Medical Decision Making. Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine
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1 Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine
2 Billing 101: Down coding Compared to national benchmark: HFH -1% on critical care When compared to Level 5 billing: Loss of $220 professional charges/pt Loss of $765 facility charges/pt HFH -9% Level 5 charts When compared to Level 4 billing: Loss of $215 processional charges/pt Loss of $494 facility charges/pt
3 40.00% 35.00% July-Dec % 25.00% 20.00% 15.00% DEM Mean FSPC Mean 10.00% 5.00% 0.00% Other 45.00% 40.00% 35.00% Jan-June % 25.00% 20.00% DEM Mean FSPC Mean 15.00% 10.00% 5.00% 0.00% Other
4 Downcoding Focus on 10% of patients Can increase charges by 20%
5 Why do you care? You will in less than 3 years What is good for the dept. affects you Revenue = power
6 What can you do to help? Improve documentation To reflect what we actually see and do To reflect the complexity of our patients and our workup s To capture the appropriate revenue
7 Level 5 Chart HPI: Four location, quality, severity, timing, associated sx, duration, context, modifying factors ROS: Ten Constitutional, Eyes, ENMT, CV, Respiratory, GI, GU, MSK, Integumentary, Neuro, Psych, Endocrine/Metabolic, Hematologic/Immunological
8 Level 5 Chart ROS Do you have any fever, chills, nausea, vomiting, cough, sore throat, rashes or bruises, pain in your head, back, belly, chest, or burning when you urinate? There is your 10 in once phrase.
9 Level 5 Chart PMHx, Family Hx, Social: PE Three: Epic does this for you (mostly) 8 systems MDM Constitutional, Eyes, ENMT, CV, Resp., GI, GU, MSK, Skin, Neuro., Psych, Heme/Immun.
10 MDM In talking with coding this is our #1 issues. Because we often don t do it And please.fill out the boxes.
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13 MDM: RISK Presenting Problem Minimal Low one self limited minor problem 1 stable chronic prob., 2 minor problems, or acute uncomplicated illness/injury Moderate High Mild exacerbation, 2 chronic stable problems, new problem/uncertain dx, acute illness Severe exacerbation, MS changes, Life threat
14 MDM: Risk Diagnostic procedures Minimal Labs (no IV), CXR or EKG Low X-rays (mult.), ABG Moderate CT AND x-rays High emergency surgery
15 MDM: Risk Management Options Minimal RICE, bandage, gargle Low RICE Moderate PO meds High IV meds
16 MDM Level 1 or 2 Level 3 Level 4 Level 5
17 Critical Care Can be billed by staff only Do not click CC in your notes
18 Medical Decision Making Arguably the most important piece of the medical chart HPI paints a picture MDM plays art critic
19 Common Mistakes Missed information on triage/ems/nursing notes (general ED notes) worse HA of life slurred speech
20 Common Mistakes Unanswered abnormal VS Unanswered abnormal VS Unanswered abnormal VS Unanswered abnormal VS Unanswered abnormal VS Unanswered abnormal VS Unanswered abnormal VS
21 Common Mistakes Lack of patient reassessment VS Pain Symptom relief CP Abd. Pain Vomiting Wheezing
22 Common Mistakes Poor consult documentation Who did you talk to and when Make consultant aware of charting curb-siding
23 Common Mistakes Discharge Instructions Ambiguous No information on what to watch for or why to come back Lack of follow up instructions (and time course to do so)
24 Common Mistakes Non Documentation Procedures and failed attempts etc. Also hurts from a billing standpoint Information from old chart/osh Repeat EKG s (order and document) Adverse events Itching after med. etc.
25 Community Experience Regional Group Risk Management Audit Abdominal Pain Chest Pain HA Fever in Child CC s represent 75% of dollars lost in ED suits
26 Community Experience How this is done 12 charts (3 per CC) 3-4 months after hire Sit down evaluation with Risk Management physician
27 HFH Experience Charting metric Twice a year for PGY-2 and above Yearly for PGY-1 s
28 Building a Chart EMR dependent Typing is not ideal ( job seekers) Be aware of templates/macros LE Amputees with +2 DP/PT pulses bilaterally are unusual and hard to find preformatted discharge instructions
29 How to Put it Together Just put it somewhere MDM section Reassessment (.now phrase) Diff Dx.
30 How to Put it Together Summarize Presentation This is a patient who presented with cough and SOB ED Course Pt. was given nebs/steroids and labs/cxr were obtained Studies Labs unremarkable (.edlabs) CXR showed no pna
31 How to Put it Together Summarize Patient Response to Tx: Pt states she felt better after tx Eating/Up and ambulatory in ED Asking for to go home
32 How to Put it Together Evaluate the Differential Dx. Based on. I doubt. EKG unchanged, no exertional component to symptoms I doubt ACS No leg swelling/pain, no travel or recent surgery I doubt PE Given. I favor. Pt. has hx of COPD, improved with nebs and steroids I favor COPD exacerbation
33 How to Put it Together Case for Discharge/Treatment Plan Why is this COPD exacerbation going home? Given pt. does not desat. during ambulation, is afebrile, feels improved, I feel they can be d/c with oral steroids and abx as well and increase home neb. use Follow up Phone call Ability to obtain timely f/u iphone etc. Document the call/attempt
34 How to Put it Together Discharge Info. Spell out exactly what to watch for and reasons to seek further care Follow up (did you talk with PMD) return if worse or if concerned Incidental findings: document in chart and on d/c Instructions Need for repeat cxr in 6 months etc.
35 Appy CA Cardiopulmonary Arrest CVA (ischemic) Ectopic FB FXR ICH Infection/Sepsis Epidural Abscess Meningitis Cardiac/MI Missed MI Respiratory Arrest Dissection/Aneurysm (not intra-cranial) PE Bowel Ischemia Total # Percent Most Common Dx Total %
36 How to Put it Together (finally) Case for Admission Medical Necessity Important for billing (ATMO/IPAS too) Why is this COPD exacerbation being admitted? Increased O2 requirement Abnormal CXR Need for serial cardiac markers etc.
37 Coding Queries As of 7/31 $ 55,000 waiting on resident charting (queries only) to be billed Finish carts same day/next day Respond to queries ASAP (even off service) Ask me if? s
38 Coming to a ED near you:
39 Summary MDM Needs to play a larger role in documentation Should reflect disposition thought processes and data Must include commonly missed items Abnormal VS, reassessments etc. Follow up and discharge instructions ought to be viewed with increased importance
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