Does Your EMR Lead You to the Right Code? Amy Dunatov, MPH, FACMPE, CCS-P, ICDCT-CM April 29, 2015
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1 Does Your EMR Lead You to the Right Code? Amy Dunatov, MPH, FACMPE, CCS-P, ICDCT-CM April 29, 2015
2 Disclosure Information National Urgent Care Convention April 2015 Amy C. Dunatov, MPH, FACMPE, CCS-P, ICDCT-CM Disclosure of Relevant Financial Relationships Salaried with MSOC Health Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation.
3 Objectives Assess level of E/M documentation and coding knowledge Understand why an EMR may not always suggest the correct CPT/E&M code Assess how to decide if the code is incorrect Understand tips for ensuring compliance Review common missed revenue opportunities and compliance red flags
4 E&M Review and Your EMR
5 Evaluation & Management History of Present Illness Examination 95 & 97 Guidelines Medical Decision Making
6 E&M - History Chief Complaint History of Present Illness Elements Review of Systems Past, Family, Social History
7 MD documents HPI MD documented PMH but can be assistant Assistant documents past surgical history 7
8 E&M-History Elements Location - Modifying Factors Duration - Associated Signs Timing & Symptoms Severity - Context Quality OR Status of Three Chronic Conditions 97 Only
9 Examples of HPI Patient complains of chest pain which began 2 hours ago. Occurs with minimal exertion. Rates pain a 9 on 1-10 scale. The patient has never experienced anything like this previously. OR Type II diabetes, uncontrolled, BS 170 Hypertension, well-controlled Hyperlipidemia, stable on Lipitor 9
10 E&M-History Review of Systems Constitutional - Musculoskeletal Eyes - Integ ENMT - Neurological Cardiovascular - Psychological Respiratory - Endocrine GI - Hem/Lymph GU - Allergy/Immunology OR Document positives with statement All Other Systems Negative
11 E&M-History Past, Family, Social History Surgeries/Hospitalizations Diet Illness/Injury Family History Marital Status Alcohol/Tobacco/Caffeine Use
12 Body Areas Head/Face Neck Chest/Breast/Aux Abdomen Genit/Groin/Buttocks Back/Spine Extremities E&M-Exam 95 Systems Constitutional Eyes ENMT Respiratory Cardiovascular GI GU Musculoskeletal Skin Neurological Psychological Hem/Lymph/Imm
13 E&M-Exam 97
14 Musculoskeletal Exam
15 Coding Level 15
16 Coding Level Example 16
17 E&M-Medical Decision Making Number of Diagnoses Chronic problem Stable or worsening New Problem w/o additional workup New Problem w/ additional workup Data Labs/X-rays/Old Records Risk/Complexity Chronic problem w/ mild exacerbation, Rx Drug Management
18 MDM Example Patient is seen in the office for: Hypertension, stable, continue on Lisinopril 10mg Stable, diet controlled DM2 (HGBa1c 6.2)
19 E&M New Patient ( ) Level 1 - Problem focused/pf/straight Fwd Level 2 - EPF/EPF/SF Level 3 - Detailed/Detailed/Low Level 4 - Comp/Comp/Moderate Level 5 - Comp/Comp/High **Lowest History/Exam/MDM determines the code
20 E&M Established ( ) Level 1 - No MD Presence Required Level 2 - Problem focused/problem focused/straight forward Level 3 - EPF/EPF/Low Level 4 - Detailed/Detailed/Moderate Level 5 - Comp/Comp/High ** MDM should dominate code selection
21 Time Based Billing-Office ( ) Must Include: Total time spent face-to-face with patient Greater than 50% of time was spent on counseling/coordination of care Content of counseling/coordination of care
22 Time Based Billing Office New Patients minutes minutes minutes minutes minutes Established Patients minutes (not MD) minutes minutes minutes minutes 22
23 Example of Time Based Visit CC: follow-up dyslipidemia Interval history: The patient is here to ask why he needs to stay on statin medication for cholesterol. Most recent LDL was 131 Exam: BP 144/90 Assessment - Dyslipidemia 1) Borderline hypertension 2) Plan Continue statin therapy 3) Recheck blood pressure at next visit A total of 15 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care. We discussed in depth the importance of primary prevention of coronary disease with aggressive treatment of high cholesterol. I also educated the patient about lifestyle modifications which may improve blood pressure. 23
24 Other Billing, Coding, and Documentation Concerns
25 Documentation & Authentication Medical records must be complete and legible Should include: a. Reason for encounter, findings and test results b. Assessment/diagnosis c. Plan of care d. Date and legible signature Signature method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. Addendum rules
26 Other Errors Use of templates Cloning/copying previous note Medication units incorrect or no documentation to support charge Wrong supplies code Missed/incorrect or no documentation to support x-ray Missed charge or no documentation to support procedure Missed ultrasound guidance
27 Bottom Line Understand how the EHR calculates HPI & exam Check templates for accuracy Consult with a coding expert Audits are a reality 27
28 Thank You Amy Dunatov, MPH, FACMPE, CCS-P, ICDCT-CM
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