Document 6496679

Volume 2 . Issue 3 . March 2013
Cristy Donaldson, CPC, CPMA
Coding Specialist
 865-670-6177  [email protected]
Are you struggling with knowing how to document and
code for a Preventive and Problem visit on the same
day? As a certified coder and a certified auditor, I
frequently hear complaints from both providers and
patients about this. Here are a few simple tips and
reminders for you to follow. This will help you stay out of
hot water with patients and insurance carriers:
1) When a patient calls to schedule an appointment,
ask if the patient is new or established AND ask if the
patient is requesting a preventive/well visit or a
problem visit. Make notes in your computer about
this.
2) When the patient arrives for their appointment, the
reception area should view the notes in the
computer to determine what type of visit is
occurring. Many preventive/well services are now
covered at 100% and do not require a co-payment; in
fact, it may be considered improper to collect a copayment on such services.
3) Upon triage, the nurse or medical assistant should
again ask if the patient is having any problems that
need to be addressed during today’s visit,
particularly if the patient’s chief complaint/reason
for visit is for a preventive/well visit.
4) Providers should review this in the chart before
initiating the encounter. If the patient in the
examination room appears to be a preventive/well
visit but mentions a problem to you the provider,
you must determine the course of action. You can
treat the problem, provide the preventive/well
service, or both; however, this must be clearly
communicated to the patient. Patients will accept
their financial responsibility much better if they
know how you intend to bill their insurance before
they leave your office.
5) If you the provider elect to provide both services,
you should only bill separately for the problem visit if
the problem was significant and separately
identifiable. What does that mean? It means the
work involved for the problem must require
additional history, exam and work-up beyond what
would normally be performed during the
preventive/well visit. If the problem could easily be
treated within the scope of the preventive/well visit,
it would be inappropriate to bill separately for it. If
the problem is significant and separately identifiable,
append modifier 25 to the problem visit. The key
word is “significant”.
6) Documentation trumps all. If the provider’s
documentation does not clearly support all of the
services billed, you may find yourself in a sticky spot
with the patient and/or the insurance carrier. The
Chief Complaint/Reason for Visit must demonstrate
all of the above. If a preventive/well service is billed,
all the requirements of that service must be
performed and documented. Did you know that a
Preventive Medicine Visit requires a comprehensive
history and examination as appropriate for the age
and gender of the patient? If you report a
preventive/well and a problem service, your
documentation should support BOTH.
Continued Page 2
Page 2 / Catch the Coding Wave
7) Some insurance carriers have a hard rule and will not
pay for both on the same day. It is a good idea to get
familiar with which insurance carriers have a rule
about this.
Lastly, it is never appropriate to change a code just to
please a patient. If the patient presented for a
preventive/well visit but you determined a problem visit
must be performed instead, you must explain this to the
patient. It is not appropriate to change the code to
please the patient. Furthermore, if the documentation is
audited by the insurance carrier and it does not reflect
the services performed, you may lose your
reimbursement altogether.
Because the determination of risk is complex and not
readily quantifiable, the table of risk includes clinical
examples rather than absolute measures. The highest
level in any one category on the table determines of the
overall level of risk. See page 3 of the Audit Tool.
References: CMS 1995 Guidelines
Taking an Anatomy & Physiology course is a great way
for coders and/or anyone non-clinical to begin their
education for ICD-10. There are online and class room
based courses available with a variety of vendors.
Consider AAPC, AHIMA, your local community college or
an online college.
The key component of Medical Decision Making is
broken down into three sections:
1) Number of Diagnoses or Treatment Options
2) Amount and/or Complexity of Data
3) Table of Risk
Each of these sections receives a score and is applied to
the MDM table. The overall MDM score is determined by
the highest 2/3 sections.
This month we will focus on the Table of Risk. This table
stratifies the risk of significant complications, morbidity
and/or mortality, as well as the co-morbidities associated
with the patient’s presenting problem(s), the diagnostic
procedures(s) and/or the possible management options.
Thank you for taking the time to review this information.
If you have any questions regarding the content of this newsletter, please feel free to contact me directly at:
Cristy Donaldson, CPC, CPMA
Coding Specialist
Phone: 865-670-6177
[email protected]
DOCUMENTATION
WORKSHEET
Color Key: Items/descriptions in black represent '95 guidelines and items that did not change in '97. Items/descriptions in blue represent
changes made in the '97 guidelines. Black and white duplication may alter the intent of this tool.
THIS TOOL IS INTENDED TO BE USED ONLY AS A COMPANION TO THE PUBLISHED '95 AND '97 E/M DOCUMENTATION GUIDELINES (located a
www.cms.hhs.gov). EITHER THE '95 OR '97 GUIDELINES MAY BE USED, BUT THE TWO SETS OF GUIDELINES CANNOT BE COMINGLED
Patient Name:________________________________________________ DOB:_________________ DOS:_____________________
Chief Complaint:_______________________________________________________________________________________________
HISTORY
HPI
Brief=1-3
Extended= ('95) 4 or more elements or assoc. comorbidities
Extended= ('97) 4 or more elements or status of at least 3 chronic/inactive conditions
Location
Quality
Severity
Duration
(Where
problem is
located)
(sharp, dull,
stabbing)
(scale of 110, etc)
(how long)
Timing
(how long it
lasts, after
meals, etc)
Context
Modifying Factors
(when
walking,etc)
Associated Signs/Symptoms
(feel better after
applying ice, etc)
(swelling, redness, etc.)
ROS
Pertinent=1
Extended= 2-9
Constitutional
Eyes
ENT/Mouth
Integumentary (skin/breast)
Complete= 10 or more
Cardio
Resp
Neuro
GI
GU
Psych
Hem/Lymph
Endo
Musculo/Skel
Allerg/Immun
PFSH
Pertinent=1
Past Medical
Complete= 2 or more
Initial visits require at least one item from all three PFSH areas
Family History
Social History
HPI
ROS
PFSH
History Level
Brief
N/A
N/A
Prob Focused
Brief
Pertinent
N/A
Exp Prob Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
To qualify for a given level of history, all three elements in the table must be met.
History level based on '95 Guidelines_______________
Developed incorporating CMS/AMA 1995/1997 copyrighted materials
Form Date: 10/03/05
History level based on '97 Guidelines______________
Form Date: 02/01/06
EXAM
BODY AREAS ('95) with '97 specific elements
Elements of '97 Gen. Multi-System Exam
97
Head, incl face
Neck
'97
Constitutional ('95)
Eyes
ENT, Mouth
Cardiovasc
1. Neck (masses, etc.) 2. Thyroid
Chest, incl breasts or axillae
'97
*Please refer to '97 Single Organ System Exam
ORGAN SYSTEMS ('95 & '97)
95
guidelines for specific bullet and numeric
1.Any 3 vitals 2.General appearance
requirements for each category of single
1.Conjunctivae and lids 2.Pupils & irises 3.Optic discs
organ system exam
1.Ext ears & nose 2.EACs & TMs 3.Hearing 4.Oropharynx 5.Septum, turb 6. Lips, teeth, gums
1.Palpation of heart 2.Auscultation 3.Carotids 4.Abd aorta 5.Femoral arteries
6.Pedal pulses 7.Extremities for edema and/or varicosities
Respiratory
GI (Abd.)
GU (male) ('97)
GU (female) ('97)
Musculoskeletal
1.Inspect breasts 2.Palpation breasts/axillae
Abdomen
Genitalia, groin, buttocks
1.Respiratory effort 2.Percussion 3.Palpation 4.Auscultation
1.Masses, tenderness 2.Liver & spleen 3.Hernia 4.Anus, perineum & rectum 5.Occult test
1.Scrotal contents 2.Penis 3.Prostate gland
1.External genitalia 2.Urethra 3.Bladder 4.Cervix 5.Uterus 6.Adnexa/parametria (w/w.out speci)
1.Gait & station 2.Digit and nail 3.Joint(s), bone(s), muscles of at least one of these areas:
a) head, neck; b) spine, ribs, pelvis; c) any one of 4 extremities, & exam to include:
Back, incl spine
(1)inspection &/or palpation (2)ROM (3)stability (4)muscle strength & tone
Skin
1.Inspection of skin & subcutaneous tissue 2.Palpation of skin and subcutaneous tissue
Neuro
1.Cranial nerves 2.Deep tendon reflexes 3.Sensation
Psych
1.Judgment & insight 2.Brief mental status: (a)orient to time, place, person (b)memory (c)mood
Hematologic/lymphatic/immunologic
Each extremity
1.Palpate lymph nodes in 2 or more areas: a) neck b) axillae c) groin d) other
Prob Focused
Exp Prob Focused
Detailed
General MultiSystem Exam
Perform and document at least 2
Perform and document 1- Perform and document at
bulleted elements from at least 6
5 bulleted elements in
least 6 bulleted elements in
systems or body areas, or at least 12
one or more systems or one or more systems or body
bulleted elements from 2 or more
body areas
areas
systems or body areas
Single Organ
System Exam
Perform and document 15 bulleted elements,
whether in shaded or
unshaded box
Comprehensive
Perform all bulleted elements from at
least 9 systems/body areas (unless
specific directions limit content) and
document at least 2 bulleted elements
from each selected area
'97 Guidelines:
Body Area(s) Limited exam of affected
body area or organ
or Organ
system (1)
System(s)
'95 Guidelines:
Perform and document at
least 6 bulleted elements,
whether in a shaded or
unshaded box
Limited exam of affected body
area/system and other
related/sympt. systems (2-7)
Exam level based on '95 Guidelines__________
Exam level based on '97 Guidelines__________
Perform and document at least 12
Perform all bulleted elements, whether in
bulleted elements (except for eye &
shaded or unshaded box; document
psych exam, which should be at least
every element in each shaded box and at
9 bulleted elements) whether in
least one element in each unshaded box.
shaded or unshaded box
General multi-system exam of 8 or
more systems or complete exam of a
Extended exam of affected body
area/system and other related
systems (2-7 in more depth)
single system*
*('95)Comprehensive Exam must be 8 or more organs systems; cannot combine systems with
body areas. All lower level exams can combine organ systems and body areas
MEDICAL DECISION MAKING ('95 and '97 Guidelines)
Number of Diagnoses or Treatment Options
Amount and/or Complexity of Data
Number & category of problems/treatment options mentioned in the record (2
categories have a max allowable).
Identify data reviewed and circle number in points column
*Multiply A x B = C
Problem
Number A
Self-limited or minor
(stable, improving or
worsening)
x
x
1
max=2
Established problem to
examiner; stable; improved
x
1
Established problem to
examiner, worsening
x
2
New problem to examiner,
no further workup planned
x
3
x
4
max=1
New problem to examiner,
additional workup planned
Review/order of clinical lab tests
1
Review/order of tests in radiology section of CPT
1
Review/order of tests in medicine section of CPT
1
Discuss test with performing/interpreting physician
1
Decision to obtain old records or obtain history from
someone other than patient
1
Review & summary of old records and/or obtaining
history from someone other than patient and/or
discussion of case with another health care provider &
documentation of relevant findings
Independent visualization of image, tracing or specimen
itself (not simply review of report)
Total
Minimal= < 1
Limited = 2
Multiple = 3
Points*
Reviewed Data
Points B Result C
Total
Extensive = 4
Minimal= < 1
Limited = 2
Multiple = 3
Extensive = 4 or more
*Number values are not part of the '95 or '97 guidelines. The values are added here as a means of quantifying elements of medical decision making
Form Date: 10/03/05
2
2
Table of Risk of Complications and/or Morbidity or Mortality (highest level of risk in any category determines overall risk)
Use the risk table as a guide, understanding that it is only a guide. Circle most appropriate risk factor in each category.
Level of Risk
Presenting Problem
One self-limited/minor problem, e.g., cold,
insect bite
Minimal
Diagnostic Procedure(s) Ordered
Management Options Selected
Lab tests requiring venipuncture
Rest
Chest x-rays
Gargles
EKG/EEG
Elastic Bandages
Urinalysis
Superficial dressings
Ultrasound, e.g. echo
KOH prep
Two or more self-limiting/minor problems
Low
One stable, chronic illness, e.g., well
controlled hypertension or non-insulin
dependent DM, cataract, BPH
Acute uncomplicated illness or injury, e.g.,
cystitis, allergic rhinitis, simple sprain
Physiologic tests not under stress, e.g., pulmonary
function tests
Over-the-counter drugs
Minor surgery with no identified risk factors
Non-cardiovascular imaging studies with contrast,
e.g., barium enema
Physical therapy
Superficial needle biopsies
Occupational therapy
Clinical lab tests requiring arterial puncture
IV fluids without additives
Skin biopsies
Moderate
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, e.g. lump in breast
Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
Physiologic tests under stress, e.g., cardiac stress
test, fetal contractions stress test
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
Diagnostic endoscopies with no identified risk
factors
Prescription drug management
Deep needle or incisional biopsy
Therapeutic nuclear medicine
Cardiovascular imaging studies with contrast and
no identified risk factors, e.g., arteriogram, cardiac
cath
IV fluids with additives
Closed treatment of fracture or dislocation without
manipulation
Acute complicated injury, e.g., head injury with Obtain fluid from body cavity, e.g., lumbar puncture,
brief loss of consciousness
thoracentesis, culdocentesis
High
One or more chronic illnesses with severe
Cardiovascular imaging studies with contrast with
exacerbation, progression, or side effects of tx
identified risk factors
Cardiovascular electrophysiologic tests
Acute or chronic illnesses or injuries that may
pose a threat to life or bodily function, e.g.,
multiple trauma, acute MI, pulmonary embolus, Diagnostic endoscopies with identified risk factors
severe respiratory distress, progressive,
severe rheumatoid arthritis, psychiatric illness
Discography
with potential threat to self or others,
peritonitis, acute renal failure
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
Abrupt change in neurologic status, e.g,
seizure, TIA, weakness, sensory loss
(2 of 3 elements must be met or exceeded to qualify for a level of Decision Making)
DX/Mgmt Options
Data
Risk
Type of Med Dec Making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low complexity
Multiple
Multiple
Moderate
Moderate complexity
Extensive
Extensive
High
High complexity
Level of Decision Making__________________
Form Date: 10/03/05
Determining level of E&M for New Patient Office; Office/Outpatient Consult; Inpatient Consult (3 of 3
components required)
History
Prob Focused
Exam
Prob Focused
Med Dec Making
Straightforward
Code
99201 / 99241 / 99251
Exp Prob Focused
Exp Prob Focused
Straightforward
99202 / 99242 / 99252
Detailed
Detailed
Low Complexity
99203 / 99243 / 99253
Comprehensive
Comprehensive
Moderate Complexity
99204 / 99244 / 99254
Comprehensive
Comprehensive
High Complexity
99205 / 99245 / 99255
Determining level of E&M for Established Patient Office (2 of 3 components required)
History
N/A
Exam
N/A
Med Dec Making
N/A
Code
99211
Prob Focused
Prob Focused
Straightforward
99212
Exp Prob Focused
Exp Prob Focused
Low Complexity
99213
Detailed
Detailed
Moderate Complexity
99214
Comprehensive
Comprehensive
High Complexity
99215
Determining level of E&M for Initial Observation Care; Initial Hospital Care; Observation or Inpatient
Including Admission and Discharge (3 of 3 components required)
History
Detailed/Comprehensive
Exam
Detailed/Comprehensive
Med Dec Making
Straightforward or Low
Code
99218 / 99221 / 99234
Comprehensive
Comprehensive
Moderate Complexity
99219 / 99222 / 99235
Comprehensive
Comprehensive
High Complexity
99220 / 99223 / 99236
Determining level of E&M for Subsequent Hospital Care (2 of 3 components required)
History
Exam
Med Dec Making
Code
Prob Focus Interval
Prob Focused
Straightforward or Low
99231
Exp Prob Focus Interval
Exp Prob Focused
Moderate Complexity
99232
Detailed Interval
Detailed
High Complexity
99233
Determining level of E&M for New or Established Initial Nursing Facility Care (3 of 3 components
required)
History
Detailed/Comprehensive
Exam
Detailed/Comprehensive
Med Dec Making
Straightforward/Low
Code
99304
Comprehensive
Comprehensive
Moderate Complexity
99305
Comprehensive
Comprehensive
High Complexity
99306
Determining level of E&M for New or Established Emergency Room (3 of 3 components required);
Subsequent Nursing Facility Care (2 of 3 components required)
History
Prob Focused
Exam
Prob Focused
Med Dec Making
Straightforward
99281 / 99307
Code
Exp Prob Focused
Exp Prob Focused
Low Complexity
99282 / 99308
Exp Prob Focused
Exp Prob Focused
Moderate Complexity
99283
Detailed
Detailed
Moderate Complexity
99284 / 99309
Comprehensive
Comprehensive
High Complexity
99285 / 99310
Final level based on '95 Guidelines___________ Final level based on '97 Guidelines____________