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BILLING, CODING, DOCUMENTING. Type of Codes: Diagnosis Codes. ICD-9-CM (International Classification of Diseases)—codification of patient problems World Health Organization is author Establishes the medical necessity for visits and procedures

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type of codes diagnosis codes
Type of Codes: Diagnosis Codes
  • ICD-9-CM (International Classification of Diseases)—codification of patient problems
  • World Health Organization is author
  • Establishes the medical necessity for visits and procedures
  • The first diagnosis code is the primary reason/concern for the visit
types of codes cpt codes
Types of Codes: CPT Codes
  • CPT=Current Procedural Terminology
  • Codification of physician service
      • Evaluation & Management Level Codes
      • Procedures Codes
  • AMA is author
      • Developed by Physicians in 1966 for Billing Purposes
      • 7,500 Discrete Codes
  • 5 digit codes representing visits, procedures, and diagnostic studies
  • 2 digit modifiers are indicators why claim be paid
evaluation management levels e m
Evaluation & Management Levels (E/M)
  • 3 Key Components to an E/M Service Level
      • History (Hx) Level---Subjective
      • Examination (PE) Level---Objective
      • Medical Decision Making (MDM) Level—Assessment & Plan
  • E/M Level = Hx Level +PE Level+MDM Level
  • Levels indicate the wide variations in skill, time, effort and resources required to diagnose and treat an illness/injury
  • Levels are incremental
  • Specific level is referring to the last digit in each E/M service code
      • ie 99281 is referred to as a “ED Patient, level 1”
history component introduction
History Component Introduction
  • History level are determined by four elements

*Chief Complaint (CC)

*History of Present Illness (HPI)

*Review of Systems (ROS)

*Past, Family, and/or Social History (PFSH)

  • Can be completed by anyone i.e.; patient, family, medical student, PA, APN, resident
  • Must be reviewed by the attending physician
  • If unable to obtain information from the patient due to altered mental status, this must be indicated in the chart
  • Not all histories will need all elements
history component chief compliant
History Component: Chief Compliant
  • Concise statement describing the symptom, problem or condition for the patient visit
  • Compliant should be recorded in the patient’s own words
  • Chief Compliant forms the foundation for medical necessity
history component hpi
History Component: HPI
  • 8 elements of “History of Present Illness”
      • Location – Where the symptom or problem is occurring
      • Severity - A rating or description of severity of the symptom or pain
      • Timing – When symptom or pain occur
      • Quality – The character of the sign or symptom
      • Duration – How long a pain or symptom lasts, has been present, or persisted
      • Associated signs/symptoms – Any organ system or body area complaints associated with the chief complain
      • Context – Instances or items that can be associated with the chief compliant
      • Modifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse
  • Two Levels
      • Brief – 1-3 elements
      • Extended – 4 or more elements
history component ros
History Component: ROS
  • 14 systems
        • Constitutional symptoms (fever, weight loss, etc)
        • Eyes
        • Ears, nose, mouth, throat
        • Cardiovascular
        • Respiratory
        • Gastrointestinal
        • Genitourinary
        • Musculoskeletal
        • Integumentary (skin and/or breast)
        • Neurological
        • Psychiatric
        • Endocrine
        • Hematologic/Lymphatic
        • Allergic/Immunologic
  • Number of systems reviewed & documented determines the level



*Complete---10 or more

  • Can’t just say ROS is negative or non-contributory
  • Must document pertinent positives & negatives
history component pfsh
History Component: PFSH
  • PFSH = Past hx + Family Hx +Social Hx


      • Medications, Surgeries
      • Allergies
      • Immunization status



      • Marital status, children,
      • Living situation, employment status
      • Tobacco, alcohol, recreational/illicit drugs
  • Two Levels

1) Pertinent-- 1 specific item from any of the 3 history areas

2) Complete--1 specific item from each of the 3 history areas

history level ucd chart


Location Severity Timing Modifying Factors

Quality Duration Context Associated Signs/SX




4 or more


Constitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/Lymph

Eyes Card/Vasc GI Neuro Allergy/Immune

Resp Musculo GU Psych All Others Neg










Past Medical History Family History Social History












History Level (UCD Chart)
  • History level is equal to the lowest Hx component documented in the record
examination component
Examination Component
  • Physical Exam Elements
          • Body Areas
          • Organ Systems
          • Cannot combine Body Areas and Organ Systems for Comprehensive Exam
  • Four Levels
      • Problem Focused—0-1
      • Expanded Problem Focused----2-4
      • Detailed ----5-7
      • Comprehensive-8 or more
  • Level of exam is determined by the number of body are 0r organ system that are examined & documented
  • Can’t just say complete physical exam is negative
examination level ucd chart

Body Areas:

Head/face chest, including breasts & axillae

Neck back, spine each extremity

genitalia, groin, buttocks abdomen





Organ Systems:

Constitutional ears, nose, mouth, throat

Eyes resp GI GU

Cardio skinneuro psych

Hem, lymph, immune musculo









Examination Level (UCD Chart)
medical decision making component
Medical Decision Making Component
  • Three Elements
          • Number of Diagnoses or Treatment Options
          • Amount and/or Complexity of Data to be Reviewed
          • Risk of Complication and/or Morbidity/Mortality
  • Two out of three elements must be met or exceeded to determine the level of MDM
  • Four Levels
      • Straightforward
      • Low Complexity
      • Moderate Complexity
      • High Complexity
overall e m level
Overall E/M Level
  • Overall E/M Level equal to lowest of three level (Hx, Exam, MDM)
critical care codes
Critical Care Codes
  • Time based code
  • Time is the actual time of the attending not fellow or resident
  • Critical care time less than 30 minutes duration is reported with E/M Code
  • Documenting w/ clock time interval is best
  • Relative Value Units (RVU)—”points” you generate by taking care of patients (your productivity)
  • RVUs are determined by 2 components:
      • Evaluation and Management Codes (E&M)
      • Procedures Codes
increasing rvu
Increasing RVU
  • Increase quality of documentation to achieve greater E&M codes per visit. (i.e. document more ROS, Physical Exam)
  • Increase number of procedures done and documented
      • Procedure RVU’s are addedto the E&M code
      • Providers can receive credit for procedures done by ancillary staff
        • Ie: ED physician assistant removes ear wax for conductive hearing loss E&M 99283 (RVU= 0.67) + ear wax removal (RVU = 0.61). TOTAL = 1.28 RVU
  • Increase number of patients seen per hour
documentation for billing
Documentation for billing
  • If the documentation does not justify the coding then payment is denied or reduced
  • It is not appropriate to upcode (bill a higher level of E/M when a lower level of service is warranted
      • Extensive write up (coding) for a minor problem
documentation for billing1
Documentation for billing
  • Understand that the physician is ultimately responsible for every claim, no matter who does the billing
  • Improper billing, even without intent to defraud is considered fraud
acceptable teaching physician documentation ucd
Acceptable Teaching Physician Documentation (UCD)
  • “I saw the patient with the resident and agree with the resident’s findings and plan we developed.”
  • “I saw and evaluated the patient. Discussed with the resident and agree with the resident’s findings and plan we developed as documented in the resident’s note.”
  • “See the resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans we developed as written.”
unacceptable teaching physician documentation ucd
Unacceptable Teaching Physician Documentation (UCD)
  • “Agree with above.”
  • “Rounded, Reviewed, Agree.”
  • “Discussed with resident.” “Agree.”
  • “Seen and Agree.”
  • “Patient seen and evaluated.”
  • A legible countersignature and/or identity alone does not meet State and Federal payer requirements
documenting do s and don ts
Documenting: Do’s and Don’ts
  • Every Chart should be “bulletproof”
  • Be absolutely objective & non-judgmental in your charting
      • Remember what you write today…You may be reading back in a courtroom some day
  • Don’t leave loose ends
      • Address all patient’s complaints
      • Justify your diagnosis, treatment & billing
      • Read nurse’s note and address discrepancies
documenting do s and don ts1
Documenting: Do’s and Don’ts
  • Think worst case scenario & provide documentation that you have considered it & ruled it out
  • Avoid dangerous words (ie malingering)
  • Discharge “Golden Rule Statements”

1-Return to ED immediately if worse or any other concerns

2-Follow up with “X” clinic/pvt md in “Y” hrs/days

  • Never alter the chart after the fact because the agency or attorney has already gotten the chart before you are notified of the suit or complaint
documenting do s don ts
Documenting: Do’s & Don’ts
  • Emergent procedures (life and death) or situations where the patient is not able to give consent & no legal substitute is present…document that the consent was not available, that the situation warranted the intervention, and thus that the consent was felt to be implied
  • If in doubt about whether or not to get informed consent, get informed consent
documenting do s don t
  • DON’T

*Delete material or destroy record

*Use correction take or fluid

*Make self-serving statements

*Be cavalier, sarcastic or inappropriate

*Use the record to “vent” even to defend yourself

documenting do s don t1
Documenting: Do’s & Don’t

“When finishing the encounter in the chart - review it and ask yourself how it will appear to a reviewing agency, an adverse or friendly attorney, and to nonmedical persons (a jury)”

Jorge Martinez MD-JD

postresidency tools of the trade cd
1) Career Planning – Garmel

2) Careers in Academic EM – Sokolove

3) Private Practice Career Options - Holliman

4) Fellowship/EM Organizations – Coates/Cheng

5) CV – Garmel

6) Interviewing – Garmel

7) Contracts for Emergency Physicians – Franks

8) Salary & Benefits – Hevia

9) Malpractice – Derse/Cheng

10) Clinical Teaching in the ED – Wald

11) Teaching Tips – Ankel

12) Mentoring - Ramundo

13) Negotiation – Ramundo

14) ABEM Certifications – Cheng

15) Patient Satisfaction – Cheng

16) Billing, Coding & Documenting – Cheng/Hall

17) Financial Planning – Hevia

18) Time Management – Promes

19) Balancing Work & Family – Promes & Datner

20) Physician Wellness & Burnout – Conrad /Wadman

21) Professionalism – Fredrick

22) Cases for professionalism & ethics – SAEM

23) Medical Directorship – Proctor

24) Academic Career Guide Chapter 1-8 – Nottingham

25) Academic career Guide Chapter 9-16 – Noeller

Postresidency Tools of the Trade CD