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					Coding and
Documentation
Compliance Training


Emergency Medicine Physicians
UNC Chapel Hill School of Medicine
Purpose of this course

   To assure appropriate billing through
    knowledge of guiding principles

   To build confidence in documenting
    evaluation and management (E&M)
    services for accurate coding and
    reimbursement


                             UNC School of Medicine Compliance
Compliance Office’s Role
   Develop and assure adherence to faculty
    practice’s Compliance Plan
   Faculty, resident, nurse practitioner and staff
    education
   Medical record reviews (primarily physician-
    directed billing)
   Responses to audit requests from external
    agencies
   Investigate and resolve potential breaches in
    the Compliance Plan
   Research compliance-related issues
                                  UNC School of Medicine Compliance
Billing Professional Services

   Every billed service is assigned codes used
    for reimbursement, statistics, research and
    other purposes


   The complexity of the patient condition, as
    documented in the physician note, drives the
    level of evaluation and management service
    delivered, recorded and billed.


                                  UNC School of Medicine Compliance
Billing Professional Services

   A UNC Physicians & Associates coder assigns
    codes for Emergency Medicine physicians
    based on the content of their notes.


   With the exception of the review of systems
    and past, family and social history, the medical
    student’s documentation may not be used or
    referenced in the physician note.


                                    UNC School of Medicine Compliance
Coding Systems

   Diagnosis
     International Classification of Diseases (ICD-9CM)
     World Health Organization
   Procedure
     Current Procedure Terminology (CPT)
     American Medical Association
   Supplemental supply and procedure codes
     Healthcare Common Procedure Coding System
      (HCPCS)
     Federal government—but used by many payers


                                     UNC School of Medicine Compliance
Medical necessity


   Only services that are medically
    necessary are billable

   Necessity for the work performed
    must be established in the
    physician’s note



                             UNC School of Medicine Compliance
Reimbursement

   Based upon the effort required to
    treat the individual at the time of
    presentation

   Five levels of evaluation and
    management (E&M) services are
    designated for emergency
    department use

                              UNC School of Medicine Compliance
E&M Services Allowables
Emergency Department Codes



ED E&Ms    Medicaid   Medicare         BCBS/SHP

  99281     $ 15.34    $ 16.13           $ 46.55

  99282       25.39      26.69               58.35

  99283       57.04      59.98               98.80

  99284       89.08      93.68             168.44

  99285      139.45     146.65             231.04
                             UNC School of Medicine Compliance
E&M Services Allowables
Critical Care Codes



 Critical
              Medicaid   Medicare        BCBS/SHP
  Care

  99291
 (first 30-   $ 191.12   $ 200.93            $ 332.69
 74 min)

  99292
(ea. add’l       95.62     100.78               188.10
 30 min)

                               UNC School of Medicine Compliance
E&M code is determined by


1. Demonstration of medical necessity

2. Documentation of decision making
   complexity

3. Detail of history and physical exam
   included in the note

                          UNC School of Medicine Compliance
Critical care
   When injury or illness acutely impairs one
    or more vital organ systems such that
    there is a probability of imminent or life-
    threatening deterioration

   Document system failure and the decision-
    making required to assess, manipulate
    and support vital system functions

   Record the amount of time spent
    providing critical care to the patient
                                 UNC School of Medicine Compliance
Five Emergency Department
visit levels

   Medical decision making documentation
    is the key to selection of the code level

   Understanding how decision making is
    evaluated will help improve your
    documentation



                             UNC School of Medicine Compliance
     Medical Decision Making (MDM)
     Recording complexity and effort

Based on 2 of these 3 components:
(detailed on the following 3 pages)

    1.   Number of diagnostic and/or
         management options

    2.   Amount and complexity of data

    3.   Risk of the illness, injury or treatment


                                      UNC School of Medicine Compliance
Recording your medical
decision making
           Medical Decision Making
            1. Diagnostic & Management Options
1 point       Self-limited, minor

1 pt. ea      Established problem, stable or improved

2 pts. ea     Established problem worsening

3 points      New problem, no additional workup planned

4 ea          New problem, additional workup planned

           Total (maximum of 4 points)

                                         UNC School of Medicine Compliance
           Medical Decision Making
            2. Amount and Complexity of Data
1 point for    Review/order of 1)clinical lab 2) radiologic
each type
                 study 3)non-invasive diagnostic study
1 point        Discussion of diagnostic study w/interpreting
                 physician
2 points       Independent review of diagnostic study
1 point        Decision to obtain old records or get data from
                 source other than patient
2 points       Review/summary old med records or gathering
                 data from source other than patient
            Total (maximum of 4 points)
                                             UNC School of Medicine Compliance
     Medical Decision Making
        3. Risk

Choose highest bulleted item from any of the
following three areas (see risk table, next page)
to determine level of risk due to:

          Presenting problem

          Diagnostic procedures

          Management options

                                 UNC School of Medicine Compliance
  3.
 Risk Level
               Table of Risk
               Presenting Problem(s)
                                                      (To print: right click, choose “print,” then “current slide”)
                                                                   Diagnostic Procedure(s) Ordered                    Management Options Selected

               •One self-limited or minor problem, eg, cold,       •Laboratory tests requiring venipuncture           •Rest
               insect bite, tinea corporis                         •Chest x-rays                                      •Gargles
                                                                   •EKG/EEG                                           •Elastic bandages
Minimal (1)                                                        •Urinalysis                                        •Superficial dressings
                                                                   •Ultrasound, eg, echocardiography
                                                                   •KOH prep

               •Two or more self-limited or minor problems         •Physiologic tests not under stress, eg,           •Over-the-counter drugs
               •One stable chronic illness, eg, well               pulmonary function tests                           •Minor surgery with no identified risk
               controlled hypertension, non-insulin                •Non-cardiovascular imaging studies with           factors
               dependent diabetes, cataract, BPH                   contrast, eg, barium enema                         •Physical therapy
  Low (2)      •Acute uncomplicated illness or injury, eg,         •Superficial needle biopsies                       •Occupational therapy
               cystitis, allergic rhinitis, simple sprain          •Clinical laboratory tests requiring arterial      •IV fluids without additives
                                                                   puncture
                                                                   •Skin biopsies

               •One or more chronic illnesses with mild            •Diagnostic endoscopies with no identified risk    •Minor surgery with identified risk
               exacerbation, progression, or side effects of       factors                                            factors
               treatment                                           •Deep needle or incisional biopsy                  •Elective major surgery (open,
               •Two or more stable chronic illnesses               •Cardiovascular imaging studies with contrast      percutaneous or endoscopic) with no
               •Undiagnosed new problem with uncertain             and no identified risk factors, eg, arteriogram,   identified risk factors
               prognosis, eg, lump in breast                       cardiac catheterization                            •Prescription drug management
Moderate (3)
               •Acute illness with systemic symptoms, eg,          •Obtain fluid from body cavity, eg lumbar          •Therapeutic nuclear medicine
               pyelonephritis, pneumonitis, colitis                puncture, thoracentesis, culdocentesis             •IV fluids with additives
               •Acute complicated injury, eg, head injury                                                             •Closed treatment of fracture or
               with brief loss of consciousness                                                                       dislocation without manipulation

               •One or more chronic illnesses with severe          •Cardiovascular imaging studies with contrast      •Elective major surgery (open,
               exacerbation, progression, or side effects of       with identified risk factors                       percutaneous or endoscopic) with
               treatment                                           •Cardiac electrophysiological tests                identified risk factors
               •Acute or chronic illnesses or injuries that        •Diagnostic Endoscopies with identified risk       •Emergency major surgery (open,
               pose a threat to life or bodily function, eg,       factors                                            percutaneous or endoscopic)
               multiple trauma, acute MI, pulmonary                •Discography                                       •Parenteral controlled substances
  High (4)
               embolus, severe respiratory distress,                                                                  •Drug therapy requiring intensive
               progressive severe rheumatoid arthritis,                                                               monitoring for toxicity
               psychiatric illness with potential threat to self                                                      •Decision not to resuscitate or to de-
               or others, peritonitis, acute renal failure                                                            escalate care because of poor
               •An abrupt change in neurologic status, eg,                                                            prognosis
               seizure, TIA, weakness, sensory loss
                                                                                                               UNC School of Medicine Compliance
Medical Decision Making
Considerations

   The existence of co-morbidities and
    underlying diseases is not considered
    in selecting a level of E/M service
    unless their presence significantly
    increases the complexity of the
    medical decision making.

   If it does, document it. Don’t merely
    list it as an existing condition.

                            UNC School of Medicine Compliance
Medical Decision Making
Considerations


   Risk of the presenting problem is
    based on the risk related to the
    disease process anticipated
    between the present encounter and
    the recommended next inpatient or
    outpatient service by a physician



                           UNC School of Medicine Compliance
         MDM Calculation
Diag/.Mgmnt
                          0-1            2             3                  4
options
Amt/complexity
                          0-1            2             3                  4
of data
Overall risk            Minimal         Low       Moderate             High
Type of MDM            Strghtfwd       Low        Moderate             High
 E&M           MDM                             Definition
99281     Straightforward
99282           Low
99283        Moderate     Presenting problems are of moderate severity
99284        Moderate     Problem(s) are of high severity and require urgent
                            evaluation but do not pose an immediate, significant
                            threat to life or physiologic function
99285           High        Presenting problem(s) are of high severity and pose
                            an immediate threat to life or physiologic function
                                                    UNC School of Medicine Compliance
         MDM Calculation
Diag/.Mgmnt
                            0-1            2             3                  4
options
Amt/complexity
                            0-1            2             3                  4
of data
Overall risk              Minimal        Low        Moderate             High
Type of MDM             Strghtfwd        Low       Moderate              High
 E&M            MDM                             Definition
99281    Straightforward
99282          Low
99283       Moderate     Presenting problems are of moderate severity
                             Problem(s) are of high severity and require urgent
99284          Moderate      evaluation but do not pose an immediate, significant
                             threat to life or physiologic function
                             Presenting problem(s) are of high severity and pose
99285            High        an immediate threat to life or physiologic function
                                                      UNC School of Medicine Compliance
          Documentation requirements
The detail recorded in the history and exam generally follows
the complexity of the case. It is required that both the history
and exam meet at least these requirements.
  Level               History and Exam                          MDM

  99281             Problem focused (PF)                Straightforward

  99282       Expanded problem focused (EPF)                      Low

  99283       Expanded problem focused (EPF)                 Moderate

  99284                    Detailed                          Moderate

  99285                Comprehensive                             High
                                             UNC School of Medicine Compliance
Documenting the
history and exam
  The Four Levels of History & Exam
                History Components             Physical exam
E&M                                                                           Level
level     HPI        ROS        PFSH          („95 guidelines)
        Brief                               Limited exam of affected         Problem
99281                 NA          NA
                                            system or area
        (1-3)                                                                Focused
                                            Limited exam of affected
                    Pertinent                                               Expanded
        Brief                               system + other
99282               (at least     NA                                        Problem
        (1-3)                               symptomatic or related
                    one)                                                    Focused
                                            systems/areas
                                            Limited exam of affected
                    Pertinent                                               Expanded
        Brief                               system + other
99283               (at least     NA                                        Problem
        (1-3)                               symptomatic or related
                    one)                                                    Focused
                                            systems/areas

                    Extended    Pertinent   Extended exam of
        Extended
99284                                       affected area+other              Detailed
        (4+)        (2-9)       (1 of 3)    symptomatic…
                                            8 or more systems
        Extended    Complete    Complete    documented or a
99285                                                                   Comprehensive
        (4+)        (10-14)     (3 of 3)    complete exam of a
                                            single organ system
                                                          UNC School of Medicine Compliance
 The History
History of Present Illness
     Location        Timing                           Brief = 1-3 elements,
     Quality         Context
                                                        Extended = 4+ or review of 3
     Severity        Modifying factors
                                                        chronic or inactive conditions
     Duration        Associated signs & symptoms
Review of Systems
     Constitutional symptoms        Musculoskeletal
     Eyes                           Integumentary (skin/breast)
                                                                         Pertinent = <2
     Ears, Nose, Mouth, Throat      Neurological
     Cardiovascular                 Psychiatric                        Extended = 2-9
     Respiratory                    Endocrine
                                                                         Complete = 10-14 or
     Gastrointestinal               Hematologic/lymphatic
                                                                         “all others negative”
     Genitourinary                  Allergic/immunologic

Past, Family and Social History
       Past                                Social
     Current Medications              Living arrangements
     Prior illnesses/injuries         Marital status
     Dietary status                   Sexual history                     Pertinent = 1 of 3
     Operations/hospitalizations      Occupational history               areas
     Allergies                        Use of drugs/tobacco/alcohol
                                       Extent of education                Complete = 3 of 3
     Immunizations                                                        (2 of 3 for estab.)
                                       Current employment
        Family                         Other
     Health status/cause of death of parent, sibling, children
     Diseases related to chief complaint, HPI, ROS
     Hereditary or high risk diseases
                                                               UNC School of Medicine Compliance
The History
   Anyone, including students or the patient himself,
    may collect the review of systems and past, family
    and social history, however, the physician note
    must refer to reviewing those aspects of history to
    establish the use of those elements in the care of
    the patient.

   The physician must personally document the
    history of the present illness even if it appears in
    other providers’ notes.



                                      UNC School of Medicine Compliance
    The Physical Exam
   A general multi-system examination or a single organ system
    may be performed by any physician regardless of specialty.

   The type (general multi-system or single organ system) and
    content of examination are selected by the examining
    physician.

   Note specific abnormal & relevant negative findings of the
    affected or symptomatic area(s)--“abnormal” is insufficient.

   Describe abnormal or unexpected findings of asymptomatic
    areas or systems.

   Noting “negative” or “normal” is sufficient to document normal
    findings in unaffected areas.

                                            UNC School of Medicine Compliance
        Examples of presentations at
        various levels
99281      patient with several uncomplicated insect bites.


           a 20-year-old student who presents with a painful
99282
            sunburn with blister formation on the back.


99283      a well-appearing 8-year-old who has a fever,
            diarrhea and abdominal cramps, is tolerating oral
            fluids and is not vomiting
99283      a sexually active female complaining of vaginal
            discharge who is afebrile and denies experiencing
            abdominal or back pain
                                           UNC School of Medicine Compliance
        Examples of presentations at
        various levels

99284      an elderly female who has fallen and is now
            complaining of pain in her right hip and is unable
            to walk.
99284      a patient with flank pain and hematuria


99285      a patient with a new onset of rapid heart rate
            requiring IV drugs

99285      a patient who presents with a sudden onset of
            "the worst headache of her life," and complains of
            a stiff neck, nausea, and inability to concentrate
                                            UNC School of Medicine Compliance
Medicare Teaching
Physician Regulations
The Medicare program’s
perspective on residents

   Resident services to Medicare beneficiaries
    are paid to the hospital through Part A based
    on the proportionate share of Medicare at the
    teaching hospital

   Teaching physicians are paid by Part B
    Medicare on a fee-for-service basis only when
    they provide a personal, face-to-face
    service in addition to the resident


                                 UNC School of Medicine Compliance
Proper Teaching Physician (TP)
Documentation for Medicare
   The resident note alone, the TP note alone or a
    combination of the two may be used to support
    the level of service billed.
   Documentation by a resident or any other party
    of the presence and participation of the TP is
    not sufficient (except in cases of some procedures
    in which the teaching physician is present for the
    entire time--never for ED visit services)
   Documentation may be dictated and typed,
    hand-written or computer-generated.

                                     UNC School of Medicine Compliance
        Medicare requires attestation of
        teaching physician involvement
For Emergency Department evaluation and
management services:

           That the teaching physician performed the
            service or was physically present during the
            key or critical portions of all three
            components: history, exam and decision
            making; and

           The participation of the teaching physician in
            the management of the patient.
                                          UNC School of Medicine Compliance
Examples of Acceptable
Teaching Physician Notes

   "I performed a history and physical examination
    of the patient and discussed his management
    with the resident. I reviewed the resident's note
    and agree with the documented findings and
    plan of care."

   "I was present with resident during the history
    and exam. I discussed the case with the
    resident and agree with the findings and plan as
    documented in the resident's note.

                                     UNC School of Medicine Compliance
Examples of Unacceptable
Teaching Physician Notes

   "Seen and agree." followed by legible
    countersignature or identity;

   "Patient seen and evaluated." followed by
    legible countersignature or identity; and

   A legible countersignature or identity alone.




                                     UNC School of Medicine Compliance
Procedures
   Minor procedures of <5 minutes
        TP must be present the entire time
   Surgical procedures
        TP must be present for the key portions and
         state those portions in the attestation
        In operating suite available to return
   Two overlapping procedures
        Key portions must happen at different times
        Must be available to return to either or
         designate another TP

                                      UNC School of Medicine Compliance
    Time-based services
   Time-based procedures may be billed to
    Medicare on teaching physician time only.
    Record the actual amount of time in the note.

        Critical care

        Prolonged services

   Payers other than Medicare may be billed for
    resident time performing time-based services if
    the amount of time is documented


                                 UNC School of Medicine Compliance
North Carolina Medicaid
Teaching Physician
Regulations
    NC Medicaid teaching
    physician (TP) requirements
   TP must be "immediately available" to the resident
    and patient by telephone or pager at the least
   For procedures, the TP must use "direct
    supervision" (available in the office suite)
   The degree of supervision is the responsibility of
    the TP and is based on the skill, level of training
    and experience of the resident as well as the
    patient's condition.
   Written documentation in the medical record for
    Medicaid patients must clearly designate the
    supervising physician and be signed by that
    physician.
                                       UNC School of Medicine Compliance
        Where To Get Help
   www.med.unc.edu/compliance/

   UNC P&A Professional Charges Coders for Emergency Medicine
       Lisa Staton, CCS-P, 966-8356
       Cindy Wyrick, CPC, 966-9051
       Rhonda Peck, CPC, 962-8391

   School of Medicine Compliance Office 843-8638
       Charles Foskey, Compliance Officer
       Chris Carreiro, CPC, Office Manager
       Heather Scott, CPC, Compliance Auditor
       Wendy Smith, CPC, Compliance Auditor

   Confidential Help Line 800-362-2921 for reporting potential
    compliance problems

   The AMA’s Current Procedural Terminology (CPT) Manual
                                                 UNC School of Medicine Compliance

				
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