Volume 2 . Issue 3 . March 2013 Cristy Donaldson, CPC, CPMA Coding Specialist  865-670-6177  CDonaldson@utmck.edu Are you struggling with knowing how to document and code for a Preventive and Problem visit on the same day? As a certified coder and a certified auditor, I frequently hear complaints from both providers and patients about this. Here are a few simple tips and reminders for you to follow. This will help you stay out of hot water with patients and insurance carriers: 1) When a patient calls to schedule an appointment, ask if the patient is new or established AND ask if the patient is requesting a preventive/well visit or a problem visit. Make notes in your computer about this. 2) When the patient arrives for their appointment, the reception area should view the notes in the computer to determine what type of visit is occurring. Many preventive/well services are now covered at 100% and do not require a co-payment; in fact, it may be considered improper to collect a copayment on such services. 3) Upon triage, the nurse or medical assistant should again ask if the patient is having any problems that need to be addressed during today’s visit, particularly if the patient’s chief complaint/reason for visit is for a preventive/well visit. 4) Providers should review this in the chart before initiating the encounter. If the patient in the examination room appears to be a preventive/well visit but mentions a problem to you the provider, you must determine the course of action. You can treat the problem, provide the preventive/well service, or both; however, this must be clearly communicated to the patient. Patients will accept their financial responsibility much better if they know how you intend to bill their insurance before they leave your office. 5) If you the provider elect to provide both services, you should only bill separately for the problem visit if the problem was significant and separately identifiable. What does that mean? It means the work involved for the problem must require additional history, exam and work-up beyond what would normally be performed during the preventive/well visit. If the problem could easily be treated within the scope of the preventive/well visit, it would be inappropriate to bill separately for it. If the problem is significant and separately identifiable, append modifier 25 to the problem visit. The key word is “significant”. 6) Documentation trumps all. If the provider’s documentation does not clearly support all of the services billed, you may find yourself in a sticky spot with the patient and/or the insurance carrier. The Chief Complaint/Reason for Visit must demonstrate all of the above. If a preventive/well service is billed, all the requirements of that service must be performed and documented. Did you know that a Preventive Medicine Visit requires a comprehensive history and examination as appropriate for the age and gender of the patient? If you report a preventive/well and a problem service, your documentation should support BOTH. Continued Page 2 Page 2 / Catch the Coding Wave 7) Some insurance carriers have a hard rule and will not pay for both on the same day. It is a good idea to get familiar with which insurance carriers have a rule about this. Lastly, it is never appropriate to change a code just to please a patient. If the patient presented for a preventive/well visit but you determined a problem visit must be performed instead, you must explain this to the patient. It is not appropriate to change the code to please the patient. Furthermore, if the documentation is audited by the insurance carrier and it does not reflect the services performed, you may lose your reimbursement altogether. Because the determination of risk is complex and not readily quantifiable, the table of risk includes clinical examples rather than absolute measures. The highest level in any one category on the table determines of the overall level of risk. See page 3 of the Audit Tool. References: CMS 1995 Guidelines Taking an Anatomy & Physiology course is a great way for coders and/or anyone non-clinical to begin their education for ICD-10. There are online and class room based courses available with a variety of vendors. Consider AAPC, AHIMA, your local community college or an online college. The key component of Medical Decision Making is broken down into three sections: 1) Number of Diagnoses or Treatment Options 2) Amount and/or Complexity of Data 3) Table of Risk Each of these sections receives a score and is applied to the MDM table. The overall MDM score is determined by the highest 2/3 sections. This month we will focus on the Table of Risk. This table stratifies the risk of significant complications, morbidity and/or mortality, as well as the co-morbidities associated with the patient’s presenting problem(s), the diagnostic procedures(s) and/or the possible management options. Thank you for taking the time to review this information. If you have any questions regarding the content of this newsletter, please feel free to contact me directly at: Cristy Donaldson, CPC, CPMA Coding Specialist Phone: 865-670-6177 cdonaldson@utmck.edu DOCUMENTATION WORKSHEET Color Key: Items/descriptions in black represent '95 guidelines and items that did not change in '97. Items/descriptions in blue represent changes made in the '97 guidelines. Black and white duplication may alter the intent of this tool. THIS TOOL IS INTENDED TO BE USED ONLY AS A COMPANION TO THE PUBLISHED '95 AND '97 E/M DOCUMENTATION GUIDELINES (located a www.cms.hhs.gov). EITHER THE '95 OR '97 GUIDELINES MAY BE USED, BUT THE TWO SETS OF GUIDELINES CANNOT BE COMINGLED Patient Name:________________________________________________ DOB:_________________ DOS:_____________________ Chief Complaint:_______________________________________________________________________________________________ HISTORY HPI Brief=1-3 Extended= ('95) 4 or more elements or assoc. comorbidities Extended= ('97) 4 or more elements or status of at least 3 chronic/inactive conditions Location Quality Severity Duration (Where problem is located) (sharp, dull, stabbing) (scale of 110, etc) (how long) Timing (how long it lasts, after meals, etc) Context Modifying Factors (when walking,etc) Associated Signs/Symptoms (feel better after applying ice, etc) (swelling, redness, etc.) ROS Pertinent=1 Extended= 2-9 Constitutional Eyes ENT/Mouth Integumentary (skin/breast) Complete= 10 or more Cardio Resp Neuro GI GU Psych Hem/Lymph Endo Musculo/Skel Allerg/Immun PFSH Pertinent=1 Past Medical Complete= 2 or more Initial visits require at least one item from all three PFSH areas Family History Social History HPI ROS PFSH History Level Brief N/A N/A Prob Focused Brief Pertinent N/A Exp Prob Focused Extended Extended Pertinent Detailed Extended Complete Complete Comprehensive To qualify for a given level of history, all three elements in the table must be met. History level based on '95 Guidelines_______________ Developed incorporating CMS/AMA 1995/1997 copyrighted materials Form Date: 10/03/05 History level based on '97 Guidelines______________ Form Date: 02/01/06 EXAM BODY AREAS ('95) with '97 specific elements Elements of '97 Gen. Multi-System Exam 97 Head, incl face Neck '97 Constitutional ('95) Eyes ENT, Mouth Cardiovasc 1. Neck (masses, etc.) 2. Thyroid Chest, incl breasts or axillae '97 *Please refer to '97 Single Organ System Exam ORGAN SYSTEMS ('95 & '97) 95 guidelines for specific bullet and numeric 1.Any 3 vitals 2.General appearance requirements for each category of single 1.Conjunctivae and lids 2.Pupils & irises 3.Optic discs organ system exam 1.Ext ears & nose 2.EACs & TMs 3.Hearing 4.Oropharynx 5.Septum, turb 6. Lips, teeth, gums 1.Palpation of heart 2.Auscultation 3.Carotids 4.Abd aorta 5.Femoral arteries 6.Pedal pulses 7.Extremities for edema and/or varicosities Respiratory GI (Abd.) GU (male) ('97) GU (female) ('97) Musculoskeletal 1.Inspect breasts 2.Palpation breasts/axillae Abdomen Genitalia, groin, buttocks 1.Respiratory effort 2.Percussion 3.Palpation 4.Auscultation 1.Masses, tenderness 2.Liver & spleen 3.Hernia 4.Anus, perineum & rectum 5.Occult test 1.Scrotal contents 2.Penis 3.Prostate gland 1.External genitalia 2.Urethra 3.Bladder 4.Cervix 5.Uterus 6.Adnexa/parametria (w/w.out speci) 1.Gait & station 2.Digit and nail 3.Joint(s), bone(s), muscles of at least one of these areas: a) head, neck; b) spine, ribs, pelvis; c) any one of 4 extremities, & exam to include: Back, incl spine (1)inspection &/or palpation (2)ROM (3)stability (4)muscle strength & tone Skin 1.Inspection of skin & subcutaneous tissue 2.Palpation of skin and subcutaneous tissue Neuro 1.Cranial nerves 2.Deep tendon reflexes 3.Sensation Psych 1.Judgment & insight 2.Brief mental status: (a)orient to time, place, person (b)memory (c)mood Hematologic/lymphatic/immunologic Each extremity 1.Palpate lymph nodes in 2 or more areas: a) neck b) axillae c) groin d) other Prob Focused Exp Prob Focused Detailed General MultiSystem Exam Perform and document at least 2 Perform and document 1- Perform and document at bulleted elements from at least 6 5 bulleted elements in least 6 bulleted elements in systems or body areas, or at least 12 one or more systems or one or more systems or body bulleted elements from 2 or more body areas areas systems or body areas Single Organ System Exam Perform and document 15 bulleted elements, whether in shaded or unshaded box Comprehensive Perform all bulleted elements from at least 9 systems/body areas (unless specific directions limit content) and document at least 2 bulleted elements from each selected area '97 Guidelines: Body Area(s) Limited exam of affected body area or organ or Organ system (1) System(s) '95 Guidelines: Perform and document at least 6 bulleted elements, whether in a shaded or unshaded box Limited exam of affected body area/system and other related/sympt. systems (2-7) Exam level based on '95 Guidelines__________ Exam level based on '97 Guidelines__________ Perform and document at least 12 Perform all bulleted elements, whether in bulleted elements (except for eye & shaded or unshaded box; document psych exam, which should be at least every element in each shaded box and at 9 bulleted elements) whether in least one element in each unshaded box. shaded or unshaded box General multi-system exam of 8 or more systems or complete exam of a Extended exam of affected body area/system and other related systems (2-7 in more depth) single system* *('95)Comprehensive Exam must be 8 or more organs systems; cannot combine systems with body areas. All lower level exams can combine organ systems and body areas MEDICAL DECISION MAKING ('95 and '97 Guidelines) Number of Diagnoses or Treatment Options Amount and/or Complexity of Data Number & category of problems/treatment options mentioned in the record (2 categories have a max allowable). Identify data reviewed and circle number in points column *Multiply A x B = C Problem Number A Self-limited or minor (stable, improving or worsening) x x 1 max=2 Established problem to examiner; stable; improved x 1 Established problem to examiner, worsening x 2 New problem to examiner, no further workup planned x 3 x 4 max=1 New problem to examiner, additional workup planned Review/order of clinical lab tests 1 Review/order of tests in radiology section of CPT 1 Review/order of tests in medicine section of CPT 1 Discuss test with performing/interpreting physician 1 Decision to obtain old records or obtain history from someone other than patient 1 Review & summary of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider & documentation of relevant findings Independent visualization of image, tracing or specimen itself (not simply review of report) Total Minimal= < 1 Limited = 2 Multiple = 3 Points* Reviewed Data Points B Result C Total Extensive = 4 Minimal= < 1 Limited = 2 Multiple = 3 Extensive = 4 or more *Number values are not part of the '95 or '97 guidelines. The values are added here as a means of quantifying elements of medical decision making Form Date: 10/03/05 2 2 Table of Risk of Complications and/or Morbidity or Mortality (highest level of risk in any category determines overall risk) Use the risk table as a guide, understanding that it is only a guide. Circle most appropriate risk factor in each category. Level of Risk Presenting Problem One self-limited/minor problem, e.g., cold, insect bite Minimal Diagnostic Procedure(s) Ordered Management Options Selected Lab tests requiring venipuncture Rest Chest x-rays Gargles EKG/EEG Elastic Bandages Urinalysis Superficial dressings Ultrasound, e.g. echo KOH prep Two or more self-limiting/minor problems Low One stable, chronic illness, e.g., well controlled hypertension or non-insulin dependent DM, cataract, BPH Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain Physiologic tests not under stress, e.g., pulmonary function tests Over-the-counter drugs Minor surgery with no identified risk factors Non-cardiovascular imaging studies with contrast, e.g., barium enema Physical therapy Superficial needle biopsies Occupational therapy Clinical lab tests requiring arterial puncture IV fluids without additives Skin biopsies Moderate One or more chronic illnesses with mild exacerbation, 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 Physiologic tests under stress, e.g., cardiac stress test, fetal contractions stress test Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Diagnostic endoscopies with no identified risk factors Prescription drug management Deep needle or incisional biopsy Therapeutic nuclear medicine Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac cath IV fluids with additives Closed treatment of fracture or dislocation without manipulation Acute complicated injury, e.g., head injury with Obtain fluid from body cavity, e.g., lumbar puncture, brief loss of consciousness thoracentesis, culdocentesis High One or more chronic illnesses with severe Cardiovascular imaging studies with contrast with exacerbation, progression, or side effects of tx identified risk factors Cardiovascular electrophysiologic tests Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, Diagnostic endoscopies with identified risk factors severe respiratory distress, progressive, severe rheumatoid arthritis, psychiatric illness Discography with potential threat to self or others, peritonitis, acute renal failure Elective major surgery (open, percutaneous, or endoscopic with identified risk factors) Emergency major surgery (open, percutaneous, or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis Abrupt change in neurologic status, e.g, seizure, TIA, weakness, sensory loss (2 of 3 elements must be met or exceeded to qualify for a level of Decision Making) DX/Mgmt Options Data Risk Type of Med Dec Making Minimal Minimal or none Minimal Straightforward Limited Limited Low Low complexity Multiple Multiple Moderate Moderate complexity Extensive Extensive High High complexity Level of Decision Making__________________ Form Date: 10/03/05 Determining level of E&M for New Patient Office; Office/Outpatient Consult; Inpatient Consult (3 of 3 components required) History Prob Focused Exam Prob Focused Med Dec Making Straightforward Code 99201 / 99241 / 99251 Exp Prob Focused Exp Prob Focused Straightforward 99202 / 99242 / 99252 Detailed Detailed Low Complexity 99203 / 99243 / 99253 Comprehensive Comprehensive Moderate Complexity 99204 / 99244 / 99254 Comprehensive Comprehensive High Complexity 99205 / 99245 / 99255 Determining level of E&M for Established Patient Office (2 of 3 components required) History N/A Exam N/A Med Dec Making N/A Code 99211 Prob Focused Prob Focused Straightforward 99212 Exp Prob Focused Exp Prob Focused Low Complexity 99213 Detailed Detailed Moderate Complexity 99214 Comprehensive Comprehensive High Complexity 99215 Determining level of E&M for Initial Observation Care; Initial Hospital Care; Observation or Inpatient Including Admission and Discharge (3 of 3 components required) History Detailed/Comprehensive Exam Detailed/Comprehensive Med Dec Making Straightforward or Low Code 99218 / 99221 / 99234 Comprehensive Comprehensive Moderate Complexity 99219 / 99222 / 99235 Comprehensive Comprehensive High Complexity 99220 / 99223 / 99236 Determining level of E&M for Subsequent Hospital Care (2 of 3 components required) History Exam Med Dec Making Code Prob Focus Interval Prob Focused Straightforward or Low 99231 Exp Prob Focus Interval Exp Prob Focused Moderate Complexity 99232 Detailed Interval Detailed High Complexity 99233 Determining level of E&M for New or Established Initial Nursing Facility Care (3 of 3 components required) History Detailed/Comprehensive Exam Detailed/Comprehensive Med Dec Making Straightforward/Low Code 99304 Comprehensive Comprehensive Moderate Complexity 99305 Comprehensive Comprehensive High Complexity 99306 Determining level of E&M for New or Established Emergency Room (3 of 3 components required); Subsequent Nursing Facility Care (2 of 3 components required) History Prob Focused Exam Prob Focused Med Dec Making Straightforward 99281 / 99307 Code Exp Prob Focused Exp Prob Focused Low Complexity 99282 / 99308 Exp Prob Focused Exp Prob Focused Moderate Complexity 99283 Detailed Detailed Moderate Complexity 99284 / 99309 Comprehensive Comprehensive High Complexity 99285 / 99310 Final level based on '95 Guidelines___________ Final level based on '97 Guidelines____________