Coding for hospitalist
- 1. Healthcare IT EHR Fraud 99223's and 99233's
- 2. 2 most common EHR documentation practices used to commit fraud: 1. Copy and paste 2. Over-documentation/Up Coding
- 3. • Post payment reviews and audits are increasingly prevalent • Good documentation is the only defense for the physician • The auditor’s motto is “Not documented, not done!” In Today’s Regulatory Environment . . .
- 4. 99223 99222 99221 99220 99219 Initial Visit Codes INP - OUTP 99233 99232 99231 99226 99225 F/U Visit Codes INP - OUTP
- 5. it's not the quantity of documentation that matters, it's the quality.
- 6. 1995 vs. the 1997E/M Guidelines OPQRST (6 ELEMENTS) STATUS OF 3 CHRONIC CONDITIONS HPI PE general multi-system exam OR single organ system examinations (BULLET SYSTEM)
- 7. 99223 99222 99221 99220 99219 Initial Visit Codes Observation Inpatient Lowest level, $102 and is worth 1.92 RVUs. Moderate level, $138 and is worth 2.61 RVUs. Higuest level, $204 and is worth 3.86 RVUs. Moderate level, $102 and is worth 3.84 RVUs. Highest level, is worth 5.25 RVUs.
- 8. Level E/M Code History Physical exam MDM Time 1 99221 Detailed Detailed Low 30 2 99222 Comprehensive comprehensive Moderate 50 3 99223 Comprehensive comprehensive High 70 Level E/M Code History Physical exam MDM Time 1 99218 Detailed Detailed Low 30 2 99219 Comprehensive comprehensive Moderate 50 3 99220 Comprehensive comprehensive High 70 Observation Inpatient Initial Codes - All three key components are required
- 9. History CC HPI ROS PFMSH Detailed Comprehensive 4 HPI elements 1 1 4 HPI elements 10 Syst ROS2-9 Syst ROS 1 Complete
- 10. Physical Exam Detailed 12 bullets from any organ system Comprehensive At least 2 bullets from 9 organ systems (Bullet system) Constitutional (1 bullet for three vital signs) (1 bullet for general appearance) Eyes (1 bullet for inspection of conjunctivae and lids) (1 bullet for examination of pupils and irises) Ears, Nose, Mouth and Throat (1 bullet for external inspection of ears and nose) (1 bullet for examination of oropharynx) Neck (1 bullet for examination of neck) (1 bullet for examination of the thyroid) Respiratory (1 bullet for auscultation of lungs) (1 bullet for assessment of respiratory effort) Cardiovascular (1 bullet for auscultation of heart) (1 bullet for examination of extremities for edema or varicosities) Gastrointestinal (1 bullet for examination of the abdomen) (1 bullet for examination of liver and spleen) Lymphatic (1 bullet for examination of lymph nodes in neck) (1 bullet for examination of lymph nodes in extremities) Skin (1 bullet for inspection of skin and subcutaneous tissues) (1 bullet for palpation of skin and subcutaneous tissues) Psychiatric (1 bullet for description of patient’s judgment and insight) (1 bullet for brief assessment of mental status—orientation)
- 11. Example Comprehensive Vitals: 120/80, 88, 98.6 #1 General appearance: NAD, conversant #2 Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA #3 #4 HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate #5 #6 Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy #7 #8 Lungs: CTA, with normal respiratory effort and no intercostal retractions #9 #10 CV: RRR, no MRGs, no edema or varices #11 #12 Abdomen: Soft, non-tender; no masses or HSM #13 #14 Lymph nodes: No cervical or extremity lymphadenopathy #15 #16 Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules #17 #18 Psych: Appropriate affect, alert and oriented to person, place and time #19 #20 Example Detailed Vitals: 120/80, 88, 98 . #1 General appearance: NAD, conversant #2 Neck: FROM, supple #3 Lungs: Clear to auscultation #4 CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits #5 #6 Abdomen: Soft, non-tender; no masses or HSM #7 #8 Extremities: No peripheral edema or digital cyanosis #9 #10 Skin: no rash, lesions or ulcers #11 Psych: Alert and oriented to person, place and time #12 12 bullets from any organ system At least 2 bullets from 9 organ systems
- 12. MDM 2/3 OVERALL MDM PROBLEM POINTS DATA POINTS RISK LOW COMPLEXITY 2 2 LOW MEDIUM COMPLEXITY 3 3 MODERATE HIGH COMPLEXITY 4 4 HIGH
- 13. PROBLEM POINTS Established problem, stable or improving 1 Established problem, worsening 2 New problem, with no additional work-up planned (maximum of 1) 3 New problem, with additional work-up planned 4 Hypertension – Stable Hypothyroidism- Stable Atrial fibrillation with RVR- Uncontrolled COPD exacerbation- Uncontrolled Acute Hyponatremia- New Acute hypokalemia- New Acute respiratory failure Acute blood loss anemia
- 14. Data Reviewed Points Review or order clinical lab tests 1 Review or order radiology test (CXR, CT, MRI, Cartoid US, Doppler) 1 Review or order medicine test (PFTs, EKG,V/Q, cardiac echo or cath) 1 Discuss test with performing physician (radiologist, ER, GI) 1 Independent review of image, tracing, or specimen 2 Decision to obtain old records 1 Review and summation of old records 2
- 15. Risk Level Presenting Problems Diagnostic Procedures Management Low Risk •2 or more self-limited or minor problems •1 stable chronic illness •Acute uncomp injury or illness (cystitis) •PFTs, ABI, Echo •Non-cardiovascular imaging studies with contrast (barium enema) •Superficial needle biopsy •ABG •Skin biopsies •Over the counter drugs •Minor surgery, with no identified risk factors •Physical therapy •Occupational therapy •IV fluids, without additives Each Risk level Requires only ONE of these elements in ANY of the three categories listedRISK LEVEL CLINICAL EXAMPLE: 1. Patient with OA of the knees, severe pain, which is no longer controlled with tylenol. You examine the patient and switch to OTC ibuprofen. No labs are reviewed. Admit for PT eval OVERALL MDM PROBLEM POINTS DATA POINTS RISK LOW COMPLEXITY 2 2 LOW
- 16. Moderate Risk •1 or > chronic illness, with mild exacerbation, progression, or side effects of treatment •2 or > stable chronic illnesses •Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast •Acute illness, with systemic symptoms •Acute complicated injury, e.g., head injury, with brief loss of consciousness •Tests under stress (cardiac stress test) •Scopes without risk factors •Deep needle or incisional bx •Cardiac catheterization •Obtain fluid from body cavity, LP/thoracentesis •Minor surgery •Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors •Prescription drugs •Therapeutic nuclear medicine •IV fluids, with additives •Closed treatment of fracture Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for 5 days, found to be in mild respiratory distress due to COPD exacerbation, started on IV solumedrol and IV Ceftriaxone, his BP is stable OVERALL MDM PROBLEM POINTS DATA POINTS RISK MEDIUM COMPLEXITY 3 3 MODERATE
- 17. Risk Level Presenting Problems Diagnostic Procedures Management High Risk •1 or > chronic illness, with severe exacerbation or progression •Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, PE, severe respiratory distress, psychiatric illness, with potential threat to self or others, peritonitis, AKI •An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss •Cardiac catheterization with identified risk factors •Cardiac EP studies •Diagnostic endoscopies, with identified risk factors •Discography •Emergency Hemodyalisis •Elective major surgery (open, percutaneous, endoscopic) with risk factors •Emergency major surgery (open, laparoscopic) •Parenteral controlled substances (IV opioids) •Drug therapy requiring intensive monitoring for toxicity •Decision not to resuscitate, or to de-escalate care because of poor prognosis Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for 5 days, found to be acute respiratory failure due to COPD exacerbation, intubated, started on IV solumedrol and IV Ceftriaxone, his BP is stable, IV morphine for pain. CT angio to r/o PE pending. OVERALL MDM PROBLEM POINTS DATA POINTS RISK HIGH COMPLEXITY 4 4 HIGH
- 18. CC : Chest pain HPI : The patient is a 65 year old male who comes w the CC of sudden onset(1) chest pain, which began early this morning (2), described as “crushing”(3) and 9/10 intensity (4) PMH : GERD and hypertension FH . : Mother died at 78 of breast cancer, Father at 75 of CVA. SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years ROS : 10 point ROS reviewed and are negative except as noted in HPI Vitals: 120/80, 88, 98.6 (1) General appearance: NAD, conversant (2) Eyes: anicteric sclerae, moist conjunctivae; no lid-lag (3); PERRLA (4) HENT: Atraumatic (5), oropharynx clear with moist mucous membranes and no mucosal ulceration (6) Neck: Trachea midline; FROM, supple (7), no thyromegaly (8) or lymphadenopathy of neck area(9) Lungs: CTA(10), with normal respiratory effort and no intercostal retractions(11) CV: RRR, no MRGs (12), no pedal edema (13) Abdomen: Soft, non-tender(14); no masses or HSM (15) Extremities: No deformities or extremity lymphadenopathy (16) Skin: Normal temperature, turgor and texture; no rash, ulcers (17) or subcutaneous nodules (18) Psych: Appropriate affect,(19) alert and oriented to person, place and time (20) Plan: 1. Chest pain R/O ACS: Trop x3, lovenox 1mg/kg/BID, Morphine IV for pain, stress test and echo 2. Uncontrolled HTN: prn hydralazine, continue acei and metoprolol 3. Uncontrolled diabetes w hyperglycemia: glycemia protocol
- 19. Subsequent Visit Codes - 2/3 key components are required Level E/M Code History Physical exam MDM Time 1 99224 Focused Focused Low 15 2 99225 Expanded Expanded Moderate 25 3 99226 Detailed Detailed High 35 Level E/M Code History Physical exam MDM Time 1 99231 Focused Focused Low 15 2 99232 Expanded Expanded Moderate 25 3 99233 Detailed Detailed High 35 Observation Inpatient
- 20. Subjective ROS PFMSH 1-3 pt HPI No No HISTORY (Subjective and ROS) CC 1 Subsequent visits always follow up something from the day before or new events that occurred overnight 1 1-3 pt HPI 1 No 1 4 pt HPI Or Status 3 chronic/inactive prob 2-9 No
- 21. CC : Follow-up Shortness of breath S: Persistent SOB, severe intensity (1), associated to wheezing (2), not improving w RT TID (3), worse at night time (4) ROS General--Negative for fatigue, weight loss, anorexia Cardiovascular--Negative for CP, orthopnea, PND Endocrine--Negative for polyuria, polydipsia, cold intolerance
- 22. 1-5 bullets from At least 1 system Example Vitals: 120/80, 88, 98.6 General: NAD, conversant Lungs: CTA CV: RRR, no MRGs 99231 Focused exam 99232 Expanded exam Example Vitals: 120/80, 88, 98.6 General: NAD, conversant Lungs: Clear to auscultation CV: RRR, no MRGs Abdomen: Soft, nontender Extremities: No edema 6 bullets from 1> systems 99233 Detailed exam Example Vitals: 120/80, 88, 98.6 General: NAD, conversant Neck: FROM, supple Lungs: Clear to auscultation CV: RRR, no MRGs; normal carotid upstroke without bruits Abd: Soft, NTTP; no masses or HSM Extr: No edema or cyanosis Skin: no rash, lesions or ulcers Psych: AAOx3 12 bullets from any organ system
- 23. MDM 2/3 OVERALL MDM PROBLEM POINTS DATA POINTS RISK LOW COMPLEXITY 2 2 LOW MEDIUM COMPLEXITY 3 3 MODERATE HIGH COMPLEXITY 4 4 HIGH
- 24. CC : Follow-up Shortness of breath S: SOB overnight, severe, associated wheezing Hyponatremia noted in AM labs Persistent hyperglycemia in POCT Tolerating diet, afebrile ROS General--Negative for fatigue, weight loss, anorexia Cardiovascular--Negative for CP, orthopnea, PND Endocrine--Negative for polyuria, polydipsia Or 10 point ROS done and negative except for HPI Vitals: 120/80, 88, 98.6 General: NAD, conversant Neck: FROM, supple Lungs: +wheezing, mild resp distress CV: RRR, no MRGs; normal carotid upstroke without bruits Abd: Soft, NTTP; no masses or HSM Extr: No edema or cyanosis Skin: no rash, lesions or ulcers Psych: AAOx3 Valid Alternatives: 1. No acute distress 2. No acute events overnight Not valid Alternatives: 1. Doing well 2. In CT suit during my exam 3. much improved Plan: 2/3 MDM : 4 PP + 4 DR + HIGH RISK Acute Hypoxic resp Failure - uncontrolled Acute COPD exacerbation- worsening Hyponatremia – new Diabetes w hyperglycemia- Uncontrolled CT angio to rule out PE CXR independently reviewed w/o acute findings Continue IV solumedrol 125 BID, monitor for worsening hyperglycemia, delirium, Continue IV vancomycin and zosyn, monitor vanco through daily due to risk for toxicity Replace electrolytes as needed
- 25. Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is high. CPT code 99223 Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing to monitor. CPT code 99232 Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low, nephrology consulted, situation worsened from prior day. CPT code 99233 Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine started on floor, IV diuresis ongoing, discussed with consultants. CPT code 99233 Day 4 – Situation improves, renal function stabilizes with inotropic support and renal recommendations, breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few days. CPT code 99232 Not every day can be a 99233 day
Editor's Notes
- #3: 1. Copy and paste, by which a healthcare provider copies and pastes information from a patient's record multiple times, often failing to update the data or ensure accuracy, andover-documentation, which involves adding false or "irrelevant documentation to create the appearance of support for billing higher level services."
- #7: There are not too many differences between the 1995 and the 1997 guidelines and there are some similarities. Let’s discuss both of the guidelines now. Two major differences exist between the 1995 and 1997 E/M guidelines: HPI and the exam element. The following criteria are the same for the 1995 and 1997 E/M guidelines, including: The Review of Systems; Past, Family and Social History; and Medical Decision Making. eginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness (HPI) along with other elements from the 1995 guidelines to document an evaluation and management service.”