1. Hospitalist’s guide to Code Green
Lida Fatemi, DO, MPH
4/19/17

2. Objectives Key Components of Documentation Key Components of Coding
Streamline – Pro Fee + Facility Fee
Communication Patient Care Needs

3. Documentation  Coding  Billing
Overall picture
Documentation  Coding  Billing
E&M = Pro Fee = Professional Fee – Individual Physician
Facility Coding – How facility gets paid

4. Components of Pro Fee
E&M = Pro Fee = Professional Fee – Individual Physician
History
Physical Exam
Medical Decision Making
Looks at components of each note

5. Facility Fee How the hospital gets paid Facility Coding
High specificity in diagnosis
Severity of illness
Comorbid conditions
The entire hospital stay

6. H&P

7. Need 10 Systems
Need 8 Systems
Missing Family History

9. Key Components for H&P Pro Fee Chief Complaint
ROS – 10 systems – don’t have to reiterate the HPI
Past Medical, Social Hx, Family Hx, Surgical Hx
PE: 8 systems
Medical Decision Making – usually the first problem (up to 4)
If spent >100 minutes = Prolonged Service

10. Key Components for H&P Facility coding Specificity Providing evidence
Use “treat”
New vs. old – acute/chronic/acute on chronic/subacute
Severity of illness
Laterality

11. Progress Note

12. Need 10 Systems
Need 8 Systems

14. Key Components Progress note = subsequent visit
Pro Fee – 2 out of 3 components
Need 10 ROS
Need 8 for PE
Prolonged Service = If spent >65 minutes
Critical Care Time >30 minutes

15. Prolonged Service

16. Why is it good?
“All criteria met - Total time in minutes, indication that time dominated visit by greater than 50% and substantiating details.”

18. “What's missing? Time is specified, but no indication that over 50% of visit was dominated by counseling/coordination of care. The details, by provider, is excellent though!”

19. DC Summary

22. DC Summary Components
Pro Fee – “Face-to-Face” and > or < 30 Minutes
Facility – Diagnosis and specificity

23. Take Away… H&P: History ROS – 10 Systems PE – 8 systems
PMHx, Fam Hx, Social Hx, Surgical Hx
If spent >100 min = Prolong Service
Specificity regarding diagnosis – evidence

24. Take Away… Progress Notes If >65 min = Prolonged Service
ROS 8 systems
PE 8 systems

25. All notes Be very specific regarding diagnosis – provide evidence
Accurately capture the severity of illness of your patient
Communicate patient care
Critical care time >30 minutes – for all notes
Use status for every diagnosis (acute, chronic, acute on chronic, improving, stable, worsening)
Use: suspected, likely, questionable, possible, still to be ruled out, probable

26. Thank you!