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

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power of the pen

Power of the Pen

Iyad G. Houshan. M.D.

Assistant Professor of Medicine

Chief, Division of Hospital Medicine

University of Nevada School of Medicine

icd 9 codes
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.
evaluation and management coding e m coding
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?
definitions
Definitions
  • ICD-9 : International Classification of Diseases. ( 250.00, 272.4,…)
  • CPT : Current Procedural Terminology
  • CMS : Centers for Medicare and Medicaid Services
definitions cont d
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.
definitions cont d7
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).

e m coding
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

e m coding cont d
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.
e m coding cont d10
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)
e m coding cont d11
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.
the game
The Game

Coding Level

Documentation

the game13
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

code qualifiers
Code Qualifiers

Each Code

Physical Exam

History

MDM

HPI

ROS

PMFSH

Risk

Data

Diagnosis

Elements in organ systems

medical decision making
*Medical decision Making*
  • It has three components: Risk, Data, and Diagnosis.
  • Remember complexity of MDM is the lowest of the two highest
slide16
*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.

slide17
*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

slide18
*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

slide19
*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

lowest

LOWEST

OF THE TWO HIGHEST

( new patient visits)

code qualifiers22
Code Qualifiers

Each Code

Physical Exam

History

MDM

HPI

ROS

PMFSH

Risk

Data

Diagnosis

Elements in organ systems

history
*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

lowest24

LOWEST

OF THE TWO HIGHEST

code qualifiers26
Code Qualifiers

Each Code

Physical Exam

History

MDM

HPI

ROS

PMFSH

Risk

Data

Diagnosis

Elements in organ systems

physical exam
*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
physical exam28
*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

lowest29

LOWEST

OF THE TWO HIGHEST

initial hospital visits
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

diagnosis driving payment
Diagnosis Driving Payment
  • ICD-9 codes

HTN

DM

COPD

CHF

Asthma

Emphysema

Parkinsons

And Afib. ( being treated, on coumadin)

legible

LEGIBLE

D o c u m e n t a t i o n

“ If you did not document it, it did not happen”

subsequent hospital visit
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

subsequent hospital visit36
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

subsequent hospital visit37
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.

subsequent hospital visit38
Subsequent Hospital Visit
  • You need 2 of the 3 components to meet the requirement of the level charged.