2015 user conference coding like a pro april 24, 2015 (ehr-120) presented by: susan j. kressly, md,...

2015 User Conference

Coding Like A Pro April 24, 2015 (EHR-120)

Presented by:

Susan J. Kressly, MD, FAAPMedical Director

EHR Workshop

2015 Office Practicum User Conference

Learning Objectives

▪Review CMS criteria for coding level decisions

▪Understand the basis of OP’s coding decision support

▪Learn the basis of E/M coding levels

▪ Identify key tips to assist in documentation to support intended coding level

▪Better coding for better payment!!!


Let’s Get To

It!


Test Patient Scenario

▪Choose a test patient▪Start a new encounter▪ Initially, you are going to pretend to be

the nurse/MA ▪Here for a bug bite▪No fever, right arm, yesterday, acute, mild, improving

▪She reviews the problem list, allergies, meds, PMH, Family History, Social History

▪Does a thorough Review of Systems▪Take a temperature (97.6), grabs a height/weight ……Saves the note and it’s your turn


Test Patient Scenario

▪You examine the child and the exam is normal except for a small papule on the right arm without induration, or surrounding hive, no evidence of infection

▪You choose the normal exam template and apply it


Test Patient Scenario Part 2

▪You elaborate on the skin findings (the only abnormal thing) including the palpation

▪You also want to include something about the wrist to note it’s normal: add M/S system

▪And note about reactive lymph nodes


What coding level did you get?

How did THAT happen?


Coding: Whose Responsibility?

▪The PROVIDER▪Legal responsibility to choose the

appropriate code▪ If audited/investigated provider who saw

the patient is ultimately responsible▪Only the PROVIDER knows if the

documentation and coding level is appropriate for the visit reason/complexity

▪Will be necessary to support ICD-10 diagnosis coding


Coding Decision Support


Brief Look at the OP Coding Calculator

▪Always “suggests” a code based on documentation that is “countable”

▪Free text in other sections cannot be counted by computer but user can manually account for on calculator

▪Can add manual entry of the top 2 sections IF you check coding count override box and will be so stated in audit note


CMS 1997 Coding Guidelines

▪OP uses to suggest coding level

▪Some say are less “pediatric friendly” than the 1995 guidelines

▪1995 guidelines are more difficult for computers to “count” bullets


Problem Drive Documentation

▪Should a visit for a diaper rash be a 99212, 99213 or 99214?

▪All 3 may be appropriate depending on the details of the situation

99212?99213?

Or99214?


Diaper Rash 99212

Healthy 6 month old, presents with “diaper rash” in the AM for the past few weeks since she has been sleeping through the night. Mom reports it looks “much better” by lunchtime.

Diaper Rash 99212


Diaper Rash 99213

Healthy 15 month old presents with red, bumpy diaper rash since finished antibiotics for OM last week.

Diaper Rash 99213


Diaper Rash 99214

8 month old who presents with worsening diaper rash for 3 weeks. Cursory look at chart shows the patient has been on antibiotics 4 times this winter, and weight is at the 7%ile although tracking along the bottom of the curve.


Diaper Rash 99214


Diaper Rash 99214

▪Can automatically include Past Medical History if check “pertinent” item

▪Can automatically include Social History if check a “pertinent” item


Diaper Rash 99214

▪Can manually check if comment/text elsewhere


Diaper Rash 99214


Diaper Rash 99214

▪Assessment/Plan should document provider thinking

▪Critically important to include if E/M coding seems “out of line” with diagnosis


Medical Decision Making

▪Cannot be calculated by computer▪Must always be manually chosen▪Assessment/Plan documentation should

support reason for choosing MDM level



▪ IF you want the MDM coding level to show up on audit note, must check “coding override” check box



▪Audit notes now automatically composed and saved with the notes

▪Contain details of visit & coding calculator support


Let’s Try It!


Case Study : URI

Healthy 8 year old, no medical issues, afebrile, runny nose, congestion, history of low grade fever. Dx: simple URI

What’s your coding level?

What should it be based on healthy patient, presenting complaint?


Case Study: URI

What if that same 8 year old has asthma but is not wheezing?

What is your coding level?

What should it be?


Case Study: URI

What about a 5 month old with runny nose, congestion, fever and cough.

Does this change your level of complexity/coding?

How would you make sure you support the documentation?


Same Day Well and Sick

▪Must have “separately identified” reason for the additional sick

▪Should ask yourself: is this service medically necessary?



▪Can be an acute problem▪Should have been something that patient would have been seen for even if not in for well visit

▪Examples: otitis media, bronchiolitis, poison ivy dermatitis



▪Can be a chronic problem that you review and change/consider changing management▪Would have been a visit on it’s own, but for family convenience are doing at the same time as well

▪Examples: asthma, ADHD, anxiety, encopresis



▪Start with the well▪May want to make reference in HPI to

additional encounter

▪Save visit: critical for coding calculator to understand well + sick when start the sick



▪Use the “add encounter button” in A/P plan of well visit



▪Best Practices:▪Document exam on well visit (including pertinent abnormals)

▪Do not want to have conflicting exam elements (normal on well visit and abnormal on sick)

▪Cannot count an exam twice for purposes of level of E/M visit

▪Change HPI in sick visit



▪Best Practices:▪If using sick templates

do not include exam

▪Consider notation in exam for sick

uncheck exam box



▪Coding Decision Support▪Adds -25 modifier to indicate “separately identifiable service”▪Automatically removes History from countable elements (full history review is inherent part of a well visit)

▪Automatically removes Exam elements (comprehensive exam is inherent part of a well visit)

▪Will notice that the sick is lower than if stood alone▪Unless code based on time


Coding Based on Time

▪Counseling or Coordination of Care▪Must represent > 50% of time of visit▪Leave no doubt……document,

document, document▪Specific spent “x” minutes face to face with patient/parent ….

▪“counseling on issues related to depression/anxiety” with overview of details (do not need to transcribe visit)

▪“coordinating care with pulmonologist who we conferenced on phone while family in office”


“Typical” Time

▪ If > half way to the next code, may “round up”

Rounding Rules for Time-Based Coding

Modifiers


Key Modifiers

▪ -25: separate E/M, same day/same provider

▪ -59: distinct procedural service▪ -33: preventive care

▪Important because with ACA plans means payers cannot cost-shift to family▪Is not recognized by most Medicaid Plans

▪ -76: repeated procedural service▪Useful for repeat nebulizer treatments same day ▪Units is supposed to be for per service performed (2 units of J code for ceftriaxone)

▪ -50: bilateral procedure ▪Such as cerumen removal▪NOT all payers recognize/allow


Procedure Templates

Treatment of Wart


Resources

▪AAP Coding Resources

▪CMS Outreach Education for E/M coding

▪AAFP: Time is of the Essence: Coding on the Basis of Time for Physician Services

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf



http://www.aafp.org/fpm/2003/0600/p27.html






Questions?


We want your feedback!

Handouts:Coding Like a Pro – Coding MDM

Coding Like a Pro – Side 1Coding Like a Pro – Slide 2

2015 user conference coding like a pro april 24, 2015 (ehr-120) presented by: susan j. kressly, md,...

Documents