Rational Physician Coding for Hospital Progress Notes Peter R. Jensen, MD, CPC www.emuniversity.com
Rational Physician Coding for Hospital Progress Notes Peter R. Jensen, MD, CPC For clinically driven E/M coding education, go to www.emuniversity.com Goals Learn the documentation requirements for hospital progress notes Understand how to identify the highest ethical level of care based on the cognitive labor provided Perform the documentation in an efficient manner to ensure compliance and save time Maintain the focus on patient care
Rational E/M Coding Hospital Progress Notes Accounted for a total of $4,562,84,66 in allowed charges in 2003 This adds up to 7.3% of E/M spending Three levels of care 9923 $32.00 99232 $54.50 99233 $77.60 40% 2
Hospital Progress Notes E/M Code 9923 99232 99233 History Exam Time Detailed Detailed SF/Low Moderate High Only 2 out of 3 key components must qualify 5 25 35 3
Coding Based on Time Hospital Progress Notes E/M Cod 9923 99232 99233 E/M Code 9923 Second l frequentl code for encount Reimbur about $3 History 9923 Exam SF/Low 2 out of 3 key components must qualify Time required would be 5 minutes Time 5 4
9923 E/M Code History Exam Time 9923 SF/Low 2 out of 3 key components must qualify Problem Focused History Problem Focused Exam SF/Low Complexity Hx Det Comp HPI Brief Brief Ext Ext ROS None 2 9 0 SH None None /3 3/3 Exam Det Comp Bullets 5 from any systems 6 from any systems 2 from any systems 2 from 9 systems SF Low Mod High Prob Pts What Does a 9923 Look Like? You are following a patient with dementia who is medically stable Pre wa No Th pat Tot 2 3 4 5 Data Pts 0-2 3 4 Risk Min Low Mod High Requires two out of three 5
Problems/DD Self limited or minor ( Established problem, Established problem, worsening New problem, no add work-up planned New problem, additio work-up planned Points tests sts MD age, ords Pts 2 2 Total oints = 0 6
Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Moderate High Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Calculating the Overall Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives Prescription drug management IV fluids, with additives Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care High 4 4 High Need 2 out of 3 to qualify for given level of 7
Selecting the Target Code E/M Code History Exam Time 9923 SF/Low 5 99232 99233 Det Det Mod High 2 out of 3 key components must qualify OR 25 35 9923 to go for the history and the and didn t worry about the exam. 8
History History HPI Brief ROS None SH None CC Inte rev Target Code 9923 2 out of 3 key components must qualify History Exam E/M Insight: A Problem Focused History SF/Low It doesn t take much to qualify for a problem focused history. It is difficult (but not impossi dition, which is r more HPI ele- No elements of format and istory and would Here, we co all we need ments of the ROS or S One way to state, No n This sort of be essentiall 9
Exam Constitutional Eyes ENMT Neck Lungs Physical Exam CV GI GU Chest/Breasts CC: Inte Pre info Phy Ta E/M Insight: Not a Problem Focused Exam It doesn t take much to qualify for a problem focused exam. It is difficult not to qualify f s goal. The exa o bullets are recor essentially invisible e general hese ele- Note tha appearan ments an 0
Medical Decision-Making CC: F/U dementia In P in P A Pl Target Code 9923 2 out of 3 key components must qualify History Exam SF/Low E/M Insight: Straightforward Medical Decision-Making ecision-making with one probble, the threshold of minimal up to low risk. efore assigning any routine
Alternative Ending CC: F/U dementia In Pr in P A Pl T Two out of Three is all You Need SF/Low Remember that hospital progress notes require qualifying documentation of only two out of t Physician C nents, but a decide whic In the above hand, we c the history. of complian The next pa 2
History Alternative Ending HPI ROS Brief None SH None CC: F/U dementia Target Code 9923 2 out of 3 key components must qualify History Exam Alternative Ending: 9923 SF/Low llets In this case, we did not use the history as one of our qualifying components. The nts of history. lem focused. of the patient ich is more than any systems g key compoany systems ny systems systems 3
Ac Us rec Le ST Do bot Pro do E/M Code 99232 Take-Home Messages: 9923 History 2 out of 3 key components must qualify Time required would be 25 minutes Most freque used code f encounters Reimbursem about $55.00 99232 Exam Mod Time 25 4
99232 E/M Code History Exam Time 99232 Mod 2 out of 3 key components must qualify Expanded Problem Focused History Hx Det Comp HPI Brief Brief Ext Ext ROS None 2 9 0 SH None None /3 3/3 Expanded Problem Focused Exam Exam Det Comp Bullets 5 from any systems 6 from any systems 2 from any systems 2 from 9 systems SF Low Mod High Prob Pts A Routine Hospital Patient 2 3 4 25 Moderate Complexity Data Pts 0-2 3 4 Risk Min Low Mod High Requires two out of three You see a patient with improving COPD exacerbation Th ble Yo or To mi 5
Problems/DDx Self limited or minor (M Established problem, st Established problem, worsening New problem, no additio work-up planned New problem, additional work-up planned Risk Minimal Low 4 Total Points = 3 Presenting Problems One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Diagnostic Procedures Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast 2 2 Total Points = Management Options Rest Gargles Superficial dressings Over the counter drugs Minor surgery, with no risk factors PT/OT injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiac EP studies Diagnostic endoscopies, with identified risk factors intensive monitoring for toxicity Obtain DNR or deescalate care 6
Calculating the Overall Complexity Problems Data Risk Selecting the Target Code 2 out of 3 key components must qualify 7
Target 9923 99232 This level of care was billed 48,763,47 times in 2004 $ T An expande history requ HPI and on elements of Remember, only t let s see how the d the and didn Purpose-Driven Documentation 2 out of 3 ke 8
History HPI Brief History ROS SH None CC: F/U COPD Interval History: The patient has no spontaneous somatic complaints. Target Code 99232 2 out of 3 key components must qualify History Exam Mod E/M Insight: Not an Expanded Problem Focused History In this case, the statement, The patient has no spontaneous complaints. contains no 9
Constitutional Eyes ENMT Neck Lungs CV 2 M Exam GI GU CC: F/U COPD Interval History: The Physical Exam: An ex least 6 bull organ syst Target Code 99232 2 out of 3 key components must qualify History Exam Psychiatric Mod E/M Insight: An Expanded Problem Focused Exam You can see that it doesn t take much to qualify for an expanded problem focused exam. All you need is six to bullets from any organ systems. In this case the following six bullets were documented:. A b 2. Th 3. Au 4. As 5. Au 6. As required for an ex- This a pande 20
Medical Decision-Making Interval History: The patient has no spontaneous somatic complaints. Physical Exam: NAD, conversant; 20/80, 98.6, 24 Assess Plan: Target Code 99232 2 out of 3 key components must qualify History Exam E/M Insight: Moderate Complexity Mod We know that this adds up to moderate complexity because we added up the 2
Alternative Ending Interval History: The patient has no spontaneous somatic complaints. Physical Exam: Assessment: Plan: The exam On t abou choo Target Cod 99232 Two out of Three is all You Need ta Pts 0-2 3 4 DM od Risk Min Low Mod High 22
History Alternative Ending HPI ROS Brief SH None Alternative Ending: 99232 Now the history above does qualify as being an expanded problem focused history: Brief HPI: Q One ROS: Q On the other we only incl tion of the lu The d M d 23
Take-Home Messages: 99232 E/M Code 99233 History Det 2 out of 3 key components must qualify Time required would be 35 minutes Least frequently used code for these encounters Reimbursement is about $78.00 99233 Exam Det High n Time 99 99 99 35 24
99233 E/M Code History Exam Time Hx Det* Comp 99233 Det Det High 2 out of 3 key components must qualify Detailed History HPI Brief Brief Ext Ext ROS None 2 9 0 SH None None 0/3 3/3 Exam Det Comp Detailed Exam Bullets 5 from any systems 6 from any systems 2 from any systems 2 from 9 systems SF Low Mod High 2 3 4 35 High Complexity Prob Pts Data Pts 0-2 3 4 Risk Min Low Mod High Requires two out of three *When completing a detailed history for a hospital progress note, the usual requirement for one element of SH is waived. This means you can qualify for a detailed history for these encounters WITHOUT using any elements of SH. You se who ha The pat 34 0 74 35 V diuretics and broaden entation is about 24 25
Points Risk Minimal Low Moderate High Self limited Established Established worsening New proble work-up pla Problems/DDx New problem, additional work-up planned O ex T U un O wi A inj or A ne Pts 4 Total Points = 0 Presenting Problems One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Data Reviewed Decision to obtain old records Review of old records Diagnostic Procedures Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Pts 2 Total Points = 4 Management Options Rest Gargles Superficial dressings Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives
Calculating the Overall Complexity SF Low Moderate High Problems 2 3 4 Data 0-2 3 4 Risk Min Low Mod High Need 2 out of 3 to qualify for given level of E/M Code 9923 99232 99233 Selecting the Target Code History Det Exam Det SF/Low Mod High Time 2 out of 3 key components must qualify 5 25 35 27
99233 This level of care was billed 6,060,05 times in 2004 $,236,59,87 in allowed charges Time required would be 35 minutes A detailed* history requires an extende /3 S 99233 Detailed History Detailed Exam High Complexity A detailed exam requires at Purpose-Driven Documentation, 2 out of 3 key components must qualify 28
History Detailed HPI Extended History ROS 2-9 SH None CC: F/U CHF Interval H volume o ROS: Sta Target Code 99232 2 out of 3 key components must qualify History Exam E/M Insight: A Detailed History The above history qualifies as being a detailed history: Ex mo R Ho Mod e or SH. 29
Exam Constitutional Eyes ENMT Neck Lungs Physical Exam 2 3 CV GI GU CC: F/U CHF Interval History: The patient s CHF has worsened. HTN is poorly controlled due to volume overload. Diabetes is not controlled on current insulin sliding scale. ROS: Physi Lung The ab. Gen 2. Aus 3. Ass A detai to quali al- That s ready h making E/M Insight: Not a Detailed History Chest/Breasts tal n close 30
ROS: C P Physical Exa bibasilar cra Assessment Plan: Medical Decision-Making CC: F/U CHF Interval History: The patient s CHF has worsened. HTN is poorly controlled due to volume o Target Co 99233 The example above qualifies as being of high complexity medical decisionma n to credit for yo ddressed (to re as acute in or- He do de Yo re hidden behind th in order to get th 3
CC: F/U CHF Inter to vo ROS Phys bibas Asse Plan: Tar 9 Alternative Ending Two out of Three is all You Need The above example shows how you might document this encounter using the history and the M On the other h could just hav next page sho complete the d 32
History Detailed Alternative Ending HPI ROS Extended 2-9 SH None Interval History: The patient feels worse today. Exam: Conversant, NAD; 65/90, 28, 78 A P The history no longer qualifies as being a detailed history. In fact, the statement, The p On the requir The fo The M 33
Doc Req not Usu sign Lear Alm Take-Home Messages: 99233 Can We Use Templates? It is acceptable to use templates to doc Yo as Th per Th by 34
H i s t o r y P h y s i c a l M D M Patient: Date: CC: Interval History: : -3 HPI elements or status of - 3 problems (No ROS required) (9923) Constitutional: NAD, conversant, pleasant BP HR RR T Eyes: Anicteric sclerae, moist conjunctiva, no lid-lag PERRLA fundi clear, disc margins sharp ENMT: NC/AT Neck: Supple, FROM; no masses or JVD Self-limited or minor (max 2) (appearance) oropharynx clear; no erythema/exudate no carotid bruits Lungs: CTA and percussion normal respiratory effort CV: RRR, no MRGs normal PMI no peripheral edema ABD: Soft, NABS, no masses no HSM no hernias Skin: Normal temperature, tone, texture and turgor; no induration or subcutaneous nodules no rash, lesions or ulcers Ext: No digital cyanosis/ischemia Pedal and femoral pulses intact and symmetrical; Normal gait and station Psych: A & O X 3 appropriate affect intact judgment Neuro: CNs II - XII intact no focal sensory deficits : - 5 bullets : 6 bullets Detailed: 2 bullets 4 3 2 Problem Points New, further w/u is planned New, no further w/u planned Established, not controlled Established, stable. 2. 3. 4. 5. H o s p i t a l P r o g r e s s N o t e 2 out of 3 Key Components Required E/M Hx Exam Time 9923 SF/Low 5 99232 Mod 25 99233 Det Det High 35 Hem/Lymphatic : - 3 HPI elements or status of - 3 Det: 4 HPI elements or status of 3 problems, problems plus ROS (99232) 2-9 ROS; NO SH required (99233) Allergic/Immun (three vital signs) Assessment & Plan Exam Findings & Data Reviewed Signature Minimal Risk Low Risk Moderate Risk High Risk ROS (-) Positive Findings Constitutional Eyes ENT Cardiovascular Respiratory Gastrointestinal Genitourinary Skin Musculoskeletal Psychiatric Endocrine Neurological Data Reviewed Review and/or order clinical lab tests Review and/or order radiology tests Review and/or order medical test (Ts, EKG, echo, cath) Discuss test with performing MD Review of image, tracing, specimen Decision to obtain old records Review and summarize old records Prob Pts Data Pts Risk E/M SF Min 9923 Low 2 2 Low Mod 3 3 Mod 99232 High 4 4 High 99233 Only 2 out of 3 components required Pts 2 2 One self limited problem (e.g., cold, insect bite) Two self-limited problems One stable chronic illness Acute uncomplicated illness (e.g., cystitis/rhinitis) OTC drugs Mild exacerbation of one chronic illness Two stable chronic illnesses Undiagnosed new problem Acute illness with systemic symptoms (e.g., pyelonephritis, colitis) Prescription drug management E/M University: For practical E/M coding education go to www.emuniveristy.com Severe exacerbation of chronic illness Illness with threat to life or bodily function Abrupt change in neurological status (e.g., TIA/weakness) Parenteral controlled substances Decision for DNR or to de-escalate care Drugs requiring intensive monitoring for toxicity
F/U CHF The patient feels worse today. X 65/90 The document check boxes to X X X you can use It is important qualify for the medical de tient). Our E/M Univ their medical to calculate 36
History Physical Focus on the Medical Decision-Making Perform the documentation in a purpose-driven manner Only two out of three are needed! Avoid time-wasting over-documentation Relax and let the patient choose the level of care Peter R. Jensen, MD, CPC Online and On-site Physician-to-Physician E/M Coding Education -888-U-EM-CODE pjensen@emuniversity.com Practical E/M Coding Education www.emuniversity.com 37