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Coding and Billing for the Pediatric Hospitalist

2. Goals. Understand concepts/rulesCorrect coding = $$$$

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Coding and Billing for the Pediatric Hospitalist

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    1. 1 Coding and Billing for the Pediatric Hospitalist

    2. 2 Goals Understand concepts/rules Correct coding = $$$$ “Show ME the MONEY” Goal #1 Correct coding = compliance “But keep me out of jail” Goal #2 GOAL #3 M.I.S.S. (make it simple S…) “Senor”

    3. 3 Show Me CPT (Current Procedural Terminology) Codes More than 8,000 codes developed by AMA Official code set for electronic billing for CMS/insurance companies Translates work done by medical provider to the payer

    4. 4 Show Me Evaluation and Management Codes (RVUs) Observation Discharge (99217) (1.28) Observation Care (99218-99220) (1.28-2.99) Initial Hospital Care (99221-99223) (1.28-2.99) Subsequent Hospital Care (99231-99233) (0.64-1.51) Same day Admit/Discharge (99234-99236) Hospital Discharge (99238-99239) (1.28, 1.75) Outpatient Consult (99241-99245) Inpatient Consult (99251-99255) ER Visits (99281-99285)

    5. 5 Show Me RVUs (Relative Value Units) Translates work to $ amount $36.0666 per unit (2009) Payment based on Total RVUs (aka RBRVS) Work + Facility + Malpractice 1.28 + 0.46 + .05 = 1.79 ($64.56) for 99221 2.99 + 1.04 + .10 = 4.13 ($148.96) for 99223 Geographic variation conversion factor(CF)

    6. 6 Show Me Two main E/M guidelines (95 and 97) Either acceptable 95 more “friendly” System based 97 more subspecialty base System or specific organ based Difference is Exam www.cms.hhs.gov/medlearn/emdoc.asp

    7. 7 Show Me E/M service codes History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time History- HPI, ROS, PFSH Exam -History- HPI, ROS, PFSH Exam -

    8. 8 Show Me 4wk old with fever to 101. Admitted and discharged after 3 hospital days. E/M codes? a. 99222, 99231, 99238 b. Depends on the clinical case c. E/M codes, what’s that? d. Who cares, I’m salaried!!!!!

    9. 9 Show Me Initial Hospital Care (99221-99223) Examples from CPT 2009 99221 Mono with dehydration Cellulitis of foot requiring IV abx 99222 Fever, limp, and painful hip motion of 18 hours Acute asthma attack unresponsive to outpt tx 99223 High Fever and proptosis DKA with vomiting, fever, and tachypnea

    10. 10 Show Me Initial Hospital Care (99221-99223) IHC History Exam MDM (Time) 221 Detailed Detailed Straight/Low (30 min) 222 Comprehensive Detailed Moderate (50 min) Comprehensive Comprehensive High (70 min) Must meet all three for given level Obs admit (99218-99220), same day admit/discharge(99234-99235) uses same criteria

    11. 11 MISS (History Summary) History Levels HPI ROS PFSH Problem focused brief n/a n/a Expanded p.f. brief pro pert n/a Detailed extended extended pertinent Comprehensive extended complete compre

    12. 12 MISS (History) HPI Brief (1-3) Extended (>=4) Modifying Factors Context Quality Location Timing Duration Severity Associated Signs/symptoms

    13. 13 MISS (History) Review of Systems Problem Pertinent (1) Extended (2-9) Complete (>=10) Constitutional Musculoskeletal Eye Psych ENMT Integumentary (skin and/or breast) CV Endocrine Resp Neurologic GI Allergic/Immunologic GU Lymphatic/Hematologic

    14. 14 MISS (History) PFSH Pertinent (1 of 3) Comprehensive (2 of 3) Past History Medical, Surgical, Allergies, Medications, Immunologic Family History Pertinent family medical history Social Marital status/living arrangements, occupation, sexual history, education level, use of etoh, tobacco, drugs For comprehensive PFSH must have 3 of 3 for initial hospital care, initial observation care and consultations

    15. 15 MISS (History Summary) History Levels HPI ROS PFSH Problem focused 1-3(brief) n/a n/a Expanded p.f. 1-3(brief) 1(pro pert) n/a Detailed >=4(extend) 2-9(extend) 1 of 3(detail) Comprehensive >=4(extend) >=10(complete) 2 of 3(compre) For comprehensive PFSH must have 3 of 3 for initial hospital care, initial observation care and consultations

    16. 16 MISS (Exam) Exam – four levels Problem focused 1 “limited exam of affected body area” Expanded p.f. 2-4 (?) p.f. + “other symptomatic or related organ system” Detailed 5-7 (?) extended exam + “other symptomatic or related organ system” Comprehensive >=8 95 E/M guideline - does not delineated exact number Baylor compliance 2-7 for both exp p.f, detailed

    17. 17 MISS (Exam) Exam Organ systems Body area Constitutional Eyes Head including face ENMT Neck CV Chest Resp Abd GI Back GU Genitalia, groin, buttocks Musculoskeletal Each extremity Skin Neurologic Psychiatric Heme/lymph/immunologic

    18. 18 Show Me Initial Hospital Care 4 wk old with fever to 101 IHC HPI ROS PFSH Exam 99221 >=4 2-9 1 of 3 5-7(?) 99222 >=4 >=10 3 of 3 5-7(?) 99223 >=4 >=10 3 of 3 >=8 95 guidelines (no exact number delineated)

    19. 19 $$$$ Initial Hospital Care CC must be present HPI/PFSH/Exam Should not be a problem for comprehensive ROS ROS lacking in most “All other ROS negative” Psychiatric, Endocrine, Hematologic/Lymphatic Standardized HPI/PFSH/ROS/Exam form (see attachment) Don’t draw line Patient/parent questionnaire (see attachment)

    20. 20 Show Me Initial Hospital Care 4 wk old with fever to 101 IHC Hx/Exam MDM 99221 (1.79) no issue Straight/Low 99222 (2.97) no issue Moderate 99223 (4.13) no issue High

    21. 21 MISS (MDM) MDM (DRIVER) Four levels based on #DX/TX, Complexity, Risk

    22. 22 MISS (MDM) Number of #DX/Tx options Minimal, Limited, Multiple, Extensive Identified vs. unidentified problem Number and type of diagnostic tests/procedures Improving, resolving, worsening, or failing Consultations with other MDs

    23. 23 MISS (MDM) Amount of Data/Complexity None/Minimal, Limited, Moderate, Extensive Diagnostic test ordered or reviewed Review old records Hx from other than patient Discussions with MD who performed/interpreted initial test about contradictory or unexpected results Personal review of image tracing

    24. 24 MISS (MDM) RISK (See Handout) Minimal, Low, Moderate, High Presenting problem Diagnostic procedure ordered Management options selected Highest level determines risk

    25. 25 MISS (MDM)

    26. 26 MISS (MDM)

    27. 27 MISS (MDM)

    28. 28 MISS (MDM)

    29. 29 MISS (MDM) Initial Hospital Care (99221-99223) MDM #of Dx/TX Complexity Risk (2 of 3)

    30. 30 MISS Initial Hospital Care (99221-99223) Alternative MDM (used by coders/auditors) Point system # of Dx/TX options Self limited or minor 1 point Est. Problem, stable or improves 1 point Est. problem, worsening 2 points New problem, no additional w/u 3 points New problem, additional w/u 4 points Case = 3 or 4 points

    31. 31 $$$$ Initial Hospital Care (99221-99223) # of Diagnosis or Treatment options At least moderate complexity since the problem is new to the MD

    32. 32 MISS Initial Hospital Care (99221-99223) Complexity Review and/or order lab tests 1 point Review and/or order radiology test 1 point Review and/or order other test (EKG,etc) 1 point Discussion with initial MD of tests 1 point Review and summarize old records 2 points Obtain hx from other than patient 2 points Discussion of case with another MD 2 points Independent review of image, tracing etc 2 points Case = 1 point

    33. 33 Show Me Initial Hospital Care (99221-99223)

    34. 34 Show Me Initial Hospital Care (99221-99223)

    35. 35 Show Me Initial Hospital Care (99221-99223)

    36. 36 Show Me Initial Hospital Care (99221-99223)

    37. 37 Show Me Initial Hospital Care (99221-99223) MDM #of Dx/TX Complexity Risk (2 of 3)

    38. 38 Show Me Initial Hospital Care (99221-99223) 4 wk old with fever IHC History Exam MDM 221 (1.79) Detailed Detailed Straight/Low 222 (2.97) Compre Detailed Moderate (4.13) Compre Compre High E/M Code? 99222 (2.97) or 99223 (4.13)

    39. 39 $$$$ Initial Hospital Care (99221-99223) Time if >50% for counseling and/or coordination of care face to face then this becomes the PRIMARY component not the E/M documentation 99222 (2.97) by documentation but total time spent >= 70 min (>50% counseling/coordination of care) “80 min total. 45 min on counseling/coordination of care” MAY NOT qualify. “80 min total of which 45 minutes were used to discuss the current care of John in regards to abnormal lab results….” 99223 (4.13) instead of 99222 (2.97)

    40. 40 $$$$ Initial Hospital Care (99221-99223) Use benchmarks for comparison 99221 (1.79) 99222 (2.97) 992239 (4.13) Seattle 5% 61% 34% AAP SOHM Survey Av 1% 54% 44% TCH/BCM 1% 67% 31% MD1 2% 3% 95% MD2 6% 94% 0% MD3 0% 96% 4% Melzer et al Pediatrics July 2001;108:79-84

    41. 41 $$$$ Initial Hospital Care (99221-99223) Four D’s Document Coders/Compliance = Lawyers “If it’s not legible, it’s not documented” “If it’s not documented, it wasn’t done” Develop Templates HPI/ROS/PFSH/Exam Pt/parent questionnaire Discover Periodic audits/distribution Discuss Coders/Compliance the “gray areas”

    42. 42 $$$$ Initial Hospital Care (99221-99223) MD A (same group/billing ID) sees patient in the EC and then you admit the pt on the same day. Which CPT code/s are used? You IHC (99221-99223); MD A (nothing) Baylor Pediatric Dept (one billing ID) Me IHC (99221-99223); MD A (99281-99285) Patient was in observation and subsequently admitted the next day by same MD. Different MD? IHC 99221-99223 for both scenarios

    43. 43 Show Me Sub Hospital Care (99231-99233) Examples from CPT 2009 as guide 99231 “stable, and recovering or improving” Day three of meds for uncomplicated pneumonia Responding to IV abx for ear or sinus infection 99232 “responding inadequately to therapy or has developed minor complication” Unstable asthma complicated by pneumonia Bacterial meningitis on IV abx now with fever 99233 “unstable or has developed significant complication or new problem” Electrical burns to arm with ascending infection Pan sinusitis complicated by brain abscess and asthma not responding to current treatment.

    44. 44 Show Me Sub Hospital Care (99231-99233) SHC History Exam MDM (Time) 231 P. Focused P. Focused Straight/Low (15 min) 232 Exp. P.F Exp P.F. Moderate (25 min) 233 Detailed Detailed High (35 min) Must meet two of three for given level Inpatient F/U consult (99261-99265) uses same criteria

    45. 45 Show Me Sub Hospital Care (99231-99233) History/Exam HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations Family – health of parents/sibs/children, family members with disease realted to CC Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations Family – health of parents/sibs/children, family members with disease realted to CC Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic

    46. 46 MISS Sub Hospital Care (99231-99233) MDM # of Diagnosis or Treatment options Est. Problem, stable or improves 1 point Complexity Review and/or order lab tests 1 point Risk IV ABX therapy Moderate

    47. 47 Show Me Sub Hospital Care (99231-99233) MDM #of Dx/TX Complexity Risk (2 of 3)

    48. 48 Show Me Sub Hospital Care (99231-99233) 4 wk old with fever. IHC 99222 (2.97) or 99223 (4.13) SHC 99231 (0.89) or 99232 (1.47) How can it be 99232? “Responding inadequately” Persistent fever Level based on two of three

    49. 49 $$$$ Sub Hospital Care (99231-99233) Don’t abuse 99233 (2.09) Keep track of time with multiple visits on same day May be able to up code based on time Document properly

    50. 50 $$$$ Sub Hospital Care (99231-99233) Use benchmarks for comparison 99231 (0.89) 99232 (1.47) 99233 (2.09) Seattle 25% 66% 9% SOHM Survey 10% 67% 23% TCH/BCM 34% 59% 7% MD1 9% 87% 4% MD2 16% 22% 62% MD3 79% 20% 1% Melzer et al Pediatrics July 2001;108:79-84

    51. 51 Show Me Discharge (99238, 99239) Time based 99238 (1.47, 30 minutes or less) 99239 (2.09, >30 minutes) Includes PE, coordination of discharge, and discharge paperwork Speaking with referring PCP Prescriptions, written d/c summaries, referrals forms etc…. Discussion of care plans with patient/parent/caregiver etc…. DOES include time spent on dictations Mclam Today’s Hospitalist May 2004 p 2 (amended August 2005)

    52. 52 4 wk old with fever. IHC 99222 (2.97) or 99223 (4.13) SHC 99231 (0.89) or 99232 (1.47) Discharge 99238 (1.47) or 99239 (2.09) Show Me

    53. 53 Show Me PATH PATH – Physicians at Teaching Hospital Teaching physicians (TP) may bill for residents Personally provided the service Present during key or critical portions of the service that the resident performs Independently sees the patient and reviews the management plan with the resident Level of E/M derived by combining the residents and TP’s note. www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf

    54. 54 Show Me PATH PATH Scenario One TP sees patient without the resident. E/M guidelines as previously. Scenario Two Resident and TP sees the patient together “I was present with the 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.” (IHC) “I saw the patient with the resident and agree with the residents’ findings and plan.” (SHC) Scenario one Why bother having the resident there anywayScenario one Why bother having the resident there anyway

    55. 55 Show Me PATH PATH Scenario Three Resident sees the patient then TP follows. “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.” (IHC) “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.” (SHC)

    56. 56 $$$$ PATH Scenario One IF TP sees patient first and then the resident writes note “I performed a history and physical exam 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.” (IHC) “Hospital Day #__. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note. (SHC) If TP sees patient first “I performed a history and physical exam of the patient and discussed the management with the resident.” After the note is written by the resident “I have reviewed the resident’s note and agree with the documented findings and plan of care.”

    57. 57 $$$$ PATH TP must review notes written by resident and if disagrees then must document Pre-printed templates NOT ACCEPTABLE Not acceptable documentation “Agree with above” “Rounded, Reviewed, Agree” “Discussed with resident. Agree” “Seen and Agree” Etc…. Medical Students work – “worth slightly more than the paper its written on” Only limited to PFSH/ROS TP must document HPI/Exam/MDM

    58. 58 Show Me PATH Procedures TP must be present during “all critical and key portions of the procedure and be immediately available...” If procedure is < 5 minutes, must be present for the entire procedure What is the key portion for the LP Judgment call

    59. 59 Show Me NPP NPP (Non physician provider) Billing Same group practice Physician “provides ANY face to face portion of E/M encounter” in inpatient/outpatient/ED setting Physician or NPP UPIN/PIN number No face to face encounter Bill NPP UPIN/PIN number www.cms.hhs.gov/manuals/pm_trans/r178co.pdf

    60. 60 Show Me Prolonged Service Care Provisions for billing for time in excess for given E/M Face to Face 99354, 99355 (outpatient) 99356, 99357 (inpatient) Non Face to Face (reviewing chart, calling PMD etc…) 99358, 99359 May NOT be reimbursed 1st hour then subsequent 30 min increments Must use with other E/M codes Does not have to be continuous Must be documented No additional documentation accompanying bill required

    61. 61 Show Me Prolonged Service Care Example (time beyond defined E/M code) SHC 99232 (25 minutes) If total time spent - 25min = <30 min None 30-74 min 99354/356/358 75-104 min above + 99355/357/359 105-134 min above + 99355/357/359 x 2

    62. 62 $$$$ Prolonged Service Codes HD #2 4 wk old with fever. Spent 45 minutes explaining the plan of care to parents. On f/u visit, explained to GM same plan. Total time 80 minutes E/M code?

    63. 63 $$$$ Prolonged Service Codes Which SHC based on documentation? 99232 (25min)

    64. 64 $$$$ Prolonged Service Codes Did >50% occur face to face and used for coordination of care/counseling? YES – Then 99233 (35min) + then rest of 45 minutes use either 99356 (if face to face) or 99358 (if not face to face) NO – 99232 (25min) + 99358 (55 minutes)

    65. 65 Show Me Medical Team Conference Team Conference 99367 Time base 30 min or more Multidisciplinary Non face to face contact with patient/family May NOT be reimbursed Baylor compliance states “no dinero”

    66. 66 Show Me Consultations Family Physician asks you to consult on 4 wk old with fever to 101 admitted to his service for advice on treatment. E/M code?

    67. 67 Show Me Consultations Three types of consult Inpatient Consult (99251-99255) Outpatient Consult (99241-99245) Obs, ER, Clinic Confirmatory Consult (99271-99275) Family/patient request second opinion

    68. 68 Show Me Consultations Three Rs of consultation Request MD requesting consult must be documented Verbal or written but must be documented Reason Report Written or dictated

    69. 69 Show Me Inpatient Consult IC History Exam MDM (Time) 251 Prob. F. Prob. F. Straight (20 min) 252 Exp. P.F. Exp. P.F. Straight (40 min) 253 Detailed Detailed Low (55 min) 254 Compre Compre Moderate (80 min) 255 Compre Compre High (110 min) Must meet all three for given level Outpt consult (99241-99245) uses same criteria

    70. 70 Show Me Inpatient Consult HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations Family – health of parents/sibs/children, family members with disease realted to CC Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic HPI location , quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms ROS Constitutional, Eyes, Ear/nose/mouth/throat, CV, Respiratory, GI, GU, musculoskeletal, skin, neurological, psychiatric, endocrine, Hematologic/lymphatic, and Allergic/immunologic Past – current meds, allergies, prior illness/injury/surgery/hospitalizations, immunizations Family – health of parents/sibs/children, family members with disease realted to CC Social – current employment, occupational history, sexual history, drug/alcohol/tobacco use, marital status, education Exam Constitutional, Eyes, ENMT, CV, Resp, GI, GU, Musculoskeletal, Skin, Neurologic, Psych, Heme/lymphatic/immunologic

    71. 71 $$$$ Inpatient Consult Inpatient consult on 4 wk old with fever. E/M code? MDM = Mod or High 99254 or 99255

    72. 72 $$$$ Consultations Family MD asks you to assume care of the patient after the consult. E/M code? SHC 99231-99233

    73. 73 $$$$ Consultations Time may be factor if >50% face to face time is used for counseling/coordination of care Make MDM be the driver Four D’s (Document, Develop, Discover, Discuss)

    74. 74 $$$$ Consultations EC MD asks for consult for 4 wk old with fever to 101 after full SBI w/u is done. E/M code? MDM = Mod or High 99244 (3.65) or 99245 (4.83) if admitted to different MD or discharged by ED MD (OUTPT)

    75. 75 $$$$ Consultations EC MD sees same patient then ask for your consult. You subsequently admit to your service. E/M code? MDM = Mod or High IHC 99222-99223 (combine consult/admit)

    76. 76 $$$$ Consultations EC MD sees patient. Ask for your consult and you discharge the patient from the ER (Spanish speaking 100.1 not 101). E/M code? MDM = Mod or High 99204 or 99205 (outpt visit 3.59, 4.58) Scott Pediatric Coding Companion Issue 1 2004 99244 or 99245 (outpt consult 4.51, 5.85) Baylor Compliance

    77. 77 $$$$ Consultations Follow up visits on Consult Use SHC May not get billed if use same diagnosis as Primary MD

    78. 78 Show Me Observation To Obs or not to Obs, that is the question Doesn’t meet inpatient criteria “tweeners” Not sick enough to be admitted but too sick to be d/c’d from the EC Extended prolonged therapy from the EC Asthmatic on frequent b-agonist therapy Gastro with dehydration Diagnostic uncertainty Abd pain with negative U/S but persistent RLQ pain

    79. 79 Show Me Observation Two sets of E/M codes (classified as outpt) 99218-99220 Use if in Obs status on different calendar day from d/c Use 99217 for discharge on the second day 99234-99236 Use if Obs and d/c on the same calendar day Also used for same day admit/discharge Uses exact same E/M guidelines as IHC (99221-99223)

    80. 80 $$$$ Observation Status not a location Can be anywhere Must document Observation status Pre-printed forms (see handout) Time of admit to obs Observation note Diagnostic tests ordered Discharge criteria Ideally, have some hospital policy for which patient can be placed in Obs or admitted

    81. 81 $$$$ Observation EC MD sees patient in the ER. Hospitalist sees patient in Obs status and then d/c that day. E/M codes? Different group EC MD 99281-99285 Hospitalist 99234-99236 Same group Use 99234-99236 (EC/Obs combined) If D/C on different day then use 99218-99220 for Obs Day #1 and 99217 on Day #2

    82. 82 $$$$ Observation Hospitalist sees in EC and admits to Obs and then d/c. If same calendar day then 99234-99236 (EC/Obs combined) If different calendar day then 99218-99220 Day 1 (EC/Obs combined) and 99217 If from Obs to Admit on different day Then use 99218-99220 on day 1 and 99221-99223 (IHC) on the day of admit If same day, use only 99221-99223 (Obs/IHC combined) WWW.ACEP.org

    83. 83 $$$$ Observation Medicare If < 8 hours and same calendar day Only 99218-99220 If >8 but <24 and same calendar day 99234-99236 If two calendar day (no time restriction) Then both 99218-99220 and 99217 Same rules apply for inpatient admit

    84. 84 Show Me ER (99281-99285) 4 wk old with fever in the ER EC History Exam MDM 99281 (0.44) Prob. F. Prob. F. Straight 99282 (0.73) Exp. P.F. Exp. P.F. Low 99283 (1.64) Exp P.F. Exp P.F. Moderate 99284 (2.56) Detailed Detailed Moderate 99285 (4.0) Compre Compre High

    85. 85 Show Me EC (99281-99285) 4 wk old with fever in the ER

    86. 86 Show Me EC (99281-99285) MDM #of Dx/TX Complexity Risk (2 of 3)

    87. 87 Show Me EC (99281-99285) MDM # of Diagnosis or Treatment options New problem, additional w/u 4 points Complexity Review and/or order lab tests 1 point Review and/or order radiology test 1 point

    88. 88 Show Me EC (99281-99285) Risk (from table) Presenting Problem Mod (Acute illness with systemic symptoms…) High (Acute illness that pose a threat to life…) Diagnostic Procedure Mod (Fluid from body cavity…) Management Options Mod (IV fluids with additives) Case =Mod or High

    89. 89 Show Me EC (99281-99285) MDM #of Dx/TX Complexity Risk (2 of 3)

    90. 90 $$$$ EC (99281-99285) 4 wk old with Fever to 101 in ER. E/M Code? 99284 (2.56) or 99285 (4.0) Plus LP 62270 (4.97)

    91. 91 $$$$ EC (99281-99285) 4 wk old with fever in EC after evaluations by you is then admitted. E/M code? Admitted to you. IHC 99223 (4.13) + LP 62270 (4.97) (combine EC/IHC) Admitted to someone else (not your group) EC 99285 (4.0) + LP 62270 (4.97)

    92. 92 $$$$ EC (99281-99285) Admitted to Observation to you/group. IOC 99220 (4.13) + LP 62270 (4.97) Remember Four D’s (Document, Develop, Discover, Discuss)

    93. 93 Show Me Critical Care 4wk old with fever. Becomes septic after sign out and requires transfer to ICU after prolonged resuscitation. What do I bill?

    94. 94 Show Me Critical Care Delivery of Critical Care Service Injury/illness that impairs one or more vital organ with high probability of imminent or life threatening deterioration… Complex decision Not Location dependent (EC, ACU, ICU…) Time based Direct care Counseling and coordination of Care

    95. 95 Show Me Critical Care Critical Care Code 99291 1st Hour 99292 Subsequent 30 minutes

    96. 96 Show Me Critical Care

    97. 97 Show Me Critical Care 4wk old with fever. Becomes septic after sign out and requires transfer to ICU after prolonged resuscitation. What do I bill? How long did you spend? 2 hours total (99291 + 99292 x2)

    98. 98 $$$$ Critical Care Examples Asthmatics Bronchiolitis Gastro Document with time specified and what exactly was done. In addition to E/M code Can be multiple MDs (document properly)

    99. 99 $$$$ Critical Care Patient is now transferred from the ICU to your service. E/M code? IHC (99221 - 99223) plus prolonged service if applicable (Molteni Pediatric Coding Companion Issue 3 2004) SHC (99231 - 99233) with prolonged service codes (99356,99357) Baylor Compliance

    100. 100 Show Me Miscellaneous E/M Codes Sedation Same Physician 99143 (<5 yrs) first 30 min 99144 (>5 yrs) first 30 min 99145 additional 15 min Different Physician 99148 (<5yrs) first 30 min 99149 (>5 yrs) first 30 min 99150 additional 15 min

    101. 101 Summary Four D’s Document Coders/Auditors = Lawyers Write everything down Make it legible Develop Hx/Exam sheet Pt/parent questionnaire Super bill Discover Periodic audits/distribution Discuss Coders/compliance dept “Gray areas”

    102. 102 Resources CPT 2009 Your Billing/Coding Compliance officer CMS www.cms.hhs.gov AAP Coding for Pediatrics Pediatric Coding Companion Coding hotline (800-433-9016) or aapcoding@aap.org

    103. 103 Resources Society of Hospital Medicine www.hospitalmedicine.org American College of Emergency Physician www.acep.org Physician Practice www.physicianspractice.com Today’s Hospitalist www.todayshospital.com

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