providers augmenting their documentation to better
adhere to medical coding requirements and the new Level
of specificity required by ICD-10 codes. ICD-10 codes,
like ICD-9-CM codes, authenticate the patient’s documented diagnoses and therefore the patient’s medical need.
Further complicating matters, many providers cringe at the
idea of CDI education. It requires much more than subject
matter expertise ... it requires truly effective communication. Without a physician’s buy-in, education is a very difficult objective to meet. Communication barriers in the
coder-physician relationship often include the difficulty of
opposing points of interest.
As we move into these unprecedented times in healthcare,
our physicians are more frustrated than ever. According to
the 2012 Medscape Physician Compensation Report, half
of all physicians already spend more than 5 hours a week
on paperwork and other administrative activities. With
so much effort devoted to non-clinical requirements and
regulations, 46 percent of physicians also say they would
NOT choose medicine again as a career. It’s simply too
hard to “buy in” when you see no correlation between the
semantics required in medical documentation data elements—and your true purpose in patient care.
The good news is that physicians want to learn, despite
feeling frustrated, when the information is clinically relevant, organized, and personalized for them. Typically lifelong learners, physicians are highly intelligent, with a deep
appreciation for logic and reason. They are naturally intuitive, some even feeling spiritually drawn to practice the art
of medicine and healing. Generally hungry for and appreciative of tips and techniques in learning new skills, physicians crave correctness. Accurately documenting for coding
and billing purposes can prove a annoying dichotomy; it
is both a challenge to achieve correctness, while also an
intrusion that takes away from patient time. As certified
coders…we can help make it easier by giving providers the
information they need in a meaningful way.
Secret #2: The best way to communicate
with physicians is to ask questions that allow
them to draw their own conclusions.
Teaching a physician about the code levels is like giving the
natural-born artist a brush, paint, and canvas—explaining
the basic use for each and getting out of the way. They are
able to produce the art themselves once they have the basic
tools and know what they are used for. To have a better
understanding of the physician’s standpoint, it is important
for you to ask questions. Make sure you ask questions that
move the discussion forward and not questions that only
promote a “yes or no” answer. Questions like “what made
you more concerned about this patient encounter than the
other one?” will have a better communication impact than
a “did you understand what makes this a Level Four?”
Your goal is to promote effective communication and
asking well-designed questions will help you in achieving
this goal. Sample questions include:
Tell me about your worst patient case—how did the
patient present? Was the patient at risk for lost life or
bodily function?
zz Would a non-friendly peer agree that the patient was
“sicker”—albeit not at imminent risk for lost life or
bodily function?
zz Is it reasonable that this “sicker” patient needs to be
seen in follow-up shortly?
zz What lesser but related problem would have you less
concerned?
zz
Effective communication includes the way we listen to
physicians. Asking questions and listening to the answers
will help you steer the rest of the conversation. Sometimes,
people are not listening because they are thinking about
what they are going to say when the physician stops talking. When physician is talking, give your full attention to
what the he or she is saying. Only by listening will coders
have a better chance in verifying if the information we are
providing was successfully received.
It can be helpful to plan out what you are saying ahead of
time. Having a clear idea of what you want to say will help
you in presenting a well-structured and trustworthy message. It will also prevent you from passing a confusing message to the physician. In these cases, it is very helpful to
have the actual documentation you’d like to discuss handy.
Example:
“Doctor, I have reviewed this patient encounter and your
superbill. You selected a Level Four. You saw this patient
1 month ago for premenopausal syndrome mood swings
and prescribed Zoloft. You saw her again today in followup. You repeated a comprehensive history and exam. She
is doing well with reduced mood swings and will continue with sertraline 50 mg. You ask to see her back in 12
months or PRN if there is a change. I am concerned that
an auditor might question the higher Level of service being
billed because you are not seeing her back for 12 months
and there are no other problems documented. What was it
about this patient that put her at a higher level of concern
to be coded at a Level Four?”
It is also important to watch your body language while
talking with the physician. Communication is not just
words: a lot of communication comes through non-verbal
communication. The following body language mistakes to
avoid are:
Arms crossed: You are defensive.
zz Constant eye contact: You are aggressive.
zz Fidgeting: You are bored or impatient
zz Hunched posture: You lack confidence.
zz Little eye contact: You have low interest or lack
confidence.
zz Rubbing your nose or mouth: You are lying or unsure
of yourself.
zz Tapping: You are impatient or nervous.
zz Touching your face or hair: You are timid.
zz Watching the time: You are anxious to move on to
something else.
zz
www.aapc.com11
Don’t generalize information. Personal information is most
meaningful. If you notice a pattern of possible medical
necessity concerns, run a productivity report of the last one
to three months of Outpatient visits that shows the top
diagnosis codes used and the frequency of their use.
Conduct a physician interview to discuss what would make
the physician more or less worried about a patient.
Example Dr. ABC, Urologist:
Code
12
Count of
Occurrence
Short Description
790.93
35
Elvtd Prstate Spcf Antgn
592.0
31
Calculus Of Kidney
185
28
Malign Neopl Prostate
599.0
21
Urin Tract Infection Nos
600.00
20
Bph W/O Urinary Obs/Luts
598.9
13
Urethral Stricture Nos
599.71
12
Gross Hematuria
V25.2
12
Sterilization
607.84
10
Impotence, Organic Orign
789.00
10
Abdmnal Pain Unspcf Site
788.30
10
Urinary Incontinence Nos
AAPC 1-800-626-CODE (2633)
Sample Interview Questions:
zz Do any of these pose a threat to life or bodily function
within 24-48 hours? (Level Five)
zz Under what circumstances would you need to see
a patient back in follow-up sooner than is typically
required? (Level Four)
zz Which patient problems have you very concerned for
the patient but do not pose an imminent threat to life
or bodily function? (Level Four)
zz Which of these can commonly be diagnosed on the
first encounter and do not usually require a prompt
follow-up? (Level Three)
zz Which of these problems might you bring a patient
back for a quick check, and on doing so discover no
further medical management is needed? (Level Two)
zz Which of these diagnoses are self-limited and require
reassurance with no active medical management?
(Level One)
zz Would a non-friendly medical peer agree with your
decisions?
Another technique is to run the same report and ask the
physician which problems pose an imminent threat to life
or bodily function and then ask him or her to rank each
problem on a scale of 1-4, with 4 representing the “sicker”
patients that “keep them up at night” and 1 representing
patients about which they are not concerned. This can
form the basis for a physician to define for him or herself
what constitutes each level of service.
Example Dr. DEF, Dermatologist:
Code
Count of
Occurrence
Short Description
Immanent Threat
to Life/Function
702.0
99
ACTINIC KERATOSIS
Yes/No
239.2
96
BONE/SKIN NEOPLASM NOS
Yes/No
706.1
76
ACNE NEC
Yes/No
706.8
56
SEBACEOUS GLAND DIS NEC
Yes/No
216.3
47
BENIGN NEO SKIN FACE NEC
Yes/No
702.19
45
OTHER SBORHEIC KERATOSIS
Yes/No
228.01
42
HEMANGIOMA SKIN
Yes/No
709.2
36
SCAR & FIBROSIS OF SKIN
Yes/No
216.5
36
BENIGN NEO SKIN TRUNK
Yes/No
216.4
33
BEN NEO SCALP/SKIN NECK
Yes/No
709.09
29
OTHER DYSCHROMIA
Yes/No
216.6
27
BENIGN NEO SKIN ARM
Yes/No
692.9
24
DERMATITIS NOS
Yes/No
V10.83
19
HX-SKIN MALIGNANCY NEC
Yes/No
078.10
17
VIRAL WARTS NOS
Yes/No
216.7
14
BENIGN NEO SKIN LEG
Yes/No
459.32
13
CHR VENOUS HYPR W INFLAM
Yes/No
454.8
12
VARIC VEIN LEG,COMP NEC
Yes/No
690.10
12
SEBRRHEIC DERMATITIS NOS
Yes/No
782.1
10
NONSPECIF SKIN ERUPT NEC
Yes/No
454.1
10
LEG VARICOSITY W INFLAM
Yes/No
459.81
10
VENOUS INSUFFICIENCY NOS
Yes/No
4
3
2
1
Chapter 5: Combining
ICD-10 CDI Training Sessions
This type of CDI training format can be especially helpful
when you combine it with ICD-10 training. This is a good
way to maximize the educational use of the physician’s
time. Using the AAPC ICD-10 Code Translator located at
http://aapc.com/ICD-10/codes/index.aspx, which is based
on the General Equivalency Mapping (GEM), you will
be able to quickly see which codes inherently have additional granularity and documentation requirements. (Note:
always review mapping results in the official ICD-10 book
before applying them.)
www.aapc.com13
Example Dr. GHI, Orthopedic Surgeon (Hand)
Code
Count
Description
ICD-10 Considerations
V54.01
74
Removal Int Fixation Dev
Z47.2
883.1
38
Open Wound Finger-Compl
S61.229A
E918
36
Caught Between Objects
W23.0XXA
816.12
35
Fx Distal Phal, Hand-Opn
S62.523B D
isplaced Fracture Of Distal Phalanx Of Unspecified Thumb, Initial
Encounter For Open Fracture
S62.526B N
ondisplaced Fracture Of Distal
Phalanx Of Unspecified Thumb,
Initial Encounter For Open Fracture
S62.639B D
isplaced Fracture Of Distal Phalanx Of Unspecified Finger, Initial
Encounter For Open Fracture
S62.669B N
ondisplaced Fracture Of Distal
Phalanx Of Unspecified Finger,
Initial Encounter For Open Fracture
883.2
27
Open Wnd Finger W Tendon
S61.19A U
nspecified Open Wound Of
Unspecified Thumb With Damage
To Nail, Initial Encounter
S61.29A U
nspecified Open Wound Of
Unspecified Finger Without
Damage To Nail, Initial Encounter
S66.529A L aceration Of Intrinsic Muscle,
Fascia And Tendon Of Unspecified
Finger At Wrist And Hand Level, Initial Encounter
14
AAPC 354.2
22
Ulnar Nerve Lesion
G56.20
354.0
21
Carpal Tunnel Syndrome
G56.00
883.0
20
Open Wound Of Finger
S61.209A
813.42
19
Fx Distal Radius Nec-Cl
S52.509A
727.03
16
Trigger Finger
M65.30
727.05
14
Tenosynov Hand/Wrist Nec
M65.849
726.32
13
Lateral Epicondylitis
M77.00
1-800-626-CODE (2633)
Code
Count
Description
ICD-10 Considerations
733.82
13
Nonunion of Fracture
S42.29k U
nspecified Fracture Of Upper End
Of Unspecified Humerus, Subsequent Encounter For Fracture With
Nonunion
S42.9XK Fracture Of Unspecified Shoulder
Girdle, Part Unspecified,
Subsequent Encounter For Fracture
With Nonunion
S52.9XK Unspecified Fracture Of Unspecified
Forearm, Subsequent Encounter For
Closed Fracture With Nonunion
S52.9XM U
nspecified Fracture Of
Unspecified Forearm, Subsequent
Encounter For Open Fracture Type
I Or Ii With Nonunion
S52.9XN Unspecified Fracture Of
Unspecified Forearm, Subsequent
Encounter For Open Fracture Type
Iiia, Iiib, Or Iiic With Nonunion
S62.9XK U
nspecified Fracture Of Unspecified Wrist And Hand, Subsequent
Encounter For Fracture With Nonunion
727.41
10
Ganglion Of Joint
M67.419 Ganglion, Unspecified Shoulder
M67.429 Ganglion, Unspecified Elbow
M67.439 Ganglion, Unspecified Wrist
M67.449 Ganglion, unspecified hand
E920.9
10
Acc-Cutting Instrum Nos
W45.8XXA
E928.9
10
Accident Nos
X58.XXXA
www.aapc.com15
Chapter 6: Mastering a Good
Coder-Physician Relationship
Fast Facts
zz 700K physicians in the US
{{ 63% (442K) bill E/M services
{{ 20% (and growing) are employed by hospitals
zz 2012 average medical school grad debt = $161K
zz Within 6 years we will need 91,500 new doctors
zz 33% are in private practice  From 57% in 2007
zz On again, off again regulations (SRG, ICD-10)
zz Difficult rules (E/M, HIPAA, MU), high costs
(malpractice)
Secret #3: Coders, unlike any other
position in healthcare, are capable of helping
physicians.
Physicians are increasingly told that they need to be afraid.
They have been fighting tangible tigers—stiff regulatory compliance, decreased fee schedules, and increasing
expenses. The result is that it became easy to tune out the
chatter. Communication that makes coding clinically relevant is probably the most important contribution a coder
can make to keeping physicians happy—because they can
spend more time doing what they enjoy most: patient care.
This makes you highly valuable in today’s world of uncertainty and confusion and the ripple effect into the healthcare communities is powerful!
“Medicine is the only profession that labours
incessantly to destroy the reason for its own existence.”
~James Bryce, 1914
Let’s Help!
The best coders have also mastered the art of communicating with physicians in ways that produce positive results.
Physicians needs coders in order to minimize their uncertainty on all the rules. A good coder helps make a physician’s practice a better place to work. We are privileged in
these unprecedented and problem plagued times to be an
important part of the solution!
It’s hard to want to help someone who is often frustrated,
and perhaps even short tempered. Coders are sometimes
shot as the messenger. It can be very helpful to remind
ourselves why physicians deserve a break.
Becoming a physician requires a “character of commitment” to complete a lengthy training period where sacrifice
is demanded on several Levels. When communicating
with a physician, it is important to consider that during
indoctrination to medical training and the Hippocratic
Oath, the primary focus was on the “patient above all else.”
Little or no mention of coding is made, which is a magical, mythical, and far-off concept to the average medical
student.
In order to better understand and communicate with physicians, coders must appreciate the dedication, sacrifice,
and time spent in their professional development.
Figure 1: Time Line to becoming a physician
2008 - 2012
Under-Grad
2009
2010
2016 - 2023
Residency
2012 - 2015
Medical School
2011
2012
2013
2014
2015
2016
2017
2018
2019 - 2020
Fellowship
2019
2008
2020
2021
2022
2023
2023
2019
License to Practice
16
AAPC 1-800-626-CODE (2633)
References Cited
www.hhs.gov/afr/2013-hhs-agency-financial-report.pdf
Page 37 Evaluation and Management Services Guide www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
U.S. Bureau of Labor Statistics: www.bls.gov
H&HN: www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=1970001363 and Fierce Healthcare
www.fiercehealthcare.com/story/hospitals-employing-32-more-physicians/2012-01-09
Dept. of Health and Human Services Office of Inspector General May 2012 https://oig.hhs.gov/
AMA: www.ama-assn.org//ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/
advocacy-policy/medical-student-debt/background.page
AAMC: www.aamc.org/newsroom/reporter/december2013/363844/word.html#.UsNX-fRDuSo
Accenture: www.govconexecutive.com/2011/06/accenture-only-one-third-of-physicians-to-remainindependent-by-2013/
www.aapc.com17
neuro psych endo hemat/lymph allerg/immuno PF Type 1 New Out Pt LEVEL 2 Est Pt LEVEL EPF 2 0 3 D 1 3 4 3 or2+ (Est.) C 4 & 5 5 0 past family social PFSH: 3 4 3 4 Review/summarize data old records/add hx other than pt Independent interpretation of an image, tracing, specimen 






constitutional
eyes
ENMT
cardiovascular
respiratory
gastrointestinal
genitourinary
1 2 3 4 & 5 D C 2-‐7 Extended 8 (Systems only) PF EPF New Out Pt LEVEL 5 4 2 3 How to Effectively Teach Evaluation and Management in Under One Hour, written by Stephanie Cecchini, CPC, CEMC, CHISP © Copyright AAPC 2007-‐2012 26 Presenting Problem Example: 1+ chronic severely exacerbated / Illness or injury that poses a threat to life / Abrupt change in neurological status Clinical testing/management examples: Cardiovascular imaging with risk factors, endoscopies with risk factors, discography, medication toxicity management, major surgery with risk factors, emergency surgery with risk factors, etc. Presenting Problem Example: 1 chronic exacerbated / 2 stable chronic / New Undiagnosed with uncertain outcome / Acute with systemic symptoms / acute complicated injury Clinical testing/management examples: Stress tests, endoscopies, cardiovascular imaging, centesis, closed Tx of Fx, Rx drug management, minor surgery with risk factors, major elective surgery without risk factors, therapeutic radiation tx, etc. Presenting Problem Example: 1 –2 minor, 1 stable chronic / 1 acute uncomplicated Clinical testing/management examples: Biopsy, pulmonary function, barium enema, minor surgery without risk factors, OTC drugs, PT, OT, IV without additives, etc. Presenting Problem Example: 1 minor / self limited Clinical testing/management examples: Venipuncture, X-‐ray, EKG, U/A, U/S, rest, superficial dressings, elastic bandage, gargles, etc. H M L SF Type Est. Out Patient LEVEL musculoskeletal
skin
neurologic
psychiatric
hematologic, lymphatic immunologic
Type 




1 2-‐7 Limited Number of Body Areas/Systems Examined
head/face
neck
back
abdomen
genitalia
chest/axillae/breast
each extremity
OVERALL RISK: The quick reference guide below shows excerpts from the CMS Table of Risk. *Remember: Risk is based on the disease process anticipated between the present encounter and the next one. 






Ex 95 DG ExamMM Body Areas: Systems: Reprinted with Permission: Quick Reference Code Sheet © Copyright 2006-‐2012 Stephanie Cecchini, CPC, CEMC, CHISP 2 2 
1 New problem, w workup=4 ea. 
1 New problem(S), w/o workup =3 

Est. worsening =2 ea. 
AMOUNT/COMPLEXITY OF DATA: One Point Each: 
Clinical Labs test ordered or reviewed 
CPT® Medicine Section Test-‐ ordered/reviewed 
CPT® Radiology Section Test-‐ ordered/reviewed 
Discuss patient results w performing / consulting Dr 
Decision obtain old records or additional hx other than pt Two Points Each: Est. stable/improved = 1 ea. 
NUMBER OF DX and MANAGEMENT OPTIONS 
Minor =1 ea. (max 2 points) MDM Medical Decision Making ( 2 of 3) 1 2-‐9 10+ 1 4 or 1997:3 chronic 4 or 1997:3 chronic GI GU MS skin constit eyes ENMT cardio respir 0 context mod factor duration asso. S&S ROS: 1 location quality severity timing HPI: New PT: Default to the lowest LEVEL identified by the Hx, Ex, & MDM. Est PT: Use the LEVEL identified by the best 2 of 3 on the Hx, Ex, & MDM (99211 not a Dr Code) Hx History ( 3 of 3) Quick-‐Reference Code Sheet 5 4 3 1 & 2 New or Est. Out Pt LEVEL Appendix A
Appendix A: E/M Code Selection (Reference Sheet)
www.aapc.com19
Appendix B
Appendix B: Medical Necessity Flow Chart
20
AAPC 1-800-626-CODE (2633)
Appendix C
Appendix C
Exercises Referenced in Presentation
True or False?
1.Specialists must use 1997 guidelines for documentation.
2.“Shortness of breath” is the reason of the visit according to the patient during her statement of CC. Can this
be counted in the CC and the ROS?
3.CMS specifically states positive findings of an exam cannot be documented by simply stating the exam findings were abnormal.
4.CC must be documented in a specific statement rather than implied.
5. Counseling topics must be documented when billing for counseling time of greater than 50% of the encounter.
Multiple Choice.
1.The statement “I jumped over a railing, fell and landed on both arms outstretched” is considered which of the
following HPI statement?
A. Associated signs and symptoms
B. Modifying factors
C.Context
D.Quality
2.By CMS ‘95 guidelines, interpreted by MAC carriers, which requirement below could define a “detailed”
exam
A.4x4
B. 2–7 body systems
C. 2–4 body systems
D. All of the above
3.1995 and 1997 documentation guidelines differ in what two elements of documentation:
A. History and Medical Decision Making
B. Exam and Medical Decision Making
C. Time and Medical Decision Making
D. History and Exam
www.aapc.com21
Appendix C
4.In the History of Present illness the doctor documents the patients has abdominal pain when eating greasy
food. Which categories would this HPI would be scored in?
A. Duration, location
B. Severity, context
C. Location, context
D. Quality, timing
NOTES:
22
AAPC 1-800-626-CODE (2633)
Presentation
Medical Necessity Skills
for Coders
Written by: Stephanie Cecchini, CPC, CEMC, CHISP,
Approved ICD-10 Trainer
Presented by: [insert name of presenter]
2014 CPT® Update
1
Agenda
•
•
•
•
•
•
•
•
•
8:30-8:45 Introduce Ourselves and the Topic
8:45-10:00 DG Refresher: (with interactive examples)
– Quick Break
10:15-10:30 Medical Necessity – What is it?
10:30-10:45 How Sick is Sick?
10:45-11:15 Who Says How Sick is Sick?
11:15-12:00 ICD-10 Training (with interactive examples)
12:00-12:15 Coder-Physician Relationship
12:15-12:30 CEU Reference Number and Answer Questions
In this workshop, you will learn:
– Three little known secrets to accurate
E/M coding
– The definitions of Medical Necessity for
purposes of accurate coding
– How to clinically differentiate E/M
service Levels
– Effective techniques for
communication with physicians
regarding Medical Necessity
2014 CPT® Update
2
www.aapc.com23
Presentation
About the Presenter
• [Insert Presenter Bio]
2014 CPT® Update
3
The Medical Necessity Problem
• Medicare fee-for-service improper payments increased 18% to $36B in 2013
– The primary cause is insufficient documentation(63%).
– The other cause is classified as Medical Necessity errors (37%)
• CMS 1995 and 1997 Documentation Guidelines are not statutes
– Medical need for services rendered is the authoritative factor
• Medicare may deny payment for a service that the physician believes is
clinically appropriate, but which is not reasonable and necessary
2014 CPT® Update
24
AAPC 1-800-626-CODE (2633)
4
Presentation
Only in Healthcare
2014 CPT® Update
5
What’s the Problem?
• Coders are not Doctors but must make decisions about Medical Necessity
– A coder might code correctly per the DGs….however, miscode if they
incorrectly interpret the severity of the patient’s problem
– Coders are not medical peers to physicians
• Coders are often required to make decisions that involve MN
– Challenging the medical need is not appropriate
– Auditors may have limited access to a Medical Director or peer
– A wrong step can lead to barriers in the coder-physician
relationship
2014 CPT® Update
6
www.aapc.com25
Presentation
Coder Silence is Damaging
• EHRs are producing more “false positives” to higher levels of service
• Unvoiced concerns lead to over-payments and negative payer audits
– Audits projected to rise in 2014
• 2013 CMS reported an error rate of 10.1% for FFS.
– This is an increase from 9.9% in 2012.
– This exceeds the 10% threshold set by the Improper Payments
Elimination and Recovery Act of 2010 (IPERA)
2014 CPT® Update
7
“Meaningful” E/M Documentation
• Without it Physicians can’t be paid properly …
• Documentation requirements need to be met
• Subjective criteria on Medical Necessity and DGs
– Codes are based on a scale of how sick a patient is
– Codes are supported by documentation
• Solutions (and today’s objective topics):
– Know the DGs and Medical Necessity with E/M
– Learn to code based on how sick a patient is
– Help the Physician to understand Good Documentation
2014 CPT® Update
26
AAPC 1-800-626-CODE (2633)
8
Presentation
What is Good Documentation?
• Effective documentation is:
– clinically relevant,
– easy to navigate,
– provides a solid record of the patient problem and their care.
– Limits carry forward of old documentation
– Adheres to the 1995 and 1997 Documentation Guidelines
• Carrier interpretations
– Marshfield clinic model
– 4x4
2014 CPT® Update
9
The DGs
•
The 3 Key Components
1. History History of Present Illness (HPI)
Review of Systems (ROS) Past, Family and Social History (PFS) 2. Exam 3. Medical Decision Making Number of Diagnoses and Treatment Options
Amount and Complexity of Data
Overall Risk •
Time may be used if the total time is documented and more than 50% of the encounter is
spent in counseling or coordination of care
•
2014 CPT® Update
10
www.aapc.com27
Presentation
HPI
•
•
Handling documentation with Patients
unable to give a history
(ROS) and (PFSH) History taken from an
earlier encounter
•
– May not be medically necessary
•
•
A comprehensive service may be
performed and documented but A
comprehensive service is not always
medically necessary or billable.
Unless Preventive, a Chief Complaint
(CC) must be identifiable
– This is the first step in establishing
medical necessity.
The patient’s stated reason for the
visit
– Location
– Context
– Duration
– Quality
– Modifying factors
– Severity
– Timing
– Associated signs and symptoms
2014 CPT® Update
ROS and PFS
•
•
•
The ROS may be supplied in any format:
separate patient intake or questionnaire
form within the HPI.
ROS elements typically reference signs and
symptoms, of which both positive and
negative responses are considered. Auditors
commonly watch for indications “pt denies
fever,” “upon further questioning the…”).
ROS should be medically necessary.
– It may be considered necessary to
obtain a complete ROS when a patient
presents as an initial new patient.
– It may not be considered necessary to
repeat a complete review on every
follow-up visit.
•
•
•
Past history: The patient's past experiences
with illnesses, operations, injuries and
treatments, and medications.
Family history: A review of medical events in
the patient's family, including age at death,
diseases which may be hereditary or place
the patient at risk.
Social history: An age-appropriate review of
past and current activities, for example
occupation, smoking, alcohol use (EtOH),
sexual activity, marital status, etc.
2014 CPT® Update

28
AAPC 1-800-626-CODE (2633)
Presentation
CC: Headache. “I fell off my chair an hour ago and hit my head. I have a
throbbing headache.” The patient states the pain is 8 out of 10. Patient
denies any visual disturbances. Patient takes Zoloft 25 mg QD.
HPI:
location
quality
severity timing
context
mod factor
duration
asso. S&S
ROS:
constit
eyes
ENMT
cardio
respir
neuro
psych
endo hemat/lymph
allerg/immuno
GI
GU
MS
skin
PFSH:
past
family
social
New Out Pt LEVEL (x)
1
Est Pt LEVEL
(x)
2
1
0
0
Type
PF
1
1
0
EPF
2
3
4
2
1
D
3
4
4 10
3 or2+ (Est.)
C
4 & 5
5
2014 CPT® Update
Body Areas:
• Head/Face
BP 120/80. The patient’s gait is normal. Some tenderness. There
• Neck
is no knee effusion. The medial and lateral collateral ligaments are
• Back
intact.
• Abdomen
• Genitalia
• Chest/axillae/breast
9
Systems: • Constitutional
New Out Est. Out • Eyes
Number of Body Typ
Pt LEVEL Patient • Ears, nose, mouth and throat
Areas/Systems Examined
e
(x)
LEVEL (x)
• Cardiovascular
1 PF
1
2
• Respiratory
• Gastrointestinal
2‐7 limited EPF
2
3
• Genitourinary
• Musculoskeletal
2‐7 extended (4x4) D
3
4
• Skin
• Neurologic
8 (Systems only) C
4 & 5
5
• Psychiatric
• Hematologic, lymphatic immunologic
2014 CPT® Update
14
www.aapc.com29
Presentation
MDM: Number of Dx and Tx Options
‐ Minor =1 each (max 2)
‐ Est. stable/improved = 1 each
‐ Est. worsening =2 each
‐ New problem, w/o workup =3 each (max 1)
‐ New problem, w workup=4 each
Example
Type
Minimal:

1 point as totaled from above
Uncomplicated, noninfected insect bite
Straightforward
Limited:

2 points as totaled from above
Controlled HTN and
tachycardia
Low
Multiple:

New patient with migraine
headaches
Moderate
Extensive:

4 + points as totaled from above
Patient seen today for f/u
on OA knees and 1 year
THR check. C/O knee pain.
MRI ordered for possible
meniscus tear. R/O
symptom of osteoarthritis
and sprain
High
New or Established Outpatient LEVEL
1&2
3
4
5
2014 CPT® Update
MDM: Amount and Complexity of Data
One Point Each:
 Clinical Labs test(s) ordered and/or reviewed
 CPT® Medicine Section Test(s)- ordered and/or reviewed
 CPT® Radiology Section Test(s)- ordered and/or reviewed
 Discuss patient results with performing/consulting Dr.
 Decision to obtain old records or add hx from other than pt
Two Points Each:
 Review & sum data from old records add hx from other than pt
 (2nd) interpretation of an image, tracing, specimen
Type
1&2
Minimal:

1 point as totaled from above
Straight-forward
Limited:

Low
3
Moderate:

Moderate
4
Extensive:

4 + points as totaled from above
High
5
2014 CPT® Update
30
AAPC 1-800-626-CODE (2633)
Presentation
CMS TABLE OF RISK
Overall Risk between planned encounters
1. Presenting Problem(s)
Any example listed from a row below for any of the three columns will equal a level of risk.
2. Diagnostic Procedure(s) Ordered
3. Management Options Selected
• One self-limited or minor problem, eg
cold, insect bite, tinea corporis
•
•
•
•
•
•
• Two or more self-limited or minor
problems
• One stable chronic illness, eg, well
controlled hypertension or non-insulin
dependent diabetes, cataract, BPH
• Acute uncomplicated illness or injury, eg,
cystitis, allergic rhinitis, simple sprain
• Physiologic tests not under stress, eg,
pulmonary function tests
• Non-cardiovascular imaging studies with
contrast, eg, barium enema
• Superficial needle biopsies
• Clinical 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
• One or more chronic illnesses with mild
exacerbation, progression, or side effects of
treatment
• Two or more stable chronic illnesses
• Undiagnosed new problem with uncertain
prognosis, eg, lump in breast
• Acute illness with systemic symptoms,
eg, pyclonephritis, pneumonitis, colitis
• Acute complicated injury, eg, head injury
with brief loss of consciousness
• Physiologic tests under stress, eg,
cardiac stress test, fetal contraction stress
test
• Diagnostic endoscopies with no identified
risk factors
• Deep needle or incisional biopsy
• Cardiovascular imaging studies with
contrast and no identified risk factors, eg
arteriogram, cardiac catheterization
• Obtain fluid from body cavity, eg, lumbar
puncture, thoracentesis, culdocentesis
• One or more chronic illnesses with
severe exacerbation, progression, or side
effects of treatment
• Acute or chronic illnesses or injuries that
pose a threat to life or bodily function, eg
multiple trauma, acute MI, pulmonary
embolus, severe respiratory distress,
progressive severe rheumatoid arthritis,
psychiatric illness with potential threat to self
or others, peritonitis, acute renal failure
• An abrupt change in
neurologic status, eg, seizure, TIA,
weakness, or sensory loss
• Cardiovascular imaging studies with
contrast with identified risk factors
• Cardiac electrophysiological tests
• Diagnostic Endoscopies with identified
risk factors
• Discography
Laboratory tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, eg, echocardiography
KOH prep
•
•
•
•
Rest
Gargles
Elastic bandages
Superficial dressings
Type
Minimal
1&2
Low
3
• Minor surgery with identified risk
factors
• Elective major surgery (open,
percutaneous or endoscopic) with no
identified risk factors
• Prescription drug management
• Therapeutic nuclear medicine
• IV fluids with additives
• Closed treatment of fracture or
dislocation without manipulation
Moderate
4
• 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 not to resuscitate or to
de-escalate care because of poor
prognosis
High
5
2014 CPT® Update
2014 CPT® Update
www.aapc.com31
Presentation
MAC Rules:
•
Cahaba Government Benefit
Administrators®
•
CGS Administrators, LLC
– 95/97
– Some “extra wording” (i.e.
“contributory” not counted)
http://cgsmedicare.com/pdf/Basics_of
_Evaluation_and_Management.pdf
– 95/97
– Not Further Publicized
2014 CPT® Update
MAC Rules:
•
First Coast Service Options, Inc.
– 95/97 (version of Marshfield Clinic)
– E/M interactive worksheet
http://medicare.fcso.com/EM/165590.a
sp
•
Noridian Administrative Services,
LLC
– 95/97 Not Further Publicized
– Medical Necessity Article
https://www.noridianmedicare.com/pr
ovider/updates/docs/EM_servicesdocumentation_and_level_
of_service.pdf
2014 CPT® Update
32
AAPC 1-800-626-CODE (2633)
Presentation
MAC Rules:
•
•
LLC (FORMERLY Palmetto GBA)
LLC
– Medical Necessity Article
https://www.noridianmedicare.com/pr
ovider/updates/docs/EM_servicesdocumentation_and_level_
of_service.pdf
– Palmetto used 95/97 Marshfield
2014 CPT® Update
•
MAC Rules:
Wisconsin Physicians Service
Insurance Corporation
– References at:
http://www.wpsmedicare.com/j8macp
artb/resources/provider_types/evaland
mngmnt.shtml
•
National Government Services, Inc.
– 95/97 Marshfield
– Audit Form:
http://www.ngsmedicare.com/ngs/wc
m/connect/d410740049c1dcef894cf9b
8b8c8d5ce/1074_0412_EM_Document
ation_Training_Tool.pdf?MOD=AJPERE
S&useDefaultText=0&useDefaultDesc=
0
2014 CPT® Update
www.aapc.com33
Presentation
•
MAC Rules:
NHIC, Corp.
– 95/97 Marshfield
– Audit form:
http://emuniversity.com/COW/NHIC.p
df
•
Novitas Solutions, Inc.
– 95/97 Marshfield with 4x4
– 4x4 information: http://www.novitassolutions.com/cs/idcplg?IdcService=G
ET_FILE&RevisionSelectionMethod=La
testReleased&dDocName=00025767&
allowInterrupt=1&Rendition=Web&IsX
ml=0
2014 CPT® Update
Discussion Exercise
See Appendix C : T&F
1.
2.
3.
4.
5.
Specialists must use 1997 guidelines for documentation.
“Shortness of breath” is the reason of the visit according to the patient during her statement of CC.
Can this be counted in the CC and the ROS?
CMS specifically states positive findings of an exam cannot be documented by simply stating the
exam findings were abnormal.
CC must be documented in a specific statement rather than implied.
Counseling topics must be documented when billing for counseling time of greater than 50% of the
encounter.
See Appendix C: Multiple Choice
99213
2014
CPT® Update
34
AAPC 1-800-626-CODE (2633)
Presentation
What is Medical Necessity?
• Government:
– Per the Social Security Act 42 U.S.C. § 1395y(a)(1)(A), “SSA” Medicare only
pays for medical items and services that are "reasonable and necessary
for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member", unless there is another
statutory authorization for payment.
– National coverage determinations (NCDs) and Local Coverage
Determinations (LCDs). Section 522 of the Benefits Improvement and
Protection Act (BIPA) defines an LCD as a decision by a Medicare carrier
whether to cover a particular service in accordance with the SSA
2014 CPT® Update
25
AMA
• “Health care services or products that a prudent physician would provide to
a patient for the purpose of preventing, diagnosing, or treating an illness,
injury, disease or its symptoms in a manner that is:
• (a) in accordance with generally accepted standards of medical practice;
• (b) clinically appropriate in terms of type, frequency, extent, site and
duration; and
• (c) not primarily for the convenience of the patient, physician, or other
health care provider.”
2014 CPT® Update
26
www.aapc.com35
Presentation
“Generally Accepted”
• What is common acknowledged as “generally accepted”?
– Standards that are based on credible scientific evidence published in
peer-reviewed, medical literature generally recognized by the relevant
medical community;
– Physician specialty society recommendations;
– The views of physicians practicing in the relevant clinical area.
2014 CPT® Update
27
Leaves a Coder with Two Questions
1. How sick does a patient have to be in order to fall into one of the 5 Levels of
care (Outpatient) or 3 Levels of care (Inpatient);
– How sick is sick?
1. Who can authoritatively say how sick a patient is;
– Who can say how sick is sick?
2014 CPT® Update
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AAPC 1-800-626-CODE (2633)
28
Presentation
CPT Nature of the Presenting Problem
1.
2.
3.
4.
5.
Minimal: A problem that may not require the presence of the physician or other qualified health care
professional, but service is provided under the physician’s or other qualified health care professional’s
supervision.
Self-limited or minor: A problem that runs a definite and prescribed course, is transient in nature, and
is not likely to permanently alter health status OR has a good prognosis with
management/compliance.
Low severity: A problem where the risk of morbidity without treatment is low; there is little to no risk
of mortality without treatment; full recovery without functional impairment is expected.
Moderate severity: A problem where the risk of morbidity without treatment is moderate; there is
moderate risk of mortality without treatment; uncertain prognosis OR increased probability of
prolonged functional impairment.
High severity: A problem where the risk of morbidity without treatment is high to extreme; there is a
moderate to high risk of mortality without treatment OR high probability of severe, prolonged
functional impairment.
2014 CPT® Update
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MDM as a MN Driver?
•
Example:
– Number of Diagnoses and Management Options:
• A patient with a new problem is diagnosed during the same encounter with a
problem that is more severe than a minor problem. This is worth “3” on the MDM
scale of Number of Diagnoses and Management Options.
– Amount/Complexity of Data:
• The physician ordered and reviewed a medical test in his office. This is worth “1”
on the Amount and Complexity of Data
– Overall Risk:
• The problem requires a prescription medication, which the physician orders.
– See the chart in your workbook on page 15 and review clinical example on page 16
2014 CPT® Update
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www.aapc.com37
Presentation
Answer is a Level Four, right? Well…
•
•
•
What if the patient was sent by the physician to be worked up at an outside facility, and the
patient returned with the test results for final diagnosis with the results on the same day?
What if the provider decides that the risk of the problem is not classifiable as that associated with
Prescription drug management, but rather with the risk associated with an acute illness or injury
that poses a threat to bodily function (in this case vision)?
– In terms of code selection for Medical Necessity with an MDM driver, this could now
support a Level Five new or established Outpatient patient.
Another example :45 year old, otherwise healthy male returns for a non-resolved problem first
seen 5 days ago ….a cough x 7 days which is now productive. This patient is also under the
physician’s care for well controlled hypertension and hypercholesterolemia. The diagnosis today
is URI. She reviews all the patient’s current medications and adds to it by ordering an antibiotic.
No follow-up requested.
– MDM is moderate….is this a Level Four clinical example?
2014 CPT® Update
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Who Can Say How Sick is Sick?
• Nature of the presenting problem --- still vague
• MDM as a driver --- still not “a silver bullet
• What’s left?
– The physician
– SECRET #1
• Medical Necessity criteria is best explained in laymen’s terms that
allows the physician to define the detail using their own advanced
knowledge.
2014 CPT® Update
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AAPC 1-800-626-CODE (2633)
32
Presentation
2014 CPT® Update
*This chart should only be used for the purpose of guiding discussion: it references new outpatient visits
Scale of 1-5
•
Levels 3-5* are reserved for “sick” or injured patients.
– Lower levels are for patients who present with minor and/or well controlled
condition/s.
*This presentation refers to levels of service for outpatient visits.
2014 CPT® Update
www.aapc.com39
Presentation
Hospital Patients
• How sick is sick?
– Scale of 1-3
• Level One hospital visit is for a patient who is getting better
• Level Two hospital visit is for a patient who isn’t getting better
• Level Three for a patient who is rapidly declining.
2014 CPT® Update
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Sickest (5/3)
• Presenting Problem: An illness or injury that poses a threat to life, chronic
severely exacerbated, abrupt change in neurological status
– Typically the patient’s situation is serious, imminent, and uncertain
• Severe exacerbation of CHF
• Patient presents confused in diabetic ketoacidosis
• Morphine Sulfate IVP ordered for chest pain not controlled by Nitro
• Patient brought by parents after a failed suicide attempt
• Patient post fall on ski slopes with extradural hematoma
2014 CPT® Update
40
AAPC 1-800-626-CODE (2633)
Presentation
Sick (3/1)
•
Typical Presenting Problem: 1 –2 minor, 1-2 stable chronic, 1-2 acute uncomplicated
– Typically the diagnosis is known and/or made during the encounter
– Future follow up is often classifiable as routine
•
•
•
•
•
•
•
Patient returns with productive cough x 10 days for antibiotic
Patient with choroidal revascularization to assess efficacy of anti-VEGF
Follow up Patient with cystocele not requiring treatment
Patient in follow up with stable angina and no new symptoms
Return visit for patient with worsening plantar fasciitis
Non pregnant female with resolving hyperemesis
Patient with well controlled hypertension and hypercholestorolemia
2014 CPT® Update
Sicker (4/2)
•
Presenting Problem: 2-3 stable chronic, chronic exacerbated, acute with systemic symptoms or
injury
– Typically the diagnosis is known and worsening/complicated or further testing is required
– Future follow up is often classifiable as routine or sooner
•
•
•
•
Patient with choroidal revascularization now with new central vision loss
Patient in follow up with stable angina, not tolerating medication
Patient with suspected cellulitis of the lower leg
Patient with heel ulcer and drainage
2014 CPT® Update
www.aapc.com41
Presentation
CDI and Educating the Physician
• SECRET #2
– The best way to communicate with physicians is to ask questions that
allow them to draw their own conclusions.
• Your goal is to promote effective communication
– Ask questions that are not answered with yes or no
– “what made you more concerned about this patient encounter than the
other one?” versus
• “did you understand what makes this a Level Four?”
2014 CPT® Update
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Sample Questions
• Tell me about your worst patient case---how did the patient present? Was
the patient at risk for lost life or bodily function?
• Would a non-friendly peer agree that the patient was “sicker” ---albeit not at
imminent risk for lost life or bodily function?
• Is it reasonable that this “sicker” patient needs to be seen in follow-up
shortly?
• What lesser but related problem would have you less concerned?
2014 CPT® Update
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AAPC 1-800-626-CODE (2633)
40
Presentation
Effective Communication
•
•
Listen: Don’t think about what you will say next while the physician is talking
Have a clear idea of what you want to say so you can be organized in your delivery
– Example:
• “Doctor, I have reviewed this patient encounter, and your superbill. You selected a
Level Four. You saw this patient 1 month ago for premenopausal syndrome mood
swings and prescribed Zoloft. You saw her again today in follow-up. You repeated
a comprehensive history and exam. She is doing well with reduced mood swings
and will continue with sertraline 50MG. You ask to see her back in 12 months or
PRN if there is a change. I am concerned that an auditor might question the
higher Level of service being billed because you are not seeing her back for 12
months and there are no other problems documented. What was it about this
patient that put her at a higher Level of concern to be coded at a Level Four?”
2014 CPT® Update
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2014 CPT® Update
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Watch Your Body Language
•
Body language mistakes to avoid are:
– Arms crossed: You are defensive.
– Constant eye contact: You are aggressive.
– Fidgeting: You are bored or impatient
– Hunched Posture: You lack confidence.
– Little eye contact: You have low interest or lack confidence.
– Rubbing your nose or mouth: You are lying or unsure of yourself.
– Tapping: You are impatient or nervous.
– Touching your face or hair: You are timid.
– Watching the time: You are anxious to move on to something else.
www.aapc.com43
Presentation
•
Provider Interview
Always customize CDI
– Run a productivity report of the last one to three months of Outpatient visits that
shows the top diagnosis codes used and the frequency of their use.
– Ask Questions: Dr., what about these diagnoses make you more (i.e. 4) or less (i.e. 3)
concerned about a patient?
• See Example Dr. ABC, Urologist: Workbook Page 23
• See Example Dr. DEF, Dermatologist: Workbook Page 24
2014 CPT® Update
43
Sample Interview Questions
•
•
•
•
•
•
•
Do any of these pose a threat to life or bodily function within 24-48 hours? (Level Five)
Under what circumstances would you need to see a patient back in follow-up sooner than is
typically required? (Level Four)
Which patient problems have you very concerned for the patient but do not pose an imminent
threat to life or bodily function? (Level Four)
Which of these can commonly be diagnosed on the first encounter and do not usually require a
prompt follow-up? (Level Three)
Which of these problems might you bring a patient back for a quick check, and on doing so
discover no further medical management is needed? (Level Two)
Which of these diagnoses are self-limited and require reassurance with no active medical
management? (Level One)
Would a non-friendly medical peer agree with your decisions?
2014 CPT® Update
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AAPC 1-800-626-CODE (2633)
44
Presentation
Combining ICD‐10 CDI Training Sessions •
•
The E/M CDI conversation can easily be conducted at the same time as ICD-10
Group discussion / Critical Thinking Exercise
– Review page 26 Example Dr. GHI, Orthopedic Surgeon (Hand)
– This is a report of 2 months use of ICD-9 codes sorted by frequency.
1. Which codes require the provider to consider additional documentation for granularity?
2. What are the considerations you should make before training?
3. Would it make sense to discuss documenting requirements after discussing Medical
necessity? If so, should you discuss MDM first?
2014 CPT® Update
45
Mastering a Good Coder-Physician Relationship
• SECRET #3
– Coders, unlike any other position in healthcare, are capable of helping
physicians.
2014 CPT® Update
46
www.aapc.com45
Presentation
Sir Luke Fildes’s 1891 painting ‘The Doctor.’
2014 CPT® Update
47
Appreciating Physician Development
•
•
80% of those in pre-med will not be accepted to medical school
Medical school
– Average student financial debt in 2012 was $166K
– The majority of students will graduate with debt of at least $150,000
2014 CPT® Update
46
AAPC 1-800-626-CODE (2633)
Presentation
Growing Numbers Need Help
•
700K physicians in the US
– 63% (442K) bill E&M services
– 20% (and growing) are employed by hospitals
•
63K fewer doctors than needed by 2015
•
33% are in Private practice ↓ From 57% in 2007
•
46% would NOT choose medicine again as a career
•
On again, off again regulations (SRG, ICD-10),
•
Difficult rules (E/M, HIPAA, MU), high costs (malpractice)
2014 CPT® Update
Questions?
CEU Number is: [ Insert Number ]
“Medicine is the only profession that labours incessantly to destroy the reason for its own
existence.” ~James Bryce, 1914
About the Author:
Stephanie Cecchini, CPC, CEMC, CHISP, AHIMA Approved ICD‐10 Trainer, VP Coding Operations joined Aviacode in 2012 where she continues her
commitment to best serve the revenue cycle management needs of physicians and the healthcare community. She is an executive Level consultant with
significant healthcare business experience. Stephanie is an expert in clinical documentation requirements for coding and billing to Medicare, Medicaid and all
lines of commercial payer business. She brings to her position more than eighteen years’ involvement in healthcare regulations including: coding and billing
compliance, HIPAA privacy, security, and transactions, and HITECH “meaningful use” compliance. Previously, Stephanie served as SVP at the American Society
of Health Informatics Managers, working to fill the needs of physicians adopting Health IT and at its sister organization, AAPC as VP, Product Management. In
prior roles she served as Chief Audit Officer for Parses, Inc., designing audit programs for payers and managing overpayment recovery. As a public speaker and
published writer, she is a nationally respected advocate of fair and proper payment for medical services. Stephanie lives in Salt Lake City, Utah with her
husband Jim and their three children.
•
Stephanie is LION (Linked In Open Network). http://www.linkedin.com/in/StephanieCecchini
2014 CPT® Update
50
www.aapc.com47

Unlock the Secret to E/M Coding: Medical Necessity Skills

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