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Coding and Documentation Compliance Training Emergency Medicine Physicians UNC Chapel Hill School of Medicine.

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Presentation on theme: "Coding and Documentation Compliance Training Emergency Medicine Physicians UNC Chapel Hill School of Medicine."— Presentation transcript:

1 Coding and Documentation Compliance Training Emergency Medicine Physicians UNC Chapel Hill School of Medicine

2  UNC School of Medicine Compliance Purpose of this course To assure appropriate billing through knowledge of guiding principles To build confidence in documenting evaluation and management (E&M) services for accurate coding and reimbursement

3  UNC School of Medicine Compliance Compliance Office’s Role Develop and assure adherence to faculty practice’s Compliance Plan Faculty, resident, nurse practitioner and staff education Medical record reviews (primarily physician- directed billing) Responses to audit requests from external agencies Investigate and resolve potential breaches in the Compliance Plan Research compliance-related issues

4  UNC School of Medicine Compliance Billing Professional Services Every billed service is assigned codes used for reimbursement, statistics, research and other purposes The complexity of the patient condition, as documented in the physician note, drives the level of evaluation and management service delivered, recorded and billed.

5  UNC School of Medicine Compliance Billing Professional Services A UNC Physicians & Associates coder assigns codes for Emergency Medicine physicians based on the content of their notes. With the exception of the review of systems and past, family and social history, the medical student’s documentation may not be used or referenced in the physician note.

6  UNC School of Medicine Compliance Diagnosis International Classification of Diseases (ICD-9CM) World Health Organization Procedure Current Procedure Terminology (CPT) American Medical Association Supplemental supply and procedure codes Healthcare Common Procedure Coding System (HCPCS) Federal government—but used by many payers Coding Systems

7  UNC School of Medicine Compliance Medical necessity Only services that are medically necessary are billable Necessity for the work performed must be established in the physician’s note

8  UNC School of Medicine Compliance Reimbursement Based upon the effort required to treat the individual at the time of presentation Five levels of evaluation and management (E&M) services are designated for emergency department use

9  UNC School of Medicine Compliance ED E&MsMedicaidMedicareBCBS/SHP $ $ 16.13$ E&M Services Allowables Emergency Department Codes

10  UNC School of Medicine Compliance E&M Services Allowables Critical Care Codes Critical Care MedicaidMedicareBCBS/SHP (first min) $ $ $ (ea. add’l 30 min)

11  UNC School of Medicine Compliance E&M code is determined by 1. Demonstration of medical necessity 2. Documentation of decision making complexity 3. Detail of history and physical exam included in the note

12  UNC School of Medicine Compliance Critical care When injury or illness acutely impairs one or more vital organ systems such that there is a probability of imminent or life- threatening deterioration Document system failure and the decision- making required to assess, manipulate and support vital system functions Record the amount of time spent providing critical care to the patient

13  UNC School of Medicine Compliance Five Emergency Department visit levels Medical decision making documentation is the key to selection of the code level Understanding how decision making is evaluated will help improve your documentation

14  UNC School of Medicine Compliance 1. Number of diagnostic and/or management options 2. Amount and complexity of data 3. Risk of the illness, injury or treatment Medical Decision Making (MDM) Recording complexity and effort Based on 2 of these 3 components: (detailed on the following 3 pages)

15 Recording your medical decision making

16  UNC School of Medicine Compliance Medical Decision Making 1. Diagnostic & Management Options Self-limited, minor Established problem, stable or improved Established problem worsening New problem, no additional workup planned New problem, additional workup planned 1 point 1 pt. ea 2 pts. ea 3 points 4 ea Total (maximum of 4 points)

17  UNC School of Medicine Compliance Medical Decision Making 2. Amount and Complexity of Data Review/order of 1)clinical lab 2) radiologic study 3)non-invasive diagnostic study Discussion of diagnostic study w/interpreting physician Independent review of diagnostic study Decision to obtain old records or get data from source other than patient Review/summary old med records or gathering data from source other than patient 1 point for each type 1 point 2 points 1 point 2 points Total (maximum of 4 points)

18  UNC School of Medicine Compliance Medical Decision Making 3. Risk Presenting problem Diagnostic procedures Management options Choose highest bulleted item from any of the following three areas (see risk table, next page) to determine level of risk due to:

19  UNC School of Medicine Compliance Risk LevelPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options Selected Minimal (1) One self-limited or minor problem, eg, cold, insect bite, tinea corporis Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, eg, echocardiography KOH prep Rest Gargles Elastic bandages Superficial dressings Low (2) Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension, 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 Moderate (3) 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 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 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 High (4) 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, sensory loss Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic Endoscopies with identified risk factors Discography 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 3. Table of Risk (To print: right click, choose “print,” then “current slide”)

20  UNC School of Medicine Compliance Medical Decision Making Considerations The existence of co-morbidities and underlying diseases is not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision making. If it does, document it. Don’t merely list it as an existing condition.

21  UNC School of Medicine Compliance Medical Decision Making Considerations Risk of the presenting problem is based on the risk related to the disease process anticipated between the present encounter and the recommended next inpatient or outpatient service by a physician

22  UNC School of Medicine Compliance E&MMDMDefinition Straightforward Low Moderate Presenting problems are of moderate severity Moderate Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function Diag/.Mgmnt options Amt/complexity of data Overall riskMinimalLowModerateHigh Type of MDMStrghtfwdLowModerateHigh MDM Calculation

23  UNC School of Medicine Compliance Diag/.Mgmnt options Amt/complexity of data Overall riskMinimalLowModerateHigh Type of MDMStrghtfwdLowModerateHigh MDM Calculation E&MMDMDefinition Straightforward Low Moderate Presenting problems are of moderate severity Moderate Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function

24  UNC School of Medicine Compliance Documentation requirements LevelHistory and ExamMDM 99281Problem focused (PF) Straightforward 99282Expanded problem focused (EPF) Low 99283Expanded problem focused (EPF) Moderate 99284Detailed Moderate 99285Comprehensive High The detail recorded in the history and exam generally follows the complexity of the case. It is required that both the history and exam meet at least these requirements.

25 Documenting the history and exam

26  UNC School of Medicine Compliance E&M levelHPIROSPFSH Physical exam (‘95 guidelines) Level Brief (1-3) NA Limited exam of affected system or area Problem Focused Brief (1-3) Pertinent (at least one) NA Limited exam of affected system + other symptomatic or related systems/areas Expanded Problem Focused Brief (1-3) Pertinent (at least one) NA Limited exam of affected system + other symptomatic or related systems/areas Expanded Problem Focused Extended (4+) Extended (2-9) Pertinent (1 of 3) Extended exam of affected area+other symptomatic… Detailed Extended (4+) Complete (10-14) Complete (3 of 3) 8 or more systems documented or a complete exam of a single organ system Comprehensive The Four Levels of History & Exam History Components

27  UNC School of Medicine Compliance The History Location Quality Severity Duration Timing Context Modifying factors Associated signs & symptoms Brief = 1-3 elements, Extended = 4+ or review of 3 chronic or inactive conditions History of Present Illness Review of Systems Pertinent = <2 Extended = 2-9 Complete = or “all others negative” Past Current Medications Prior illnesses/injuries Dietary status Operations/hospitalizations Allergies Immunizations Family Health status/cause of death of parent, sibling, children Diseases related to chief complaint, HPI, ROS Hereditary or high risk diseases Social Living arrangements Marital status Sexual history Occupational history Use of drugs/tobacco/alcohol Extent of education Current employment Other Past, Family and Social History Pertinent = 1 of 3 areas Complete = 3 of 3 (2 of 3 for estab.) Constitutional symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin/breast) Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic

28  UNC School of Medicine Compliance The History Anyone, including students or the patient himself, may collect the review of systems and past, family and social history, however, the physician note must refer to reviewing those aspects of history to establish the use of those elements in the care of the patient. The physician must personally document the history of the present illness even if it appears in other providers’ notes.

29  UNC School of Medicine Compliance A general multi-system examination or a single organ system may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician. Note specific abnormal & relevant negative findings of the affected or symptomatic area(s)--“abnormal” is insufficient. Describe abnormal or unexpected findings of asymptomatic areas or systems. Noting “negative” or “normal” is sufficient to document normal findings in unaffected areas. The Physical Exam

30  UNC School of Medicine Compliance Examples of presentations at various levels patient with several uncomplicated insect bites. a 20-year-old student who presents with a painful sunburn with blister formation on the back. a well-appearing 8-year-old who has a fever, diarrhea and abdominal cramps, is tolerating oral fluids and is not vomiting a sexually active female complaining of vaginal discharge who is afebrile and denies experiencing abdominal or back pain

31  UNC School of Medicine Compliance Examples of presentations at various levels an elderly female who has fallen and is now complaining of pain in her right hip and is unable to walk. a patient with flank pain and hematuria a patient with a new onset of rapid heart rate requiring IV drugs a patient who presents with a sudden onset of "the worst headache of her life," and complains of a stiff neck, nausea, and inability to concentrate

32 Medicare Teaching Physician Regulations

33  UNC School of Medicine Compliance The Medicare program’s perspective on residents Resident services to Medicare beneficiaries are paid to the hospital through Part A based on the proportionate share of Medicare at the teaching hospital Teaching physicians are paid by Part B Medicare on a fee-for-service basis only when they provide a personal, face-to-face service in addition to the resident

34  UNC School of Medicine Compliance The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed. Documentation by a resident or any other party of the presence and participation of the TP is not sufficient (except in cases of some procedures in which the teaching physician is present for the entire time--never for ED visit services) Documentation may be dictated and typed, hand-written or computer-generated. Proper Teaching Physician (TP) Documentation for Medicare

35  UNC School of Medicine Compliance Medicare requires attestation of teaching physician involvement That the teaching physician performed the service or was physically present during the key or critical portions of all three components: history, exam and decision making; and The participation of the teaching physician in the management of the patient. For Emergency Department evaluation and management services:

36  UNC School of Medicine Compliance Examples of Acceptable Teaching Physician Notes "I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident's note and agree with the documented findings and plan of care." "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note.

37  UNC School of Medicine Compliance "Seen and agree." followed by legible countersignature or identity; "Patient seen and evaluated." followed by legible countersignature or identity; and A legible countersignature or identity alone. Examples of Unacceptable Teaching Physician Notes

38  UNC School of Medicine Compliance Procedures Minor procedures of <5 minutes TP must be present the entire time Surgical procedures TP must be present for the key portions and state those portions in the attestation In operating suite available to return Two overlapping procedures Key portions must happen at different times Must be available to return to either or designate another TP

39  UNC School of Medicine Compliance Time-based services Time-based procedures may be billed to Medicare on teaching physician time only. Record the actual amount of time in the note. Critical care Prolonged services Payers other than Medicare may be billed for resident time performing time-based services if the amount of time is documented

40 North Carolina Medicaid Teaching Physician Regulations

41  UNC School of Medicine Compliance NC Medicaid teaching physician (TP) requirements TP must be "immediately available" to the resident and patient by telephone or pager at the least For procedures, the TP must use "direct supervision" (available in the office suite) The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

42  UNC School of Medicine Compliance Where To Get Help UNC P&A Professional Charges Coders for Emergency Medicine Cindy Wyrick, CPC, Rhonda Peck, CPC, Jana Rakes, CPC, Deresa Stroud, CPC, School of Medicine Compliance Office Heather Scott, CPC, Compliance Officer Keishonna Carter, CPC, Compliance Review Analyst Nirmal Gulati, CPC, Compliance Auditor Lateefah Ruff, CPC, Office Assistant Confidential Help Line for reporting potential compliance problems The AMA’s Current Procedural Terminology (CPT) Manual


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