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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

    Billing coding documenting

    • 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
    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

    Author credit billing coding documentation david cheng md greg hall md
    Author Credit – Billing, coding, documentationDavid Cheng MD & Greg Hall MD


    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