evaluation and management coding e&m coding - university of 评估和管理编码e &amp；m编码-大学

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PowerofthePenIyadG.Houshan.M.D.AssistantProfessorofMedicineChief,DivisionofHospitalMedicineUniversityofNevadaSchoolofMedicine ICD-9codes40y.o.malewithPMHxof250.4,272.4,496,herefor491.21exacerbationandpossible410.Howdoyoutreatthispatient?40y.o.malewithPMHxofDM(renalmanifestations),dyslipidemia,COPD,hereforCOPDexacerbationandpossibleMI. EvaluationandManagementCoding“E&MCoding”WhyI’mIhere?CanIpaysomeonetodothatforme?Whatismyincentivetolearnthis? INCENTIVE DefinitionsICD-9:InternationalClassificationofDiseases.(250.00,272.4,…)CPT:CurrentProceduralTerminologyCMS:CentersforMedicareandMedicaidServices Definitions,Cont’dE&Mcodes,LikeCPTcodesarecompromisedoffivedigits.E&Mcodesspecificallybeginwith99.E&MsubsequentnumbersdependonthetypeofE&M. Definitions,Cont’dAlevel1(lastdigita1)istheleastAlevel2(lastdigita2)isgreaterThehighestcodelevelwillendina3(aninpatienthospitaladmission),ora5(Outpatientorconsultations). E&MCodingEachindividualcodelistedhasthreecomponentsthatqualifyphysicianstoworkforthespecificcode:1)History2)Physical3)medicaldecisionmakingMDM E&Mcoding,cont’dToaddadegreeofconfusiontoourcodingdilemma,thereareactuallytwosetsoftheFederalDocumentationGuidelinesforEvaluationandManagementServices. E&Mcoding,cont’dTheoriginalset,1994,affectedprimarilythehistorycomponentofthephysiciandocumentationThesecondset,1997,usesthesamehistorysegmentbutaddsphysicalexamdocumentationguidelines,featuringthenowinfamous“bullet”points.Besttousethe1997guidelines.(weusethe1994guidelines) E&Mcoding,cont’dIntheCPTbook,whenlookingupaspecificE&Mcode,thethreelistedqualifiers:History,Physical,andMDMarefoundPhysiciansdon’tthinkcodefirst.Wethinkclinicalmatters,diagnoses,labsandtests,andhistoryandphysical.Takingcareofthepatientsfirstbeforethecodes. TheGameDocumentationCodingLevel TheGameDocumentationCodingLevelMedicalNecessityMedicarewillnotpayforanythingunless“MedicalNecessity”ismetMedicalNecessityisnotclinicalatallitisfinancialterm CodeQualifiersEachCodeMDMHistoryPhysicalExamRiskDataDiagnosisHPIROSPMFSHElementsinorgansystems *MedicaldecisionMaking*Ithasthreecomponents:Risk,Data,andDiagnosis.RemembercomplexityofMDMisthelowestofthetwohighest *MDM*Risk:High:“Severe”exacerbationofchronicillness.Acuteillnessthreateninglifeorlim,Abruptchangeinneurologicalstatus,OrderingofCVangiography,endoscopywithriskfactors,ptneedsemergentmajorsurgery,Parenteralcontrolledsubstances,DNRdecision. *MDM*RiskModerate:mildexacerbation,progression,2ormorestablechronicillnesses,acuteillnesswithsystemicsymptoms(pyelonephritis,colitis,..),orderingofstresstest,ednoscopywithoutriskfactors,needlebiopsy;ptneedselectivemajorsurgery,prescriptiondrugmanagement,IVfluidswithadditives *MDM*DataReview,orderlab……………..1pointReview,orderRadiology……..1PointOthertests……………………..1PointObtainingoldrecords…………1PointReviewandsummaryofoldrecords………………….2PointsIndep.Interpretationoftest….1PointDiscussionofunexpectedresultwithinterpdoctor………1PointMAXPOINTS=4 *MDM*Diagnosis:#ofneworchronicselflimitingproblems…………………Max2pointsPresentingproblemimproved,wellcontrolled#_X1=Inadequatecontrol,worsening#_X2=Newproblemnoworkup……3pointsNewproblemwithworkupplanned..4pointsMAXPOINTS=4 LOWESTOFTHETWOHIGHEST(newpatientvisits) ComplexityofMDMRiskDataDiagnosisComplexityofMDMMin11straightfowLow22LowModerate33ModHigh44High CodeQualifiersEachCodeMDMHistoryPhysicalExamRiskDataDiagnosisHPIROSPMFSHElementsinorgansystems *History*CC:“whyareyouseeingthispatientHPI1-3elements=brief,4elementsorcommenton3chronicconditions=extendedPMFSH1of3categories=pertinent3of3categories=complete●ROS=1problempertinent2-9extended10complete LOWESTOFTHETWOHIGHEST *History*HPIROSPMFSHOverallHistoryBriefN/AN/AProblemfocusedBriefProblempertinentN/AExtendedproblemfocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensive CodeQualifiersEachCodeMDMHistoryPhysicalExamRiskDataDiagnosisHPIROSPMFSHElementsinorgansystems *PhysicalExam*ProblemfocusedExamination:onetofiveelementsinoneormoresystemsExtendedProblemFocusedExamination:examofatleast6elementsinoneormoresystemsDetailed:forageneralexam2elementsin6organsystemsor12elementsinatleast2organsystemComprehensive:2elementsin9organsystems *PhysicalExam*Organsystems(14)-Eyes-Constitutional-Neck-E,N,Mouth,throat-Chest,including-CVSBreastandaxilla-G.I.-Respiratory-Lymphatic-Genitalia,groin,-SkinButtock-Psychiatric-Musculoskeletal-Neurologic LOWESTOFTHETWOHIGHEST InitialHospitalVisits99221:LevelI,LowDetailedorcomprehensivehistoryandexam,lowcomplexityMDM99222:LevelII,ModerateComprehensivehistoryandexam,ModeratecomplexityMDM99223:LevelIII,HighComprehensivehistoryandexam,HighcomplexityMDM Why Reimbursement$$$CPTCode2006Paymen2007paymen%paem.Cha99221int.car$68.22$84.9224.5%99222int.car$112.93$118.715.1%99223int.car$157.27$173.1810.1%99231subseq$34.11$35.764.8%99232subseq$55.71$63.6714.3%99233subseq$79.21$90.9114.8%99238disch$70.87$65.61-7.4%99239disch$96.64$94.70-2.0% DiagnosisDrivingPaymentICD-9codesHTNDMCOPDCHFAsthmaEmphysemaParkinsonsAndAfib.(beingtreated,oncoumadin) LEGIBLEDocumentation“Ifyoudidnotdocumentit,itdidnothappen” SubsequentHospitalVisitlevel1(99221)ChiefComplaint.ProblemfocusedHistory(1-3elements,NoROS,NoPFSHrequired).ProblemfocusedExam(bodyarearelatedtoproblem).MDMstraightforwardorlowcomplexity SubsequentHospitalVisitLevel2(99232)ChiefComplaintExpandedproblemfocusedHistory(1-3elements,1ROS,NoPFSHrequired)ExpandedProblemfocusedExam(2-4systems).MDMmoderatecomplexity SubsequentHospitalVisitLevel3(99233):ChiefComplaintDetailedHistory(4ormoreelements,2-9ROS,1PFSH).DetailedExam(5-7systems).MDMhighcomplexity. SubsequentHospitalVisitYouneed2ofthe3componentstomeettherequirementofthelevelcharged.