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Case Presentation. Elad Bicer January 31, 2007. The signout…. 60 Female h/o COPD CC: SOB, Cough Sats 87%  intubated  tx for pnemonia. BP 105/60. Right femoral central line placed. 3L given past 3 hours. ICU screened in. Sounds good I say…. The Chart…. Not Billable!.

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Case presentation

Case Presentation

Elad Bicer

January 31, 2007

The signout

The signout…

  • 60 Female

  • h/o COPD

  • CC: SOB, Cough

  • Sats 87%  intubated  tx for pnemonia. BP 105/60. Right femoral central line placed. 3L given past 3 hours. ICU screened in.

  • Sounds good I say…

The chart

The Chart…

Not Billable!

D ocumentation for billing a brief tutorial for slr ed providers

Documentation for Billing A brief tutorial for SLR ED providers

Anthony Carrozza MD

Elad Bicer MD

Richard Lanoix MD

Patricia Carey MD

Dan Wiener MD

I m just a resident is this really necessary

I’m just a resident… is this really necessary?

  • Master the skills that will:

    • Increase your marketability

    • Improve your groups income

      • Improve staffing, equipment, better working environment

    • Improve your own income

Physician reimbursement 101

Physician Reimbursement 101

  • Documentation for reimbursement is the process of communicating the value of the medical care you provide.

  • The basic premise is simple:

    • Document what you thinkand what you do.



  • The goal of this tutorial is to teach you the process of documenting the value of your services.

  • The value of each patient encounter is conveyed via the CPT (Common Procedural Terminology) system.

  • The basic structure of the system and requirements for each CPT code will become clear shortly…

Cognitive payments

Cognitive payments

  • Your medical training has provided you the analytical tools for performing a complex decision making process

  • Furthermore, these “analytic tools” or decision-making capacity is what distinguishes you from all other members of the health care team

  • This “cognitive” effort has a lot of monetary value

Getting paid for thinking

Getting paid for thinking…

  • Now you need the tools to communicate your thinking according to the rules- the CPT guidelines.

  • Communicating your thinking/rationale in these terms allows the hospital to appropriately bill for your indispensable services.

The basic idea

The basic idea

  • The level of complexity of each patient encounter can be categorized into certain “levels”.

  • These levels take into account the:

    • Complexity of presenting problem

    • Complexity of diagnostic workup

    • Risk of Diagnostic workup

    • Risk of Treatment plan

The structure of cpt coding levels

The structure of CPT Coding Levels

  • Most of the value in Emergency Medicine is contained in five basic CPT codes.

  • Each correlates with an increasing complexity of service.

  • These codes are:

    • 99281- “Level 1”

    • 99282- “Level 2”

    • 99283- “Level 3”

    • 99284- “Level 4”

    • 99285- “Level 5”

Documentation requirements

Documentation Requirements

  • Each of these codes has specific documentation requirements.

  • It may seem overwhelming to memorize the requirements of each CPT code.

  • Learning a few basic points is all that is required to document correctly.

Coding vs billing

Coding vs. Billing

  • “Coding” in the context of this presentation, is the act of translating the written chart into CPT codes.

    • This is the responsibility of trained “coders”

  • These CPT codes are then used to generate a bill for the patient or third party payer.

Putting things into perspective

Putting things into perspective

Nation vs slr

Nation vs. SLR

  • Your patients are just as sick and you should document accordingly.

  • As a rough guideline, in the Main ED you will see:

    • 30% “Level 3”

    • 30% “Level 4”

    • 30% “Level 5”

    • 10% “Level 1, 2, and Critical Care”

Reality check

Reality Check

  • Coders have a superficial understanding of medicine

  • Communicate the complexity by:

    • Fulfilling basic documentation requirements

    • Documenting your decision making process

  • In the Land of Billing and Coding you get paid for what you have written, not for what you actually did.

Tips for this presentation

Tips for this presentation

  • Please do not be compelled to memorize the many details of this presentation.

  • This is mainly an overview to be used in conjunction with the “Quick Reference for Billing” cheat sheet

  • It is readily available in the ED during your shift.

Required items for every chart

Required items for every chart

  • 1- Name

  • 2 – CC

  • 3 – Linkage

  • 4 – Dx

  • 5 – Signatures

The chief complaint

The Chief Complaint

  • In order to write a clear HPI and make your life easier, the CC should be a symptom- NOT a diagnosis or event.

    • “SOB” instead of “Asthma”

    • “Back pain” instead of “MVC”

    • “R arm weakness” instead of R/O CVA

Past medical family social history

Past Medical, Family, Social History

  • These are three distinct elements of the chart, which are simply counted by the coder. You need:

    • 2 out of 3 elements for Level 5

    • 1 out of 3 for other levels

    • Example of 2 of 3 elements:

Ros requirements

ROS Requirements

  • According to CPT guidelines:

    • 10 ROS are needed for a Level 5 chart

    • 2 ROS for a Level 4 chart or lower

  • Note: The requirements are for categories of ROS, not individual ones. SOB and Cough are considered ONE ROS (respiratory).

Ros faq


  • What if I am unable to obtain the ROS for some reason?

    • There is a section above the ROS, which allows you to check the reason for not being able to obtain the ROS

    • Completing this section gives you credit for the ROS requirements of a level 5 chart

History of present illness

History of Present Illness

  • 4 Modifiers of the CC are required for Levels 4 and 5.

  • Since these codes are the majority of your charts, just try to make it a habit of documenting them first.

  • Modifiers include:

    • Timing, Duration, Intensity, Location, Quality, Aggravating/Alleviating factors, Associated symptoms, Context

How easy it is

How easy it is…

  • Example of chart with 8 modifiers:

  • Example of chart with 6 modifiers:



  • Document 4 modifiers for your main CC down on paper first, then continue with your narrative if that’s what you choose.

  • For billing purposes, the amount of writing is not as important as the content.

  • Tip: If you can’t get a sufficient HPI, state why :

    • “Unable to obtain additional Hx secondary to patients altered mental state, and other sources unavailable.”

    • You get credit for all 4 HPI elements!

Common pitfall too many complaints not enough modifiers

Common Pitfall- Too many complaints, not enough modifiers

  • 40 yo c/o mild Back pain for 2 days. Dysuria, mild x 2 days, assoc with vag discharge. Right leg pain, 7/10.

  • There are at least 3 complaints:

    • Back pain- 2 modifiers

    • Dysuria-3 modifiers

    • Leg pain- 2 modifiers

  • Solution: Pick the most relevant CC and go with it!

Physical exam

Physical Exam

  • There are 12 Physical Exam organ systems.

  • These are reflected by the 14 ROS systems minus endocrine and immunologic.

Physical exam requirements

Physical Exam Requirements

  • According to CPT guidelines,

    • Level 5 charts- 8 systems

    • Level 4 charts- 5 systems

    • Level 3 charts- 2 systems

  • Note: Only one PE finding is necessary for credit in one system, and stating “Normal” counts!

Example of all 12 pe elements

Example of all 12 PE Elements

  • Tip#1 You don’t need to write the category

  • Tip #2 You don’t have to state a finding. “Nml” counts.

Level 5 clause

Level 5 Clause

  • If for some reason, urgency prevented you from performing parts of the History and Physical- you can still get credit for a level 5 chart!

    • State - “Unable to perform PE secondary to treatment urgency”

      • Ie: active cpr, pt being wheeled to Cath Lab, etc.

Physical exam myth 1

Physical Exam Myth #1

  • “The physical exam needs to be written in categories, with each finding in the corresponding section.”

    • Ie. CVS- RRR, no M/R/G

  • Reality is that the physical exam can be written in paragraph or list form. It is the coder that decides which finding is included in each category.

    • Ie. RRR, PERRL, CTA, +BS = 4 systems

Medical decision making mdm

Medical Decision Making (MDM)

  • MDM reflects the complexity and severity of the patient encounter.

  • In order to accurately reflect MDM the chart should include:

    • Brief Differential Diagnosis

    • Diagnostic Plan

    • Treatment plan

    • Reassessment notes

High yield mdm documentation

High Yield MDM Documentation

  • Differential Diagnosis

    • Documenting the severe or life threatening possibilities strengthens your MDM.

  • Diagnostic Plan

    • Invasive modalities (LP, IV contrast) strengthen your MDM more than noninvasive procedures (Xray, EKG).

High yield documentation cont

High Yield Documentation cont…

  • Treatment plan

    • More complex treatment options results in higher MDM.

    • Document IV/IM meds, consults, prescriptions given, records reviewed, PMD spoken to.

  • Reassessment notes

    • These matter since they reflect the frequency of your attention to the patient.

Medical decision making components

Medical Decision Making Components

Procedure coding

Procedure Coding

  • Procedures are also represented by CPT codes.

  • Some are much more valuable than even the E/M level 5 code!

  • Therefore, it is important to document your actions as well as your thoughts.

Documenting your procedures

Documenting your procedures

  • The description of each procedure is best documented in steps and in the order they were performed.

  • The more descriptive you are, the better for both billing and medico-legal purposes.

Tips for common procedures

Tips for Common Procedures

  • Wound care

    • The length and complexity of the repair is probably the most important.

    • If you repaired it in layers, say it.

  • Fracture care

    • State if reduced

    • State the type of splint used

    • Document your neurovascular exam

Keep in mind

Keep in mind…

  • There are many procedures that we frequently do not document such as:

    • CPR

    • Nerve blocks

    • Procedural sedation

    • Slit lamp examination with corneal staining

  • EKG and Xray interpretations can be billed as procedures. Just write your findings and indicate “12 lead”.

Procedure note example

Procedure Note Example

  • “1% lidocaine injected locally. Wound irrigated, explored, debrided. 4-0 vicryl x 2 for deep sutures. 5-0 nylon in simple interrupted fashion. Total length 5.5 cm.”

  • “right ulnar gutter splint placed, cap refill <2sec no motor/sensory deficits”

The big picture

The BIG picture

  • Your thoughts (E/M level) and actions (Procedures) can result in multiple CPT codes for a single patient encounter

  • The aggregate value of these codes is reflected by your professional fee.

Back to our pt s chart

Back to our pt’s chart

  • NB due to name of resident

  • If name written: Billable 99283 with intubation (?)

What was missing you ask

What was missing you ask?

  • Level 5 Charting

  • Central Line placement

  • CC Note

  • Missed opportunity:

    • Any ideas?

Attending specific issues

Attending Specific Issues

  • Linkage statement

    • Check box “I examined the patient…”

    • Write: “I agree with resident note and plan”

  • Facility Charges

  • Critical Care billing!

Facility charges

Facility Charges

  • Each patient encounter not only generates a professional fee, but also a fee for the hospital.

  • This is called the Facility Fee.

  • Facility Fee reflects resources utilized during the delivery of care; i.e.:

    • Space occupied by patient

    • Nursing and support staff

    • Supplies

    • Utilities

Documentation for the facility fee

Documentation for the facility fee

  • Currently at our institution, documentation for the facility fee is a matter of checking boxes on the charge ticket.

Critical care the heart of em

Critical Care-The Heartof EM

  • Critical Care is the essence what we do as EP’s.

  • It is what distinguishes us from many specialties.

  • Competency in performing critical care medicine is extremely valuable.

  • Let’s see how to communicate that value…

What qualifies as critical care cc

What qualifies as Critical Care(CC)?

  • Critical Care is performed when there is a high probability of imminent or life threatening deterioration.

  • At SLR, this occurs on a more common basis than currently perceived.

  • Critical Care includes most…

    • medical activations.

    • trauma activations.

    • ICU screens.

Requirements for the cc note

Requirements for the CC note

  • Chief complaint

  • Course of events, justifying critical care.


    • This is the most important item.

    • CC must be at least 30 min to be billed.

  • CC has no history, ROS, or PE requirements.

Writing a cc chart

Writing a CC Chart

  • The CC note can be thought of as a procedure note.

  • Requirements for the CC CPT code does not include most details needed for E/M 1-5 codes

  • In fact, it takes more effort to write an E/M Level 5 chart than it does for a CC chart

  • Let’s see how easy it is…

Example note

Example Note

  • That’s it…

  • It’s simple

  • It pays

  • Tip: The resident note should support the CC note

Quick question 1

Quick Question #1

  • If I write a CC note, should I document for a level 5 chart?

    • Yes, technically your professional fee can include BOTH level 5 and CC billing.

    • CC is not just another level, you should think of it as a sort of procedure.

Quick question 2

Quick Question #2

  • How do I determine the amount of CC provided?

  • CC time includes:

  • CC time excludes time spent performing unbundled procedures.

Advanced billing

Advanced Billing

  • CPT codes can be translated into RVUs(Relative Value Units)

    • The more valuable the service the more RVUs

    • Eg. Level 1 (0.44) vs CC (5.48)

    • Eg. NG tube (0.49) vs. Shoulder dislocation (6.45)

  • The RVU is given a monetary value- this is determined by Medicare and the region that care is provided. In 2006 each RVU billed at ~$37.

Relevance of rvus

Relevance of RVUs

  • Some EDs track the productivity of physicians, not only by the number of patients seen per hour, but also by number of RVUs/hr

  • It becomes obvious that the better you document, the more RVUs you will generate- leading to more revenue for both you and your institution.

Congratulations it s over

Congratulations it’s over!

  • Total missed charges:

    • Level 5: $185.91

    • CC: $298.41

    • Central Line: $135.96

    • Intubation: $119.91

    • Total Missed Charges:

      • $740.19

      • If billed level 3 w/ intub, then: $551.62



  • Beyond Basics Seminar, 2005 reference book. Taught and compiled by James Blakeman of EM Seminars.


  • Medicare Resident & New Physician Training program, Facilitators guide. 7th Ed. Available from cms.

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