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Briefing: COMPASS Simplified Coding Method. Date: 24 March 2010 Time: 0900–0950 . Partnership. AFMSA/SG6, OCIO AFMOA, Deputy Chief, Clinical Business & Analysis Division AFMOA, AF Chief Consultant for Preventive Medicine AFMOA, Medical Coder/Auditor AFMOA, Medical Coder/Auditor.

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briefing compass simplified coding method

Briefing: COMPASS Simplified Coding Method

Date: 24 March 2010

Time:0900–0950

partnership
Partnership

AFMSA/SG6, OCIO

AFMOA, Deputy Chief, Clinical Business & Analysis Division

AFMOA, AF Chief Consultant for Preventive Medicine

AFMOA, Medical Coder/Auditor

AFMOA, Medical Coder/Auditor

simplified e m coding
Simplified E&M Coding

E&M coding is complex

Providers need tools to quickly and accurately determine E&M coding

AHLTA coding calculator is unreliable and inaccurate

COMPASS coding method delivers simplified tools for accurate, rapid E&M coding

guidelines for e m coding
Guidelines for E&M Coding
  • There are 3 components of E&M coding
    • History
    • Physical exam
    • Medical Decision Making (MDM)
  • DoD guidelines mandate use of MDM in the determination of E&M coding
  • Established patients: Need 2 out of 3 components
  • New patients: Need all 3 components
established patients
Established Patients
  • Focus on History and MDM (2 of the 3)
  • History
    • All encounters should have a detailed history
    • “CC/ 4:2:1” = detailed history
      • Chief Complaint
      • 4 bullets for HPI “what, where, how bad, modifying factors”
      • 2 Review of Systems (ROS), 1 bullet from 2 systems
      • 1 Element from PMHx, PSHx, Family Hx, Medications
established patients mdm
Established Patients–MDM
  • A “Yes” response to any one of the items below gives a 99214 *

(Assuming CC/4:2:1)

    • 3 Established Problems Stable or Improving
    • 1 Established + 1 Established Worsening
    • 1 New Problem + Rx
    • Review and Summation of Old Note + Rx
    • Order Rad/ECG + Independent Review + Rx

*If the answer is “no” to all questions above, the code is a 99213 UNLESS the patient has 1. Only one problem which is self-limited/established stable AND 2. Minimal data review or minimal management (rest/Band-Aids, salt water gargles, etc.)- then it is a 99212

new patients
New Patients
  • All 3 elements required
  • History is detailed or comprehensive
    • CC/4:2:1 = detailed
    • CC/4:10:4 = comprehensive
      • Chief Complaint
      • 4 bullets for HPI “what, where, how bad, modifying factors”
      • 10 Review of Systems (ROS), 1 bullet from 10 systems
      • 4 Elements (Complete PMHx, PSHx, Family Hx, Rx)
  • Physical exam: determining bullets is challenging
    • 12 bullets in 2 systems or 2 bullets in 6+ systems = detailed
    • 2 bullets from EACH of 9 systems = comprehensive
  • MDM
new patient mdm
New Patient MDM
  • A “Yes” response to any one of the items below gives a 99203 *
    • 2 Established (problems) Stable or Improving
    • 1 Established Worsening + OTC med
    • 1 New Problem + OTC med
    • Review and Summation of Old Note + OTC med
    • Order Rad/ECG + Independent Review + OTC med

*Two assumptions: 1. Detailed History 2. Detailed Exam

  • A “Yes” response to any one of the items below gives a 99204*
    • 3 Established (problems) Stable or Improving
    • 1 Established + 1 Established Worsening
    • 1 New Problem (not self-limited or minor) + Rx
    • Review and Summation of Old Note + Rx
    • Order Rad/ECG + Independent Review + Rx

*Two assumptions: 1. Comprehensive History 2. Comprehensive Exam

when to trust ahlta
When to Trust AHLTA
  • Override coding calculator – see quick reference sheet
    • Override AHLTA for New and Established patients
  • You can trust AHLTA for
    • Coding based on time
      • Must document counseling and coordination time
    • Coding Preventive Health Visits