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

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

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

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.

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.

Coding Systems Diagnosis Procedure 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

Medical necessity Only services that are medically necessary are billable Necessity for the work performed must be established in the physician’s note

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

E&M Services Allowables Emergency Department Codes ED E&Ms Medicaid Medicare BCBS/SHP 99281 $ 15.34 $ 16.13 $ 46.55 99282 25.39 26.69 58.35 99283 57.04 59.98 98.80 99284 89.08 93.68 168.44 99285 139.45 146.65 231.04

E&M Services Allowables Critical Care Codes Medicaid Medicare BCBS/SHP 99291 (first 30-74 min) $ 191.12 $ 200.93 $ 332.69 99292 (ea. add’l 30 min) 95.62 100.78 188.10

E&M code is determined by Demonstration of medical necessity Documentation of decision making complexity Detail of history and physical exam included in the note

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

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

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

Recording your medical decision making

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 The third and final component of your note is the assessment and plan or the medical decision making documentation. Complexity of decision making is based on two of three areas, the number of diagnostic or management options considered, the amount and complexity of data reviewed or ordered and the risk to the patient of the condition itself or the treatment, significant complications, loss of function or life. In the first two areas, points are assigned and they are designed to quantify complexity based on the status of the problem or problems being treated and other relevant problems or underlying conditions that affect your decision making. For example, your patient returns unchanged after being treated with a prescription and also has a condition you are not treating but must consider in the treatment plan. 2 points for the established problem not improving, 1 point for the underlying condition you must consider would total 3 points. In the second area, points are totaled for all the different data that is reviewed to arrive at a treatment plan. One point each for lab tests ordered or reviewed, another point for radiological studies, a third point for EKGs or PFTs and the like. Documenting a request for records to be forwarded from another practice, review of those records or of the notes of other providers should be recorded in the assessment area as they are part of your decision making. The risk table is included as the last page of your handout and is a guide for determining what is considered high or moderate risk. Please read over it so as get an idea what is considered high complexity. Whatever approximates your situation will provide the level of risk. 4 ea Total (maximum of 4 points)

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 The third and final component of your note is the assessment and plan or the medical decision making documentation. Complexity of decision making is based on two of three areas, the number of diagnostic or management options considered, the amount and complexity of data reviewed or ordered and the risk to the patient of the condition itself or the treatment, significant complications, loss of function or life. In the first two areas, points are assigned and they are designed to quantify complexity based on the status of the problem or problems being treated and other relevant problems or underlying conditions that affect your decision making. For example, your patient returns unchanged after being treated with a prescription and also has a condition you are not treating but must consider in the treatment plan. 2 points for the established problem not improving, 1 point for the underlying condition you must consider would total 3 points. In the second area, points are totaled for all the different data that is reviewed to arrive at a treatment plan. One point each for lab tests ordered or reviewed, another point for radiological studies, a third point for EKGs or PFTs and the like. Documenting a request for records to be forwarded from another practice, review of those records or of the notes of other providers should be recorded in the assessment area as they are part of your decision making. The risk table is included as the last page of your handout and is a guide for determining what is considered high or moderate risk. Please read over it so as get an idea what is considered high complexity. Whatever approximates your situation will provide the level of risk. 1 point 2 points Total (maximum of 4 points)

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

3. Table of Risk (To print: right click, choose “print,” then “current slide”) Risk Level Presenting Problem(s) Diagnostic Procedure(s) Ordered Management 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

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.

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

MDM Calculation Diag/.Mgmnt options 0-1 2 3 4 Amt/complexity of data Overall risk Minimal Low Moderate High Type of MDM Strghtfwd E&M MDM Definition 99281 Straightforward 99282 Low 99283 Moderate Presenting problems are of moderate severity 99284 Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function 99285 High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function The level of medical decision making documented is determined by at least two of the three areas meeting the level.

MDM Calculation Diag/.Mgmnt options 0-1 2 3 4 Amt/complexity of data Overall risk Minimal Low Moderate High Type of MDM Strghtfwd E&M MDM Definition 99281 Straightforward 99282 Low 99283 Moderate Presenting problems are of moderate severity 99284 Problem(s) are of high severity and require urgent evaluation but do not pose an immediate, significant threat to life or physiologic function 99285 High Presenting problem(s) are of high severity and pose an immediate threat to life or physiologic function The level of medical decision making documented is determined by at least two of the three areas meeting the level.

Documentation requirements 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. Level History and Exam MDM 99281 Problem focused (PF) Straightforward 99282 Expanded problem focused (EPF) Low 99283 Moderate 99284 Detailed 99285 Comprehensive High

Documenting the history and exam

The Four Levels of History & Exam E&M level HPI ROS PFSH Physical exam (‘95 guidelines) Level 99281 Brief (1-3) NA Limited exam of affected system or area Problem Focused 99282 Pertinent (at least one) Limited exam of affected system + other symptomatic or related systems/areas Expanded Problem Focused 99283 99284 Extended (4+) Extended (2-9) Pertinent (1 of 3) Extended exam of affected area+other symptomatic… Detailed 99285 Complete (10-14) Complete (3 of 3) 8 or more systems documented or a complete exam of a single organ system Comprehensive History Components

The History History of Present Illness Review of Systems 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 Review of Systems Constitutional symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin/breast) Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic Pertinent = <2 Extended = 2-9 Complete = 10-14 or “all others negative” Past, Family and Social History Social Living arrangements Marital status Sexual history Occupational history Use of drugs/tobacco/alcohol Extent of education Current employment Other Past Current Medications Prior illnesses/injuries Dietary status Operations/hospitalizations Allergies Immunizations The history of the present illness or HPI will be either extended or brief. An extended HPI includes at least 4 of the eight descriptors listed here or a brief statement of the status of 3 chronic or inactive conditions relevant to the problem being treated. An extended HPI is required for the highest two levels of established patient codes if history is a key component and for the three highest levels of new patient or consult codes (refer to coding card). You’ll see in the far left column the established patient codes and next to it the new and consult codes listed. The next portion of the history is the review of systems which may be categorized as pertinent, extended or complete. You’ll see on the coding card where a complete review of systems is only necessary for a level 5 established patient, but must be documented for either a level 4 or a level 5 new patient or consult. If you’ve gathered information on at least 10 systems you may choose to document only the pertinent positive and negative responses and include the the statement “the balance of ten systems reviewed is negative” or “all other systems negative” to record a complete review. The last portion of the history is the past, family and social history. One item from each area is required for a complete PFSH, only two of the three are needed for an established patient to be complete. For a level 4 or 5 new patient visit all three must be documented, 2 areas completed will suffice for a established level 5 where history is one of the key components of the visit. Pertinent = 1 of 3 areas Complete = 3 of 3 (2 of 3 for estab.) Family Health status/cause of death of parent, sibling, children Diseases related to chief complaint, HPI, ROS Hereditary or high risk diseases

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.

The Physical Exam 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 is the next component of the visit. You’ll determine the type and extent of exam you perform based upon the situation. The documentation should be recorded in enough detail to inform the next health care provider of the extent of your exam and observations. It may be minimal where normal, noting the body area or organ system examined and the statement “negative” or “normal.”

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 99281 99282 99283 99283

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 99284 99284 99285 99285

Medicare Teaching Physician Regulations

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

Proper Teaching Physician (TP) Documentation for Medicare 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.

Medicare requires attestation of teaching physician involvement For Emergency Department evaluation and management services: 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.

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.

Examples of Unacceptable Teaching Physician Notes "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.

Procedures Minor procedures of <5 minutes Surgical procedures 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

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

North Carolina Medicaid Teaching Physician Regulations

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.

Where To Get Help www.med.unc.edu/compliance/ UNC P&A Professional Charges Coders for Emergency Medicine Cindy Wyrick, CPC, 966-9051 Rhonda Peck, CPC, 962-8391 Jana Rakes, CPC, 843-6096 Deresa Stroud, CPC, 843-3135 School of Medicine Compliance Office 843-8638 Heather Scott, CPC, Compliance Officer Keishonna Carter, CPC, Compliance Review Analyst Nirmal Gulati, CPC, Compliance Auditor Lateefah Ruff, CPC, Office Assistant Confidential Help Line 800-362-2921 for reporting potential compliance problems The AMA’s Current Procedural Terminology (CPT) Manual