Risk Based Coding Physician Training - The Fox Group.pdf
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The presentation focuses on risk-based coding for physicians, detailing the three key elements of evaluation and management (E&M) coding: history, physical examination, and medical decision-making (MDM). It categorizes patient risk levels (minimal, low, moderate, high) and outlines their corresponding complexity in medical decision-making. Additionally, it addresses documentation standards, the importance of accurate diagnosis coding for reimbursement, and updates on billing practices for consultations.
Risk Based Coding Physician Training - The Fox Group.pdf
- 2. This presentation about documentation & coding is designed to take a complex issue and make it … • Logical • Meaningful • useful
- 3. What is Risk-Based E&M Coding? The three elements of E&M Coding Include: • History • Physical Examination • Medical Decision-Making The MDM is usually the ultimate determining factor for level of service. • The risk to the patient is a major component of MDM
- 4. Complexity of Medical Decision-Making Risk • Minimal • Low • Moderate • High Data • Minimal • Limited • Moderate • Extensive Diagnoses/Medical Management Options • Minimal • Limited • Multiple • Extensive
- 5. Risk?
- 6. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4 (extensive) High
- 7. Complexity of Medical Decision-Making Risk – Patients at High Risk include: • One or more chronic illnesses with severe exacerbations, progression, or side effects of treatment • Acute or chronic illnesses or injury that pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress • And needs diagnostic testing or procedural intervention Risk – Patients at Moderate Risk include: • One or more chronic illnesses with mild exacerbations, progression, or side effects of treatment • Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis, e.g. lump in breast • Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis • And needs diagnostic testing or procedural intervention
- 8. Complexity of Medical Decision-Making Risk – Patients at Low Risk include: • Two or more self-limited or minor problems • One stable chronic illness, e.g. well controlled hypertension or non- insulin dependent diabetes, cataract, BPH • Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain • And needs diagnostic testing or treatment, e.g., medications, rehab therapy Risk – Patients with Minimal Risk include: • One self-limited or minor problems, e.g. cold, insect bite, tinea corporis • And needs diagnostic testing, e.g., laboratory tests requiring venipuncture or treatment, e.g., rest, gargle
- 9. Data?
- 10. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4 (extensive) High
- 11. Complexity of Medical Decision-Making Data includes review of Clinical Information: • Clinical lab(s) (all labs = 1 pt.); • X-ray(s)(all imaging studies = 1 pt); • Decision to obtain old records (=1 pt); • Direct visualization/interpretation of study (= 1pt); • Other Medical diagnostic test(s)(=1pt); • Discussion of unexpected results with performing/interpreting physician (=1 pt). • 2 points for review and summary of old record from source other than patient
- 12. Complexity of Medical Decision-Making Data • Minimal……… 1 Data Element (1 point of Data) • Limited………..2 Data Elements (2 points of Data • Moderate……...3 Data Elements (3 points of Data • Extensive……… 4 or more Data Elements (at least 4 points of Data
- 13. DX / MGT?
- 14. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4 (extensive) High
- 15. Complexity of Medical Decision-Making Diagnoses/Medical Management Options • Minimal – one self-limited problem (existing or new) • Limited – more than presenting problem, well controlled, or a new problem not controlled or worsening • Multiple - a new problem, with no additional work-up planned or multiple diagnoses problems as described above • Extensive – a new problem with additional work-up planned, or multiple diagnoses/problems as described above
- 17. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4 (extensive) High
- 18. Complexity of Medical Decision-Making The MDM is usually the ultimate determining factor for level of service. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded. The level of the lower of the two highest components determines the level of MDM.
- 19. Some Examples
- 20. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4 (extensive) High
- 21. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward Low 2 (limited) 2 (limited) Low Moderate 3 (mod) 3 (multiple) Moderate High 4 (extensive) 4(extensive) High
- 22. Complexity of Medical Decision-Making RISK DATA DX/MGT COMPLEXITY MDM Minimal 1 (minimal) 1 (minimal) Straight- forward (99201-99202) Low 2 (limited) 2 (limited) Low (99203) Moderate 3 (mod) 3 (multiple) Moderate (99204) High 4 (extensive) 4 (extensive) High (99205)
- 23. Evaluation and Management Services… History – Chief complaint (CC); history of present illness HPI; systems review (ROS); past, family, and social history (PFSH) . Exam – Physical examination of the patient. Medical Decision Making – Diagnosis or management options; amount and/or complexity of data to be reviewed; risk of complications and/or morbidity or mortality.
- 24. History… Problem Focused – CC, and brief HPI or condition. Expanded Problem Focused – CC, brief HPI, and a problem-pertinent ROS. Detailed – CC, expanded HPI, a ROS, and pertinent PFSH. Comprehensive – CC, extended HPI, extended ROS, and complete PFSH.
- 25. Chief Complaint (CC)… Is a concise statement. . . usually in the patient’s own words or the patient’s primary caregiver’s (which could be a parent or the legal guardian to the patient) own words that . . . describes the symptoms, problems, conditions, diagnoses or other factors that explain the reason for the visit.
- 26. Chief Complaint (CC)… Sign, Symptom or Condition –“pain, shortness of breath, fever.” Management or Follow-up Visit – “management of diabetes & hypertension”, “Follow-up visit for dizziness” Request for Service - “Annual physical examination with complaints of weakness and malaise
- 27. History of Present Illnes Chronological history surrounding the present problem – must be described using: • Location • Quality • Severity • Duration • Timing • Context • Modifying Factor • Associated Signs & Symptoms
- 28. Review of Systems (ROS) levels… Problem Pertinent (1 system)- directly related to the patient’s problem. Extended (2-9 systems)- directly related to the patient’s problem identified in the HPI and limited number of additional systems. Comprehensive (10 or more systems)- directly related to the patient’s problem in the HPI plus all additional body systems.
- 29. Review of Systems (ROS)… A ROS obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The same documentation guidelines can be applied when re-recording a previously documented patient’s Past Family Social History (PFSH).
- 30. Review of Systems (ROS)… Example of confirming ROS statement by the physician: • The patient indicates that he has not experienced any of the symptoms on the ROS form. • The physician documents in the patient’s chart note “All systems were reviewed and were negative.” • The physician’s documentation of the patient’s ROS would now qualify as Comprehensive.
- 31. Past Medical, Family and Social History Patient’s Past Medical History • Prior illness, surgeries, medications (current or past) Family History • Hereditary diseases • Death of parents, siblings Social History • Smoking , alcohol, drug, caffeine consumption • Socio-economic concerns • Occupational History
- 33. Level of History HISTORY Problem Focused Expanded Problem Focused Detailed Comprehensive HPI Brief (1-3) Brief (1-3) Extended (4+) Extended (4+) ROS None (0) Problem Pertinent (1) Extended (2-9) Complete (10+) PFSH None (0) None (0) Pertinent (1) Complete (3)
- 34. Physical Examination (PE)… Comprehensive Exam- General multi- system exam Or, A complete exam of a single organ system
- 35. Body Systems/Areas • Eyes • Psych • ENMT • Hem/Lymph/Imm • Respiratory • Head, including Face • Cardiovascular • Neck • GI • Chest/breasts/axilla • GU • Abdomen • Musco • Genitalia/groin • Skin • Back • Neuro • Each Extremity
- 36. Physical Examination (PE)… System/Body Area Elements of Examination Constitutional *Any 3 of 7 VS *General appearance of patient (Nourishment, habits, deformities, grooming, etc.) Eyes *Conjunctiva & Eyelids *Pupils & Irises *Optic Disc ENMT *External Ears & Nose *EAC & TM *Hearing *OP *Lips Teeth & Gums *Nasal Mucosa, Septum , Turbinates Neck *Neck * Thyroid *Oropharynx Respiratory *Effort *Auscultation *Percussion *Palpation *Inspection of Chest with notation of symmetry and expansion Cardiovascular *Palpitations *Ausculation *Exam of peripheral vascular system by observation :Carotids , Abdominal aorta, FA, PP, Edema, Varicose
- 37. System/Body Area Elements of Examination Chest *Inspection of breasts *Palpation of breasts & Axilla Gastrointestinal *Masses, Tenderness * Examination of Liver & Spleen *Hernia *Anus , rectum Genitourinary *Male-Scrotal contents, Penis, PG *Female-Ext Genit,CX,Uterus Lymph *Palpation of Lymph Nodes in 2 or > areas-Neck , Axilla , Groin , Other Integumentary *Inspection & Palpation of Skin & Subcutaneous Tissues Neurology *Cranial Nerves *DTRs *Sensation Psychiatry *Orientation to Time/Person/Place *Memory *Mood & Affect Musculoskeletal *Gait & Station *Assessment of muscle strength & tone with notation of atrophy and abnormal movements *Inspection/Palpation of digits & nails Physical Examination (PE)…
- 38. Physical Examination (PE)… Problem Focused Exam – Limited exam of affected body area or organ system - 1 to 5 elements (out of 16) Expanded Problem Focused Exam – Limited exam of affected body area or organ system - at least 6 elements (out of 16) Detailed Exam- Extended examination of affected body area or organ system - at least 12 elements (out of 16) Comprehensive - Comprehensive Examination - at least 2 elements from 9 areas/systems
- 39. Requirements for 99204/205 4 –HPI (Location, Quality, Severity, Duration, etc.) 10 – Systems Reviewed 2 – PFSH Documented 2 of 9 PE – 2 elements of 9 systems Documented 4 – MDM (High Risk, 4 Data, 4 Options) Evident
- 40. ICD 9-CM Coding The CPT code or service is the driving force behind reimbursement, however, the ICD-9 CM Diagnosis Code must support the CPT code in order to be reimbursed. The system of diagnosis codes used is the International Classification of Disease (9th) revision, Clinical Modification. The primary diagnosis must support or justify the physician’s service. • For instance, the primary diagnosis by the consultant would be the reason for the physician visit • This diagnosis is not necessarily the admitting diagnosis.
- 41. ICD 9-CM Coding According to the ICD-9 Official Coding Guidelines a diagnosis can only be assigned when it is explicitly stated in the patient’s medical record. • Diagnoses codes must be documented and supported in the patient’s progress note for that date of service. • When the physician provides more than one diagnosis code, the physician is responsible for determining the primary diagnosis for the patient’s visit(s) • Diagnosis codes must be sequenced (1, 2, 3 and 4) as an important part of the billing process • It is unacceptable to carry over a diagnosis code from one encounter to another for billing purposes without restating the diagnosis in the current patient visit.
- 42. What about Consultations? Billing for Consultations vs. New Patient Visits •CMS is no longer accepting claims for consultations using CPT Code ranges 99241-99245 and 99251-99255 for •Other payors may still accept consultation codes- check with the payor.
- 43. What about Consultations? Inpatient Services to Medicare Patients • Bill services to a New Patient* using CPT Codes 99221-99223 once per admission. Add modifier AI if you are the principal physician of record. • Other services may be reported using Subsequent Hospital Care codes (99231-99233), including services to • complete the initial visit, • monitor progress, • revise recommendations, or • address a new problem. • * A New Patient is a patient neither you or any member of your Group (same tax ID# used for billing) have seen in the past three years.
- 44. What about Consultations? Outpatient Services to Medicare Patients • Bill services to a New Patient* using CPT Codes 99201-99205 for the first visit. • Other services may be reported using Established Patient codes (99211- 99215). • * A New Patient is a patient neither you or any member of your Group (same tax ID# used for billing) have seen in the past three years.
- 45. General Principles of Medical Records Documentation Complete and Legible Each encounter should include: • Reason/Chief Complaint • Relevant History • PE findings • Diagnostic Test results • Assessment/Diagnosis • Plan for care • Date of Service • Legible identity of the provider Progress, response to and changes in treatment and revision of diagnosis should be documented CPT & ICD 9 CM codes reported or the billing statement should be supported by documentation in the medical record
- 46. Course Complete!
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