Power of the Pen

1. Power of the Pen Iyad G. Houshan. M.D. Assistant Professor of Medicine Chief, Division of Hospital Medicine University of Nevada School of Medicine

2. ICD-9 codes • 40 y.o. male with PMHx of 250.4, 272.4, 496, here for 491.21 exacerbation and possible 410. • How do you treat this patient? • 40 y.o. male with PMHx of DM ( renal manifestations), dyslipidemia, COPD, here for COPD exacerbation and possible MI.

3. Evaluation and Management Coding“E&M Coding” • Why I’m I here? • Can I pay some one to do that for me? • What is my incentive to learn this?

4. INCENTIVE

5. Definitions • ICD-9 : International Classification of Diseases. ( 250.00, 272.4,…) • CPT : Current Procedural Terminology • CMS : Centers for Medicare and Medicaid Services

6. Definitions, Cont’d • E&M codes, Like CPT codes are compromised of five digits. • E&M codes specifically begin with 99. • E&M subsequent numbers depend on the type of E&M.

7. Definitions, Cont’d • A level 1 ( last digit a 1) is the least • A level 2 ( last digit a 2) is greater • The highest code level will end in a 3 ( an inpatient hospital admission), or a 5 (Outpatient or consultations).

8. E&M Coding • Each individual code listed has three components that qualify physicians to work for the specific code: 1) History 2)Physical 3) medical decision making MDM

9. E&M coding, cont’d • To add a degree of confusion to our coding dilemma, there are actually two sets of the Federal Documentation Guidelines for Evaluation and Management Services.

10. E&M coding, cont’d • The original set , 1994, affected primarily the history component of the physician documentation • The second set, 1997, uses the same history segment but adds physical exam documentation guidelines, featuring the now infamous “bullet” points. • Best to use the 1997 guidelines. ( we use the 1994 guidelines)

11. E&M coding, cont’d • In the CPT book, when looking up a specific E&M code, the three listed qualifiers: History, Physical, and MDM are found • Physicians don’t think code first. • We think clinical matters, diagnoses, labs and tests, and history and physical. Taking care of the patients first before the codes.

12. The Game Coding Level Documentation

13. The Game Medical Necessity Coding Level Documentation Medicare will not pay for anything unless “Medical Necessity” is met Medical Necessity is not clinical at all it is financial term

14. Code Qualifiers Each Code Physical Exam History MDM HPI ROS PMFSH Risk Data Diagnosis Elements in organ systems

15. *Medical decision Making* • It has three components: Risk, Data, and Diagnosis. • Remember complexity of MDM is the lowest of the two highest

16. *MDM* • Risk: High: “Severe” exacerbation of chronic illness. Acute illness threatening life or lim, Abrupt change in neurological status, Ordering of CV angiography, endoscopy with risk factors, pt needs emergent major surgery, Parenteral controlled substances, DNR decision.

17. *MDM* • Risk Moderate: mild exacerbation, progression, 2 or more stable chronic illnesses, acute illness with systemic symptoms ( pyelonephritis, colitis,..), ordering of stress test, ednoscopy without risk factors, needle biopsy; pt needs elective major surgery, prescription drug management, IV fluids with additives

18. *MDM* • Data Review, order lab……………..1 point Review, order Radiology……..1 Point Other tests……………………..1 Point Obtaining old records…………1 Point Review and summary of old records………………….2 Points Indep. Interpretation of test….1 Point Discussion of unexpected result with interp doctor………1 Point MAX POINTS = 4

19. *MDM* • Diagnosis: # of new or chronic self limiting problems…………………Max 2 points Presenting problem improved, well controlled #_X1= Inadequate control, worsening #_X2 = New problem no work up……3 points New problem with work up planned.. 4 points MAX POINTS=4

20. LOWEST OF THE TWO HIGHEST ( new patient visits)

21. Complexity of MDM

22. Code Qualifiers Each Code Physical Exam History MDM HPI ROS PMFSH Risk Data Diagnosis Elements in organ systems

23. *History* • CC : “ why are you seeing this patient • HPI 1-3 elements= brief, 4 elements or comment on 3 chronic conditions= extended • PMFSH 1 of 3 categories=pertinent 3 of 3 categories=complete ● ROS= 1 problem pertinent 2-9 extended 10 complete

24. LOWEST OF THE TWO HIGHEST

25. *History*

26. Code Qualifiers Each Code Physical Exam History MDM HPI ROS PMFSH Risk Data Diagnosis Elements in organ systems

27. *Physical Exam* • Problem focused Examination: one to five elements in one or more systems • Extended Problem Focused Examination: exam of at least 6 elements in one or more systems • Detailed: for a general exam 2 elements in 6 organ systems or 12 elements in at least 2 organ system • Comprehensive: 2 elements in 9 organ systems

28. *Physical Exam* • Organ systems (14) -Eyes -Constitutional -Neck -E,N,Mouth,throat -Chest, including -CVS Breast and axilla -G.I. -Respiratory -Lymphatic -Genitalia,groin, -Skin Buttock -Psychiatric -Musculoskeletal -Neurologic

29. LOWEST OF THE TWO HIGHEST

30. Initial Hospital Visits • 99221 : Level I, Low Detailed or comprehensive history and exam, low complexity MDM • 99222 : Level II, Moderate Comprehensive history and exam, Moderate complexity MDM • 99223 : Level III, High Comprehensive history and exam, High complexity MDM

31. Why

32. Reimbursement $$$

33. Diagnosis Driving Payment • ICD-9 codes HTN DM COPD CHF Asthma Emphysema Parkinsons And Afib. ( being treated, on coumadin)

34. LEGIBLE D o c u m e n t a t i o n “ If you did not document it, it did not happen”

35. Subsequent Hospital Visit • level 1 ( 99221) Chief Complaint. Problem focused History ( 1-3 elements, No ROS, No PFSH required). Problem focused Exam ( body area related to problem). MDM straightforward or low complexity

36. Subsequent Hospital Visit • Level 2 ( 99232) Chief Complaint Expanded problem focused History ( 1-3 elements, 1 ROS, No PFSH required) Expanded Problem focused Exam ( 2-4 systems). MDM moderate complexity

37. Subsequent Hospital Visit • Level 3 ( 99233): Chief Complaint Detailed History ( 4 or more elements, 2-9 ROS, 1PFSH). Detailed Exam ( 5-7 systems). MDM high complexity.

38. Subsequent Hospital Visit • You need 2 of the 3 components to meet the requirement of the level charged.