1. 2015 User Conference Coding Like A Pro April 24, 2015 (EHR-120) Presented by: Susan J. Kressly, MD, FAAP Medical Director EHR Workshop

2. 2015 Office Practicum User Conference Learning Objectives ▪ Review CMS criteria for coding level decisions ▪ Understand the basis of OP’s coding decision support ▪ Learn the basis of E/M coding levels ▪ Identify key tips to assist in documentation to support intended coding level ▪ Better coding for better payment!!!

3. 2015 Office Practicum User Conference Let’s Get To It !

4. 2015 Office Practicum User Conference Test Patient Scenario ▪ Choose a test patient ▪ Start a new encounter ▪ Initially, you are going to pretend to be the nurse/MA ▪Here for a bug bite ▪No fever, right arm, yesterday, acute, mild, improving ▪She reviews the problem list, allergies, meds, PMH, Family History, Social History ▪Does a thorough Review of Systems ▪Take a temperature (97.6), grabs a height/weight ……Saves the note and it’s your turn

5. 2015 Office Practicum User Conference Test Patient Scenario ▪ You examine the child and the exam is normal except for a small papule on the right arm without induration, or surrounding hive, no evidence of infection ▪ You choose the normal exam template and apply it

6. 2015 Office Practicum User Conference Test Patient Scenario Part 2 ▪ You elaborate on the skin findings (the only abnormal thing) including the palpation ▪ You also want to include something about the wrist to note it’s normal: add M/S system ▪ And note about reactive lymph nodes

7. 2015 Office Practicum User Conference What coding level did you get? How did THAT happen?

8. 2015 Office Practicum User Conference Coding: Whose Responsibility? ▪ The PROVIDER ▪ Legal responsibility to choose the appropriate code ▪ If audited/investigated provider who saw the patient is ultimately responsible ▪ Only the PROVIDER knows if the documentation and coding level is appropriate for the visit reason/complexity ▪ Will be necessary to support ICD-10 diagnosis coding

9. 2015 Office Practicum User Conference Coding Decision Support

10. 2015 Office Practicum User Conference Brief Look at the OP Coding Calculator ▪ Always “suggests” a code based on documentation that is “countable” ▪ Free text in other sections cannot be counted by computer but user can manually account for on calculator ▪ Can add manual entry of the top 2 sections IF you check coding count override box and will be so stated in audit note

11. 2015 Office Practicum User Conference CMS 1997 Coding Guidelines ▪ OP uses to suggest coding level ▪ Some say are less “pediatric friendly” than the 1995 guidelines ▪ 1995 guidelines are more difficult for computers to “count” bullets

12. 2015 Office Practicum User Conference Problem Drive Documentation ▪ Should a visit for a diaper rash be a 99212, 99213 or 99214? ▪ All 3 may be appropriate depending on the details of the situation 99212? 99213? Or 99214?

13. 2015 Office Practicum User Conference Diaper Rash 99212 Healthy 6 month old, presents with “diaper rash” in the AM for the past few weeks since she has been sleeping through the night. Mom reports it looks “much better” by lunchtime.

14. Diaper Rash 99212

16. 2015 Office Practicum User Conference Diaper Rash 99213 Healthy 15 month old presents with red, bumpy diaper rash since finished antibiotics for OM last week.

17. Diaper Rash 99213

19. 2015 Office Practicum User Conference Diaper Rash 99214 8 month old who presents with worsening diaper rash for 3 weeks. Cursory look at chart shows the patient has been on antibiotics 4 times this winter, and weight is at the 7%ile although tracking along the bottom of the curve.

20. 2015 Office Practicum User Conference Diaper Rash 99214

21. 2015 Office Practicum User Conference Diaper Rash 99214 ▪ Can automatically include Past Medical History if check “pertinent” item ▪ Can automatically include Social History if check a “pertinent” item

22. 2015 Office Practicum User Conference Diaper Rash 99214 ▪ Can manually check if comment/text elsewhere

23. 2015 Office Practicum User Conference Diaper Rash 99214

24. 2015 Office Practicum User Conference Diaper Rash 99214 ▪ Assessment/Plan should document provider thinking ▪ Critically important to include if E/M coding seems “out of line” with diagnosis

25. 2015 Office Practicum User Conference Medical Decision Making ▪ Cannot be calculated by computer ▪ Must always be manually chosen ▪ Assessment/Plan documentation should support reason for choosing MDM level

26. 2015 Office Practicum User Conference Medical Decision Making ▪ IF you want the MDM coding level to show up on audit note, must check “coding override” check box

27. 2015 Office Practicum User Conference Medical Decision Making ▪ Audit notes now automatically composed and saved with the notes ▪ Contain details of visit & coding calculator support

28. 2015 Office Practicum User Conference Let’s Try It!

29. 2015 Office Practicum User Conference Case Study : URI Healthy 8 year old, no medical issues, afebrile, runny nose, congestion, history of low grade fever. Dx: simple URI What’s your coding level? What should it be based on healthy patient, presenting complaint?

30. 2015 Office Practicum User Conference Case Study: URI What if that same 8 year old has asthma but is not wheezing? What is your coding level? What should it be?

31. 2015 Office Practicum User Conference Case Study: URI What about a 5 month old with runny nose, congestion, fever and cough. Does this change your level of complexity/coding? How would you make sure you support the documentation?

32. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Must have “separately identified” reason for the additional sick ▪ Should ask yourself: is this service medically necessary?

33. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Can be an acute problem ▪Should have been something that patient would have been seen for even if not in for well visit ▪Examples: otitis media, bronchiolitis, poison ivy dermatitis

34. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Can be a chronic problem that you review and change/consider changing management ▪Would have been a visit on it’s own, but for family convenience are doing at the same time as well ▪Examples: asthma, ADHD, anxiety, encopresis

35. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Start with the well ▪ May want to make reference in HPI to additional encounter ▪ Save visit: critical for coding calculator to understand well + sick when start the sick

36. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Use the “add encounter button” in A/P plan of well visit

37. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Best Practices: ▪Document exam on well visit (including pertinent abnormals) ▪Do not want to have conflicting exam elements (normal on well visit and abnormal on sick) ▪Cannot count an exam twice for purposes of level of E/M visit ▪Change HPI in sick visit

38. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Best Practices: ▪If using sick templates do not include exam ▪Consider notation in exam for sick uncheck exam box

39. 2015 Office Practicum User Conference Same Day Well and Sick ▪ Coding Decision Support ▪Adds -25 modifier to indicate “separately identifiable service” ▪Automatically removes History from countable elements (full history review is inherent part of a well visit) ▪Automatically removes Exam elements (comprehensive exam is inherent part of a well visit) ▪ Will notice that the sick is lower than if stood alone ▪Unless code based on time

40. Same Day Well and Sick

41. 2015 Office Practicum User Conference Coding Based on Time ▪ Counseling or Coordination of Care ▪ Must represent > 50% of time of visit ▪ Leave no doubt……document, document, document ▪ Specific spent “x” minutes face to face with patient/parent …. ▪“counseling on issues related to depression/anxiety” with overview of details (do not need to transcribe visit) ▪“coordinating care with pulmonologist who we conferenced on phone while family in office”

42. 2015 Office Practicum User Conference “Typical” Time ▪ If > half way to the next code, may “round up”

43. Rounding Rules for Time-Based Coding

44. Modifiers

45. 2015 Office Practicum User Conference Key Modifiers ▪ -25: separate E/M, same day/same provider ▪ -59: distinct procedural service ▪ -33: preventive care ▪Important because with ACA plans means payers cannot cost-shift to family ▪Is not recognized by most Medicaid Plans ▪ -76: repeated procedural service ▪Useful for repeat nebulizer treatments same day ▪Units is supposed to be for per service performed (2 units of J code for ceftriaxone) ▪ -50: bilateral procedure ▪Such as cerumen removal ▪NOT all payers recognize/allow

46. 2015 Office Practicum User Conference Procedure Templates Treatment of Wart

47. 2015 Office Practicum User Conference Resources ▪ AAP Coding Resources ▪ CMS Outreach Education for E/M codingOutreach Education for E/M coding ▪ AAFP: Time is of the Essence: Coding on the Basis of Time for Physician ServicesTime is of the Essence: Coding on the Basis of Time for Physician Services

49. 2015 Office Practicum User Conference Questions ?

50. 2015 Office Practicum User Conference We want your feedback! Handouts: Coding Like a Pro – Coding MDM Coding Like a Pro – Side 1 Coding Like a Pro – Slide 2