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Hospitalist Coding and Billing (For Dummies) Judith Hooffstetter, MD Hospitalist.

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Presentation on theme: "Hospitalist Coding and Billing (For Dummies) Judith Hooffstetter, MD Hospitalist."— Presentation transcript:

1 Hospitalist Coding and Billing (For Dummies) Judith Hooffstetter, MD Hospitalist

2

3 Objectives Describe basics of coding and billing List documentation requirements for E/M levels Explain new consultative codes

4 Anatomy of a Charge Card H&POBSSubsequent F/UAdmitting AI DXICD-9 Code Acute on Chronic CHF A fib DMII Uncontrolled250.0 Hypothyroid Stable246.9 COPD496.0

5 ICD-9 and CPT Relationship CPT codes explain WHAT service was performed (level of visit or procedure) ICD codes explain WHY the service was performed (the diagnosis)

6 ICD-9 Classification based system that groups data into broad categories Required by the World Health Organization for reporting mortality data for comparison across countries. ICD-9 CM is a modification of the code and has been used in the US since 1979.

7 Anatomy of ICD-9 CM Have 3,4 or 5 numeric or alpha numeric codes 17 main division of chapters and then further broken down into code sections, code categories, code subcategories and code subclassifications. The more numbers, the more specific

8 Cardiac dysrhythmia Ventricular fibrillation and flutter Ventricular fibrillation only

9 Current Procedural Terminology (CPT) CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.

10 CPT Codes for Hospitalists Admit and Consult Codes Subsequent Follow Up Critical Care Codes Extended Time Codes Discharge Codes

11 How You Get Paid!!

12 Admission Codes for Hospitalists CMS – AI (admission modifier)

13 Elements for E&M visits (How you document for the level) History – CC – HPI– ROS – PFSH (past, family, social history) Exam – number of organ systems Decision making – #diagnoses or management options – Amount of data/complexity – risk level to patient

14 Inpatient Level of Care Key Components Patient HistoryDetailedComprehensive Patient ExamDetailedComprehensive Medical Decision Making (MDM) LowModerateHigh For H&P 3 of 3 key elements need to be met

15 Subsequent Level of Care Key Components Patient HistoryProblem focusedExpanded Problem Focused Detailed Interval Patient ExamProblem focusedExpanded Problem Focused Detailed MDMStraightforwardModerateHigh Subsequent Care requires 2/3 elements

16 History Matrix Type of HistoryHPIROSFH/SOC Hx Problem focusedBrief (1-3 elements) n/a Exp Problem Focused Brief (1-3)Problem Pert. (1 system) n/a DetailedExtended (4 elements or status of 3 chr Extended (2-9 systems) Pertinent (1 element) ComprehensiveExtendedComprehensive (10 system) Complete 3/3

17 ROS Must Note Pertinent Positives and Negatives in at least 10 systems for Comprehensive Can no longer say all ROS negative (Can refer to check list on written guide) Can say unable to obtain from patient (if patient obtunded etc).

18 Organ Systems (1997 Guidelines) Cardiovascular Respiratory Ear, Nose, and Throat Eye Genitourinary Hematologic/Lymphati c/Immunologic Musculoskeletal Neurological Psychiatric Skin

19 Patient Exam Type of ExamRequired PE Problem Focused1 – 5 bullets (or one body system or organ system) Expanded Problem Focused6 bullets (2-4 body areas or organ systems) DetailedAt least 2 bullets from specified systems or 12 bullets (5-7 body areas or organ systems) Comprehensive18 elements with at least 2 from each system (8+ body areas or organ system)

20 Medical Decision Making Matrix Type of Decision Making Number of Diagnosis Amount and complexity of data Risk of Complication or Morbidity or Mortality StraightforwardMinimal (1)Minimal (1) or none Minimal LowLimited (2) Low ModerateMultiple (3)Moderate (3)Moderate HighExtensive (4)Extensive 4High MUST MEET 2/3 COMPONENTS Final MDM requires that 2 of 3 above components are met or exceeded

21 Amount and complexity of data ActionPoints Review And/or order clinical test (labs) 1 point Review and/or order of radiology1 point Review and/or order of medical test (vaccines, echo, ekg, pft) 1 point Discussion of test with performing MD 1 point Independent review of test2 points Old records or hx from another person and summarizing 2 points

22 Moderate Complexity 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, pyelonephritis, 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

23 High Complexity 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, An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss Cardiovascular imaging studies with contrast with identified risk factors Elective and emergency major surgery Parenteral controlled substances or drug therapy requiring intensive monitoring for toxicity

24 Pearls ActionLevel Prescription drug managementmoderate 2+ stable chronic illnessmoderate Abrupt MS change (seizure, TIA)high 1 chronic illness w/severe exacerbation, progression high Make DNRhigh Cardiovascular imaging studies with contrast with identified risk factors high Emergent major surgeryhigh Parenteral pain medicationhigh

25 Subsequent Level of Care Key Components Patient HistoryProblem focusedExpanded Problem Focused Detailed Interval Patient ExamProblem focusedExpanded Problem Focused (6) Detailed (12) MDMStraightforwardModerateHigh Subsequent Care requires 2/3 elements

26 Time Based Coding for Subsequent Care When counseling/coordination of care is > 50% of service AND When TIME based code would be higher level of service

27 Time Based Code CPT CODETime minutes minutes minutes

28 Inpatient Consults Request for consult must be documented by requesting and completing physician Consulting physician must document opinion and/or advice (send cc to requesting physician) Document the problem for which YOU are seeing the patient (to prevent concurrent care denials) Document time = total time

29 Consults Codes (CMS)

30 Consult Codes No longer use consult codes ( ) for CMS Can still use them for commercial payers Use admission codes (but without the AI modifier). Can use prolonged service codes ( ) if applicable

31 Crosswalk for Inpatient Consults Old CPTHistoryExamMDMNew code 99253Det HxDet Exam At least 2 bullets from specified systems or 12 bullets Low Comp Hx18 elements with at least 2 from each system Moderate Comp Hx18 elements with at least 2 from each system High99223

32 Prolonged Service Codes Greatly increases reimbursement Use with and when appropriate Never use with CAN BE A FLAG FOR MEDICARE AUDITS – so must be used appropriately and well documented

33 Discharge Codes Used when time is less <30 minutes Used when time is less >30 minutes MUST DOCUMENT IN YOUR DICTATION TIME SPENT

34 TO RECAP

35 Inpatient Admission Level 3 ComponentLevel 3 Requirements HistoryComprehensive Exam18 elements with at least 2 from each system MDMHigh

36 Subsequent Visit Level 2 ComponentService Required ExamProblem focused - 6 bullets MDMModerate OR DOCUMENT BASED ON TIME

37 Subsequent Visit Level 3 ComponentRequired Exam18 elements with at least 2 from each system MDMHigh OR BASED ON TIME

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