*OB/Gyn. Hospital Billing. April 2, 2014 Erika Bloomquist, CPC

Transcription

1 OB/Gyn Hospital Billing April 2, 2014 Erika Bloomquist, CPC

2 Initial Date Diagnoses Billing Level Code Patient Label ZK 3/1 1,2 A1 Or two patient identifiers BB 3/2 1,2 S2 TS 3/3 1,2 D1 Inpt. Obs Transfer Diagnoses: 1.) DM 2 - uncontrolled 2.) GHTN 3.) 4.) 5.) 6.) 7.) 8.) 9.) 10.) Provider Signatures: ZK signature, BB signature, TS signature

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4 PP History Exam Decision making Time Inpt. Initial A1 low severity detailed detailed straightforward 30 Min A2 moderate severity comprehensive comprehensive mod. complexity 50 min A3 high severity comprehensive comprehensive high complexity 70 min Inpt. Subsequent S1 sri problem focused problem focused straightforward 15 min S2 rt mc expanded PF expanded PF mod. complexity 25 min S3 udscnp detailed detailed high complexity 35 min Obs. Initial O1 low severity detailed detailed straightforward 30 min O2 moderate severity comprehensive comprehensive mod. complexity 50 min O3 high severity comprehensive comprehensive high complexity 70 min Obs. Subsequent OS1 sri problem focused problem focused straightforward 15 min OS2 rt mc expanded PF expanded PF mod. complexity 25 min OS3 udscnp detailed detailed high complexity 35 min Same Day Adm/DC Obs or Inpt A/D1 low severity detailed detailed straightforward 40 min A/D2 moderate severity comprehensive comprehensive mod. complexity 50 min A/D3 high severity comprehensive comprehensive high complexity 55 min sri - stable, recovering, improving; rt mc - responding inadequately to therapy, or minor complication; usdc np - unstable, developing significant complications or new problem

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6 Postop: Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. CMS, August 2013 Medical complications of pregnancy (i.e. cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemsesis, preterm labor, premature rupture of membranes, trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately CPT

7 The supervising physician must document his/her involvement in the key component(s) of the encounter AND Document patient face-to-face

8 This statement or any variations of are considered insufficient to support shared billing.

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10 Can be performed as a shared/split service but each provider must separately document and sign off on the services he/she personally performed for the patient. A notation of "seen and agreed" or "agree with above on the resident s documentation is not acceptable. Make separate and distinct notes in the patient chart.

11 If the resident will be dictating the comprehensive note, the supervising physician must document his/her own physical exam and impression & plan to support the fact that the supervising physician both had a face-to-face encounter with the patient and participated in a substantial (key) portion(s) of the services rendered to the patient.

12 Can be performed as a shared/split service but each provider must separately document and sign off on the services he/she personally performed for the patient. As with initial visits, a notation of "seen and agreed" or "agree with above" is not considered acceptable documentation.

13 The supervising physician must document his/her own physical exam (Best Practice: min. of 2 systems) and impression & plan.

14 No c/o Doing better Feeling fine * If your patient is doing better, document the original CC and current status, i.e. f/u PTL doing better.

15 Both the diagnoses that you are managing and the diagnoses that may be managed by another physician, but do impact your care, will be considered in your medical decision making. However, the diagnoses that you are managing will be the primary diagnoses that you list on your billing card. For example: Preterm labor patient whose diabetes will be managed by another physician Diabetes will not be your primary diagnosis on that billing card.

16 Noncontributory statements will not be counted For example: Family history noncontributory will take your level 3 admission to a level 1 admission.

17 There is no way to calculate the number of systems that were reviewed unless you state it. For example: All other systems were negative If only pertinent systems were reviewed, then state it. For example: Five-point system review was negative except for.

18 HealthStream under Education tab on WMC Intranet Offsite: 2 CME credit hours per course *

19 The Resident E&M Coding Course New Provider Orientation & Training for OBGYNs Admission H&Ps Hospital Progress Notes New Office Patients Established Office Patients

20 Centers for Medicare & Medicaid Services, Global Surgery Fact Sheet, Aug Centers for Medicare & Medicaid Services, Guidelines for Teaching Physicians, Interns, and Residents, Dec American Medical Association, Current Procedural Terminology, 2014.

21 Brenda Smith, CPC Erika Bloomquist, CPC