Start with the Problem

Transcription

1 Start with the Problem Jen Godreau, BA, CPC, CPEDC Director of Development & Operations Supercoder.com December 2011

2 Phone: (866)

3 Four Parts of a History Chief Complaint (CC) History of Present Illness (HPI) Past Medical Family Social History (PMFSH) Review of Systems (ROS). Phone: (866) customerservice@supercoder.com 3

4 Example: 99202: A level 2 new patient office visit requires an expanded problem-focused history. An expanded problem focused history requires: Type CPT Medicare CC Required for sick Required for sick HPI Brief 1-3 element/s ROS Problem Pertinent 1 system PFSH Not required Phone: (866) customerservice@supercoder.com 4

5 8 Areas That Help Determine HPI Location The place on the patient's body where the symptoms exist Context What the patient was doing when the problem occurred Phone: (866)

6 8 Areas That Help Determine HPI Quality Represents the chief complaint or signs or symptoms Timing The time of day the patient experienced the signs and symptoms Phone: (866)

7 8 Areas That Help Determine HPI Severity Just how serious is the patient s condition? Duration How long have the patient's signs and symptoms been present? Phone: (866) customerservice@supercoder.com 7

8 8 Areas That Help Determine HPI Modifying Factors What the patient did to alleviate pain or exacerbate Associated signs and symptoms Are any other problems the patient has in addition to the chief complaint? Phone: (866)

9 HPI Element Principles 1997 EM Guidelines allow you to count the status of chronic conditions 1-2 chronic conditions counts as a brief HPI; 3 or more is an extended HPI Physician must obtain and document the HPI must indicate his actual review and interaction Phone: (866) customerservice@supercoder.com 9

10 Guidelines never defined if staff are allowed to document the history of present illness Ancillary staff does not have permission to collect the HPI Ancillary staff can collect ROS and PFSH E/M service code values include physician work for performing the HPI. Phone: (866)

11 No double dipping. You get credit for any given HPI element only once In a note that indicates: dull, aching back pain, Dull +Aching 1 quality Phone: (866) customerservice@supercoder.com 11

12 Let s try it! Est patient here today for sore throat (location) and productive cough (associated signs and symptoms). Throat hurts worst at night (timing) and is a 7 (severity) Solution? The physician documented four elements in the note. Four elements counts as an extended HPI. For an established patient visit, an extended HPI supports a level greater than or equal to For a new patient visit code, extended HPI supports an E/M level greater than or equal to provided the visit meets all other required elements as well. Phone: (866) customerservice@supercoder.com 12

13 What Is ROS? Physician reviews systems directly related to the problem or problems identified in the HPI portion of the E/M and a number of additional systems. CPT defines ROS as: an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. Phone: (866) customerservice@supercoder.com 13

14 ROS helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options. Phone: (866)

15 Example: A patient reports to the FP complaining of a headache. The FP inquires about how long the headache has lasted, and a few other questions to rule out migraines. The FP discovers that the patient has not taken any medication for the headaches, he prescribes several overthe-counter options to deal with the condition, and tells the patient to come back in for another exam if the headaches worsen or increase in frequency. In this instance, you can only consider 1 system reviewed (neurological), since the FP has apparently only inquired about the system directly related to the problem. Phone: (866) customerservice@supercoder.com 15

16 Count These Systems CPT identifies the following ROS elements Constitutional Symptoms [fever, weight loss, etc.] Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary [skin and/or breast] Neurological Psychiatric Endocrine hematologic/lymphatic allergic/immunologic. Phone: (866)

17 What Are the Different ROS Levels? Problem-pertinent: When the physician reviews one system, you have a problem-pertinent ROS. This ROS level can support up to a level-two new patient E/M 99202, an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision making or a level-three established patient service 99213, an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity Phone: (866) customerservice@supercoder.com 17

18 What Are the Different ROS Levels? Extended: When the physician reviews two to nine systems, the encounter is an extended ROS. Extended ROS can support up to a level-three new patient service 99203, a detailed history; a detailed examination; and medical decision-making of low complexity) or level-four established patient service (99214, a detailed history; a detailed examination; medical decision-making of moderate complexity. Phone: (866) customerservice@supercoder.com 18

19 What Are the Different ROS Levels? Complete: For a complete ROS, most insurers accept a review of 10 or more systems with all others documented. Per CPT, a complete ROS requires a review of all additional body systems (14 systems). CMS Documentation Guidelines define a complete ROS as covering at least 10 organ systems. A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. E/M Documentation Guidelines With a complete ROS, reporting a 99204, or is possible -- depending on other encounter specifics. Phone: (866) customerservice@supercoder.com 19

20 Example: An internist sees a patient with multiple chronic conditions: COPD, CHF, hypertension, and diabetes. The physician asks questions about 10 of the systems, including constitutional, eyes, cardiovascular, respiratory, integumentary, neurological, and endocrine. He documents the positive and pertinent negative responses for 10 of the systems and writes: 10 of 14 systems obtained, remainder of systems are negative. This documentation would count as a complete ROS. Phone: (866) customerservice@supercoder.com 20

21 Tips: You can use a form or template to record ROS. Keep any form as part of the medical record When referring to old forms, include the review date and location of the previously recorded information. Include all 14 systems on form. Phone: (866) customerservice@supercoder.com 21

22 PMFSH Don t need until you get to a detailed history or on the new patient side a In the ED, you d be talking about a ( a detailed history; a detailed examination; and medical decision making of moderate complexity ) Observation code requires a detailed history For inpatient, 99221, 99243, and requires a detailed history Phone: (866) customerservice@supercoder.com 22

23 PMFSH A complete PMFSH addresses 2 or 3 of the PMFSH elements. Established patient visit requires 2 of 3 Initial visits and consults requires 3 of 3 A complete PMFSH might support up to Including: / / Phone: (866) customerservice@supercoder.com 23

24 Patient History Past medical: look for information on the patient s allergies, current medications, past illnesses and surgeries, and any conditions that may be relevant to the presenting problem. Example: A patient is taking insulin to treat her diabetes. The physician notes this, in case he decides to prescribe medication that may interact negatively with insulin. Phone: (866) customerservice@supercoder.com 24

25 Patient History Family history : a review of medical events in the patient s family, including diseases that may be hereditary or place the patient at risk. Also includes any inheritable condition or disease that is relevant to why the patient is seeking medical attention. Example: A patient presents with rectal bleeding. The physician notes that the patient s family has a history of colon cancer, this will affect treatment Phone: (866) customerservice@supercoder.com 25

26 Patient History Social history is just as important as family and past history. Items you should include: workplace living conditions marital status age-appropriate review of past and current activities Phone: (866)

27 Example: A 50-year-old man presents to the ED with chest pain. He has been experiencing shortness of breath and upper extremity discomfort for the past four hours. The patient has a history of coronary artery disease (CAD) and hypertension (HTN). He is and has been a smoker for 20 years, and his father had cardiovascular disease and died of an acute myocardial infarction (MI) at age 53. In this instance, the physician addressed past (CAD, HTN), family (father s CAD), and social (smoker) histories. 3 PFSH supports a complete PFSH. Phone: (866) customerservice@supercoder.com 27

28 Office Visits New Patient Codes History Exam Decision Making Problem Focused Problem Focused Straight forward Expanded Problem Focused Expanded Problem Focused Straight forward Detailed Detailed Low complex Comprehen sive Comprehen sive Moderate complex Time FF Comprehen sive Comprehen sive High complex Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3 Phone: (866) customerservice@supercoder.com 28

29 Office Visits Established Patient Codes History Exam Decision Making Not Required Not Required Not Required Problem Focused Problem Focused Straight Forward Expanded Problem Focused Expanded Problem Focused Low Complex Detailed Detailed Mod Complex Time FF Comprehen sive Comprehen sive High complex Key # 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3 Phone: (866) customerservice@supercoder.com 29

30 Level of History Chief Complaint (CC) Levels of History History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH) CPT Medicare CPT Medicare CPT Medicare Problem Focused Required Brief 1-3 elements Not Required Not Required Expanded Problem Focused Required Brief 1-3 elements Problem- Pertinent 1 system Not Required Detailed Required Extended 4 + elements OR 3+ chronic or inactive conditions Comprehensive Required Extended 4 + elements OR 3+ chronic or inactive conditions Extended 2-9 systems Pertinent 1 element Complete 10 systems Complete 2 or 3 elements Phone: (866) customerservice@supercoder.com 30

31 OFFICE/OUTPATIENT VISITEstablished Patient (Document either 2 or 3 key components history, exam & medical decision making at the required level OR time spent counseling the patient) History Level of Not Required Problem- Expanded Detailed Comprehensive History Focused Problem-Focused CC Not Required Required Required Required Required HPI Not Required 1-3 elements 1-3 elements 4 + elements OR 3 + chronic or inactive 4 + elements OR 3 + chronic or inactive conditions conditions ROS Not Required Not Required 1 system 2-9 systems systems PFSH Not Required Not Required Not required 1 of 3 elements 2 of 3 elements Physical Examination Level of Not required Problemfocused Expanded Detailed Comprehensive Exam Problem-Focused 1995 Not required 1 system 2-4 systems 5-7 systems 8 or > systems 1997 Not required 1-5 elements 6-11 elements 12 or > elements Level of MDM Not required Comp multisystem OR GU Medical Decision Making Straightforwar Low Moderate High d Face-To-Face Time 10 minutes 15 minutes 25 minutes 40 minutes Typical 5 minutes Times supervision* *Physician must be in the office during the E/M service. Phone: (866) customerservice@supercoder.com 31

32 Phone: (866)