EMERGENCY MEDICINE PHYSICIAN E & M, CRITICAL CARE AND OBSERVATION & PROCEDURE CODING. Medical Account Services, Inc.

EMERGENCY MEDICINE PHYSICIAN E & M, CRITICAL CARE AND OBSERVATION & PROCEDURE CODING Medical Account Services, Inc. Presented By: Lynne Severn MBA, CPC, CPMA 351 Ballenger Center Drive, Ste. 250 Frederick, MD 21701 240-529-1456 severnl@masbilling.com All rights reserved g T B THE BASICS 2 1

CHECK YOUR RECORDS FOR THE FOLLOWING: The medical record should be complete and legible The patient s name and the date of service should appear on every page of the record Date of Service on the record should match the date of service on the claim The medical record should clearly indicate the identity and professional credentials of all the people who contributed to the service Information in the record should support all diagnosis reported on the claim All procedures should be clearly documented E & M Documentation should include HPI, ROS, PFSH, Exam and MDM Health risk factors should be identified Patient s progress, response to and changes in treatment, and diagnosis revisions should be documented Any condition that prevents you from collecting basic information should be noted 3 PROVIDER SIGNATURES Documents must have a legible full signature Legible first initial & last name If the signature is not legible then over or under the illegible signature you must : Type or print the provider s name Requirements are not considered to be met if: Initials only There is an unsigned typed note with providers typed name There is an unsigned handwritten note Statement - signature on file Illegible full or partial signature Stamp signatures CMS Signature Requirements -CMS MLN MM6698 - March 16, 2010 4 2

ICD-9 SIGNS AND SYMPTOMS VS. FINAL DIAGNOSIS ICD-9s are reported on all bills. The ICD-9 rules were not designed for billing purposes. Unfortunately, payers are now using the ICD-9s to establish medical necessity for claims. Payers can use the diagnosis to deny line items/claims. Claims processing problems arise when the services provided are not supported by the primary diagnosis. Conclusion Be aware of the need to establish medical necessity Use pain and injury codes where appropriate Incorporate signs and symptoms as appropriate ICD-9 codes should explain the reason for the visit in the medical record and support the necessity for the treatment of an illness and are important in submitting a claim cleanly the first time. 5 6 SHARED VISITRULESR 3

SPLIT/SHAREDVISIT RULES Qualified Non Physician Providers (NPPs) who are permitted to assist a physician during a shared visit are: Nurse practitioners Physician assistants Clinical nurse specialists Certified nurse midwife Medicare reimburses services provided by an NPP alone at 85% of the rate it reimburses physicians. However, CMS reimburses visits shared between the physician and the NPP at 100% of the allowed amount to the physician. To obtain the full reimbursement allowed, the physician must document his or her participation in the care of the patient along with the NPP s documentation of his or her portion of the care. If the documentation does not support the physician s presence and the portion of work the physician performed, the NPP should report the care alone. 7 REPORTINGSPLIT/SHARED VISITS TO MEDICARE The split/shared visit rules state that both the NPP and the physician must have a face-to-face encounter with the patient on the day the facility or practice reports the service. (The Handshake Rule) Both the physician and the NPP should document their own participation in the medical record. The physician practice employs the NPP. Warning - do not report a shared visit when a hospital facility or other entity employs the NPP. The physician cannot simply co-sign the chart and state reviewed and agree in the record without seeing the patient personally. The physician must perform and document at least some of the three key components of E/M services (i.e., the history, the exam, and the medical decision-making) https://www.cms.gov/transmittals/downloads/r178cp.pdf 8 4

9 TEACHING PHYSICIAN RULES 10 5

Why Do We Need to Know the Teaching Physician Rules? The PATH audits led to the creation of compliance programs at major teaching institutions across the United States, often because those institutions were forced to pay settlements to the federal government due to abuses found when teaching physicians either did not meet the physical presence requirements when residents or fellows performed services or did not properly document their role in the billing of those services. HIM professionals must understand the guidelines to accurately code and bill medical services properly and handle PATH audits. 11 BECAUSE. Resident services are paid directly to hospitals via the Accreditation Council for Graduate Medical Education (ACGME). Teaching physicians are paid for their hi involvement in the care of patients, not for time spent teaching. According to the Medicare Part B Reference Manual: In the teaching setting, physician services provided to individual patients are considered to be the payment responsibility of the Part B carrier. Conversely, physician services that are furnished for the general benefit of patients (i.e., supervising and teaching of residents) are considered to be services to the hospital and are therefore the payment responsibility of the Part A intermediary. 4 In other words, teaching physicians who intend to bill for their services must document their involvement in the specific care of the patient. 12 6

TP RULES The TP must demonstrate in the documentation their personal involvement in the care of the patient. The TP must briefly describe his/her presence and participation in the service. The TP must see the patient and personally write or dictate a note in order to bill for the services. The TP must Tie-In to the resident note to be able to use their documentation to support the code selected for payment purposes. 13 TEACHING PHYSICIAN TIE IN STATEMENT The attending physician always needs to write a linking statement in order for us to be able to use any of the resident s documentation 14 7

WE CANNOT USE ANY OF THE RESIDENT S DOCUMENTATION TO SUPPORT THE LEVEL OF SERVICE BILLED WITHOUT THE TEACHING PHYSICIAN LINKING STATEMENT. THE TP DOCUMENTATION DO S ANDDON'TS It has been clearly established that the following statements by the teaching physician, appended to the resident/fellow s note, are not sufficient i to support a billable service. 16 8

TEACHING PHYSICIAN REQUIREMENTS FOR PROCEDURE NOTES Use the GC modifier to indicate that the Teaching Physician (TP) was present during the key portion and immediately available during other parts of the service 5 minutes or Less Resident must document that the TP was present for the entire procedure or surgery and both must sign the note Endoscopy procedures - the TP must be present for the entire viewing Longer than 5 minutes TP must be present during key portion(s) of the procedure Resident must document the TP s presence during the key portions of the procedure in the note and both must sign http://www.cms.gov/mlnproducts/downloads/gdelinesteachgresfctsht.pdf http://www.cms.gov/transmittals/downloads/r811cp.pdf 17 GOODPROCEDURENOTE BY ATTENDING & RESIDENT Detailed notes from senior resident As well as the Teaching Physician 18 9

Students can only document History Never the exam or MDM Recommend students not document on any of the documentation used for billing. 19 20 E&MC CODING 10

EM/LEVEL WORKSHEET 1. History 2. Physical Examination 3. Medical Decision Making 21 HIGHMARK AUDIT SHEET 22 11

HIGHMARK INTERPRETATION NEGATIVELY IMPACTS MDM IN THE ED SETTING EKGs Pulse Oxygen Minimal 99281 Low 99282 Moderate 99283 & 99284 High 99285 NEED 4 (coders often can only find 2 or 3 data points) 23 PLEASE NOTE IN ED NOT THE SAME AS OFFICE 24 12

EMERGENCY & OBSERVATION DOCUMENTATION REQUIREMENTS Service CPT History Physical Exam MDM EMS Level 1 99281 Problem Focused Problem Focused Straightforward EMS Level 2 99282 Expanded Problem Focused EMS Level 3 99283 Expanded Problem Focused Expanded Problem Focused Expanded Problem Focused Low Moderate EMS Level 4 99284 Detailed Detailed Moderate EMS Level 5 99285 Comprehensive Comprehensive High Observation Level 1 Mult. Calendar Days Observation Level 2 Mult. Calendar Days Observation Level 3 Mult. Calendar Days 99218 Detailed or Comprehensive Detailed or Comprehensive Straightforward to Low 99219 Comprehensive Comprehensive Moderate 99220 Comprehensive Comprehensive High Observation D/C Day 99217 + + + Same Day OBS & D/C Level 1 Same Day OBS & D/C Level 2 Same Day OBS & D/C Level 3 99234 Detailed or Comprehensive Detailed or Comprehensive Straightforward or Low 99235 Comprehensive Comprehensive Moderate 99236 Comprehensive Comprehensive High 25 THE FINAL LEVEL CODED IS ONLY AS STRONG AS THE WEAKEST COMPONENT If one key component falls short of a given E/M level, the final code level l falls as well. Three Documentation Sections: History Physical Exam Medical Decision Making 26 13

CHIEF COMPLAINT Required for all visit and levels of service. This must be noted for every patient seen in the Emergency Department 27 HPI ALWAYS TRY TO LIST FOUR OF THE FOLLOWING ELEMENTS THIS ALLOWS THE CODERS TO POTENTIALLY MEET A LEVEL 99285 Modifying Factors Quality Severity Timing Context Location Duration Associated Signs & Symptoms 28 14

EXAMPLE OF AN EXTENDED HPI CONTEXT, QUALITY, LOCATION AND ASSOCIATED SIGNS AND SYMPTOMS 29 HPI Levels 99281, 99282 & 99283 - Need 1 to 3 elements Levels 99284 & 99285 - Need 4 or more elements Two HPI Types: Brief 1 to 3 HPI (99281 99283) elements - Patient complains of dull ache in left ear over the past 24 hours Extended at least 4 HPI elements (99284 99285) Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen 30 15

REVIEW OF SYSTEMS Levels 99281, 99282 and 99283 require one system Level 99284 requires 2 to 9 systems Level 99285 requires 10 systems or more unless you note that all systems were negative except as marked or you note that the history collection was limited due to the patient s altered mental status or patient acuity 31 THIRD DOCUMENTATION REQUIREMENT REVIEW OF SYSTEMS Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological l Psychiatric Endocrine Hematologic/Lymphatic Allergic/immunologic 1. Complete ROS consists of at least 10 organ systems 2. The ROS can be documented by listing the system followed by negative or normal 3. The ROS can also be documented by listing the signs or symptoms that the patient has denied 4. Documenting review of systems negative or normal does not meet any numerical requirement and is not considered a ROS. Always indicate a negative or positive statement for each system 5. Documenting any pertinent positives and negative combined with the statement all other systems negative will be considered a complete ROS. However, all other systems negative indicates that the physician has reviewed all 14 systems 32 16

JUST NOTING ALL OTHER SYSTEMS NEGATIVE IS NOT ENOUGH DOCUMENTATION TO SCORE A COMPLETE ROS. YOU MUST HAVE SOME PERTINENT POSITIVES OR NEGATIVES 33 ROS ITEMS CAN BE FROM TAKEN FROM THE HPI SECTION BUT YOU CANNOT USE THE SAME DOCUMENTED ELEMENT AS AN ROS ELEMENT IF YOU HAVE ALREADY USED IT AS AN HPI ELEMENT. HPI Elements Location GI Duration 2 days Quality Like no Pain she has ever had Associated Signs and Symptoms diarrhea with some blood tinged to it ROS Elements GI Cardiovascular Respiratory GU 34 17

PFSH TWO TYPES PERTINENT & COMPLETE 1. Pertinent 99284 (1 area) 2. Complete - In-patient & Observation Complete 99285 (2 areas) cases Review 2 of the history areas: Medical Family Social Review all 3 history areas: Medical Family Social 35 NO PAST, FAMILY OR SOCIAL HISTORY COLLECTED = 99281-99283 36 18

E/M DOCUMENTATION INSTRUCTIONS *Complete PFSH: 2 hx areas: a) Estab pts, office (outpt) care; domiciliary care; home care b) Emergency Dept c) Subseq nursing facility care 3 hx areas: a) New pts, office (outpt) care; domiciliary care; home care b) Consultations c) Initial hospital care d) Hospital Observation e) Comprehensive nursing facility assessments 37 THE EMERGENCY MEDICINE CAVEAT If the physician is unable to obtain history from the patient or other source, the record should describe the patient s medical condition/other circumstance, which precludes obtaining a history. CMS 1995 Guidelines Urgent/emergency conditions Patient s inability to communicate Patient at a very high level of risk Immediate action necessary 38 19

THE EMERGENCY MEDICINE CAVEAT You must state the reason the history is not obtained and documented on the record. Must act quickly to prevent deterioration of patient statuss Patient too ill to speak, uncooperative, unconscious 39 EXAM - 1995 EXAMINATION GUIDELINES Problem Focused 1 Body Area or Organ System Expanded dproblem Focused 2-7Body Areas or Organ Systems; with ihlimited i dexam of Affected Body Area/System. Detailed Comprehensive 2-7 Body Areas or Organ Systems; with Extended Exam of Affected Body Area/System. 8 or More Organ Systems; or a Complete Single System Exam Body Areas Head (including face); Neck; Chest (including breast/axillae); Abdomen; Genatalia; Groin; Buttocks; Back (including spine); Each Extremity Organ Systems Constitutional (vital signs, general appearance); Eyes; ENT; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Skin; Neurologic; Psychiatric; Hematologic/Lymphatic/Immunologic. 40 20

DOCUMENTING A SYSTEM = COMPLETING AT LEAST TWO BULLET ITEMS 41 Medical Necessity MEDICAL NECESSITY IS THE OVERRIDING FACTOR IN DETERMINING WHETHER A SERVICE IS A COVERED BENEFIT. YOU CAN PERFORM A COMPLETE HISTORY AND EXAM BUT WITHOUT DOCUMENTING THAT IT IS MEDICALLY NECESSARY THE OIG WOULD SAY THE CASE WAS OVER-CODED IF THE LEVEL OF SERVICE PROVIDED WAS MORE THAN WHAT IS NECESSARY TO EVALUATE AND MANAGE THE PATIENT S CONDITION THAT PROMPTED THE VISIT. 42 21

MEDICALDECISION MAKING Number of Dx or Treatment Options Almost all ED patients qualify as a new problem to the examiner. They only differ based on whether or not any additional workup is planned. 43 NUMBER OF DIAGNOSIS OR TREATMENT OPTIONS -CONTROVERSY Method 1 - Counting any diagnostic work-up that occurs in the ED as additional work-up planned tends to cause many encounters to score to a higher MDM and E&M level than what may be warranted dbased on the nature of presenting problem. From a clinical i l perspective it is hard to make the argument that a patient that presents with a sore throat and has a strep test done should be scored as Extensive with regards to the number of diagnoses or management options. This can lead to scoring low risk cases as 99284s simply because of the MDM scoring system. Method 2 - For ED E&M services reserve the additional work-up planned for those patients who will receive additional work-up after the ED encounter. This will help your coders more clearly differentiate between 99283, 99284 and 99285 within your practice. The 2 common interpretations are described above, however, Medicare carrier Highmark s interpretation is an extension of #2. The state that the additional work-up must be after the current encounter and has to be performed by the same MD. Their position is that the ED MD would never be given credit for additional work-up planned. 44 22

AMOUNT/COMPLEXITY OF DATA REVIEWED Points Type of Data 1 Review/Order Clinical Lab Tests 1 Review/Order Tests in 7XXXX of CPT 1 Review/Order Tests in 9XXXX of CPT 1 Discuss Test Results with Performing MD 2 Independent Visualization of Image, Trace, Specimen 1 Decision to Obtain Old Records/ HX from others 2 Review/Summarize Old Records and/or Obtain HX from Others, and/or Discuss with other Provider SF Low Moderate High Number of Diagnostic and Management Options Amount and/or Complexity of Data Reviewed Minimal (1) Minimal/No ne Limited (2) Limited (2) Multiple (3) Moderate (3) Extensive (4) Extensive (4) Risk (refer to table of risk) Minimal Low Moderate High 45 WEAK MDM BECAUSEWECAN T SCOREDATA REVIEWED POINTS OR DOCUMENT RISK = 99284 EKG BOX NOT CHECKED FOR INTERP. BY ME, NO TREATMENT NOTED, NO RXS, NO CONSULTS = WEAK MDM 46 23

Speaking with another health care provider from another practice or service = 2 MDM points you must be specific and identify who you spoke with. 47 Deciding to collect the history from the parents or others = 1 point Summarizing and collecting the history from the parents = 2 points 48 24

Ordering an EKG = 1 MDM point Doing the interpretation = 2 MDM points but you must indicate it was my interpretation 49 NO EXTRA MDM DATA POINTS SCORED 50 25

EXAMPLES OF T-SYSTEM BOXES THAT SCORE MDM DATA POINTS 1. Hx Exam Limited 3. X-Rays 2. ROS Box 4. Wound Description / Repair 51 MORE MDM DOCUMENTATION BOXES 5. Prior Records Reviewed & Counseled Patient etc. 6. Treatment / Intubated 7. EKG, Lab, X-Rays 8. Procedures 52 26

MEDICAL DECISION MAKING Risk of complications and/or morbidity SF Low Moderate High Number of Diagnostic and Management Options Amount and/or Complexity of Data Reviewed Risk (refer to table of risk) Minimal (1) Minimal /None Limited (2) Limited (2) Multiple (3) Moderate (3) Extensive (4) Extensive (4) Minimal Low Moderate High 53 FOR A LEVEL 99285: Points Type of Data 1 Review/Order Clinical Lab Tests 1 Review/Order Tests in 7XXXX of CPT 1 Review/Order Tests in 9XXXX of CPT 1 Discuss ss Test Results with Performing MD 2 Independent Visualization of Image, Trace, Specimen 1 Decision to Obtain Old Records/ HX from others 2 Review/Summarize Old Records and/or Obtain HX from Others, and/or Discuss with other Provider HISTORY: 04 HPI PHYSICAL EXAM: 10 ROS 8 Organ Systems with 02 PFSH two bullets each MDM: High Risk and 4 Data Points See chart above 54 27

55 CRITICALCAREC CODING DEFINITION OF CRITICAL CARE Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to; central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. 56 28

MEDICARE POLICY FOR CRITICAL CARE Before coding critical care ask and answer the following questions: 1. Does the record demonstrate work preformed during the encounter is more intensive than the work of other E/M codes of the same time duration? 2. Does the record demonstrate the patient has acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration? 3. Does your documentation demonstrate; direct personal involvement, frequent assessments, a high-complexity of MDM and urgent interventions? 4. Is the time spent specifically recorded? 57 ACTIVITIES QUALIFYING FOR CRITICAL CARE Time spent w/patient Reviewing test results Discussing patient s care w/medical staff Documenting critical care services in medical services record Discussing patient s condition with family (but only questions regarding treatment) 58 29

OTHER CODING REQUIREMENTS Only one physician may bill for critical care services during any one single period of time even if more than one physician is providing care to a critically ill/injured patient. Both of the following medical review criteria must be met in addition to the CPT definitions: Clinical Condition Criterion There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient s condition which requires the highest level of physician preparedness to intervene urgently. Treatment Criterion Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient s condition. Providing medical care to a critically ill patient should not be automatically determined to be a critical care service for the sole reason that the patient is critically ill. The physician service must be medically necessary and meet the definition of critical care services as described previously in order to be considered covered. 59 No Shared Visits When Billing for Critical Care A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified NPP for the specified reportable period of time and shall not be representative ti of a combined service between a physician and a qualified NPP. 60 30

TP CRITICAL CARE RULES Time spent teaching may not be counted towards critical care time. Time spent by the resident in the absence of the Teaching Physician is not counted toward critical care time. The Teaching Physician must be present for all critical care time billed. Only time spent by the resident and Teaching Physician together with the patient, or time spent by the Teaching Physician alone with the patient, may be counted towards critical care time. The TP must document their PERSONAL time involved. 61 Medical Review Guidelines regarding Full Attention Since critical care is a time-based code, the physician s progress note must contain documentation of the total time involved providing critical care services. Time involved performing procedures that are not bundled into critical care (i.e., billed separately) may not be included ddand counted toward critical care time. The physician s py progress note must document that time involved vdin the performance of separately billable procedures was not counted toward critical care time. Time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when the patient is unable or incompetent to participate in giving a history and/or making treatment decisions and the discussion is absolutely necessary for treatment decisions under consideration that day, and all of the following are documented in the physician s progress note for that day: the reason the patient was unable or incompetent to participate in giving history and/or making treatment decisions the necessity of the discussion (e.g., no other source was available to obtain a history or because the patient was deteriorating so rapidly needed to discuss treatment options with family immediately ) the treatment decisions for which the discussion was needed a summary of the discussion as related to the treatment decision. The physician s progress note must link the family discussion to a specific treatment issue and explain why the discussion was necessary on that day. All other family discussions, no matter how lengthy, may not be counted towards critical care time. 62 31

CRITICAL CARE 99291: Code used to report the 1 st hour ( up to 74 minutes) on a given date of service. 99292: Code used for each 30 minutes beyond the 1 st hour. Critical care of less than 30 minutes may not be reported separately 63 BUNDLED SERVICES Interpretation of cardiac output measurements Chest x-rays Blood gases Blood draw from specimen Analysis of information data stored in computers Gastric intubation Pulse oximetry Temporary transcutaneous pacing Ventilator Management Vascular access procedures Family psychotherapy 64 32

65 O C OBSERVATION CODING OBSERVATION CARE DEFINED Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Highmark/CMS 66 33

IT ISIMPORTANT TO DOCUMENT OBSERVATION CORRECTLY BECAUSE: OIG CERT findings of inappropriate admits RAC findings lack of medical necessity for short stays Coding and Billing rules are confusing Hospital and Physician billing both depend on time line being established 67 OBSERVATION REQUIREMENTS Intended for short stays of 24 48 hours Out-patient locations 22 or 23 A written order to begin observation services is required Start time must be documented End time must be documented Services provided must be consistent with the order 68 34

OBSERVATION DOCUMENTATION Medical record must demonstrate: Consistency between the practitioner intent and services provided Medical necessity of services Medical appropriateness of the observation stay **Include a dated and timed order for observation, interval progress notes and a discharge note** 69 OBSERVATION SERVICES 99217 Observation care discharge 99218 99220 Initial Observation care 99224-99226-Subsequent Observation care 99234 99236 Observation or Inpatient Care Services (Including Admission and Discharge Services) 70 35

E/M DOCUMENTATION INSTR. *Complete PFSH: 3 hx areas: a) New patients, office, out-patient care; domiciliary care; home care b) Consultations c) Initial hospital care d) Hospital Observation e) Comprehensive nursing facility assessments 71 WITHOUT ALL 3 HISTORIES (PFSH) YOU CANNOT BILL ABOVE OBSERVATION CODES 99218 OR 99234. NO MATTER WHAT THE PATIENT S ACUITY AND MDM INDICATE 72 36

73 P N PROCEDURE NOTES INTUBATION- NEED TO KNOW; SIZE OF THE TUBE, HOW IT WAS PLACED, CONFIRM CORRECT PLACEMENT, POST PROCEDURE PATIENT STATUS The patient was positioned appropriately and a # 4 endotracheal tube was placed under direct laryngoscopy. Correct placement was confirmed by presence of bilateral breath sounds without air sounds in the abdomen on auscultation. A CO 2 monitor was also used to confirm tracheal placement of the ET tube. A chest x-ray was ordered to assess for pneumothorax and verify endotracheal tube placement. The patient tolerated the procedure well and there were no complications. 74 37

LUMBAR PUNCTURE NEED TO KNOW; ANESTHESIA TYPE, PREPPED AND DRAPED, SIZE OF NEEDLE, WHERE IT WAS INSERTED, HOW MUCH FLUID WAS REMOVED, TESTS ORDERED, AND PATIENT S POST PROCEDURE STATUS Procedure - Lumbar Puncture Indication meningitis Anesthesia - local 1% lidocaine w/ epi. Informed consent was obtained from the patient's mother. The area was prepped and draped in the usual sterile fashion. Using landmarks, a 22 gauge spinal needle was inserted in the L4-L5 space. The stylet t was removed and the opening pressure was measured at 18 cm of water. 4cc of clear fluid was collected and sent for routine studies. CSF was also sent for HSV and EBV PCR. The patient tolerated the procedure well. There 75 was no blood loss or hematoma. DOCUMENTING THE INTERPRETATION OF A 12 LEAD EKG Document at least 3 of the following 6 elements: Rhythm h and rate Axis Intervals ST segment change Comparison to prior EKG Diagnosis (i.e. acute inferior MI ) Use personal pronouns to indicate that the interpretation i was done by the ED physician My interpretation follows 76 38

BILLABLE EKG NOTE CPT CODE 93010 INTERPRETATION AND REPORT ONLY 77 SUTURING May bill in addition to E&M code (use modifier 25 on the E&M level as appropriate) Use total length of all wounds of the same type in same area Describe the complexity of the repair. Is there: Extensive contamination, i Foreign body removal Defect creation or margin revision for proper closure 78 39

FAST EXAMS (FOCUSED ASSESSMENT BY SONOGRAPHY FOR TRAUMA) Clinical approach- There is no fast exam specific code a. First look for fluid around the heart by performing a limited trans thoracic echocardiography. b. Then look for free fluid in the abdomen by performing a limited abdominal ultrasound. Dual Service 2 separate CPT codes. 93308 26 Eh rdi rph r ltim 93308-26 Echocardiography real time 76705-26 Ultrasound abdominal real time *Remember you are required to retain the actual image in your documentation as well as your separately identifiable interpretive report. 79 FAST EXAM DOCUMENTATION 93308-26 Looks for heart activity & pericardial fluid. It is directed to a single diagnostic problem. NOTE: Identify the presence or absence of pericardial fluid. 76705-26 Looks for free fluid in the abdomen or hemoperitoneum. NOTE: Identify the presence or absence of pericardial or intraperitoneal fluid. 80 40

OTHER BILLABLE ULTRASOUNDS Abdominal Aortic Aneurysm 76775-26 Echography, abdominal, B-scan and/or real time with image documentation limited (single organ, quadrant, follow-up) Pericardial Fluid 93308-26 Echocardiography, transthoracic, real-time with image documentation; limited 81 BILLABLE NOTE FOR 93308-26 82 41

OTHER COMMON ULTRASOUNDS DONE IN THE EMERGENCY DEPARTMENT Pregnancy state is known prior to the study Use CPT code 76815-26 Pregnancy state not known prior to the study Use CPT code 76857-26 Echography, pregnant uterus, realtime with image; limited Echography Pelvic (non-obstetric), real-time with image; limited Is used to determine the status of the pregnancy or to evaluate a pregnancy-related condition Is used to assess a non-pregnancyrelated pelvic condition 83 ULTRASOUND GUIDANCE FOR NEEDLE PLACEMENT CPT CODE 76942-26 Ultrasound guidance is sometimes used for needle placement when performing a biopsy, aspiration, injection or starting an IV. Use still must retain an image Also used when performing the following procedures; paracentesis, thoracentesis, suprapubic aspiration, foreign body localization, or locating an abscess for drainage. 84 42

CONSCIOUS SEDATION = MODERATE SEDATION Documentation Rules Tell us who performs the procedure requiring sedation Tell us who provides the moderate sedation services Tell us the patient s age Tell us who is helping you to monitor the patient if you are also performing the procedure Tell us about monitoring the patient s cardiorespiratory functions (pulse-oximetry, cardiorespiratory monitor, and blood pressure) for the duration of the procedure Tell us when you start and stop the procedure If the same person is performing the procedure and providing the moderate sedation then we need you to note that there was an independent trained observer assisting in the monitoring of the patients level of consciousness and physiological status if the answer is yes we can bill for the procedure and the conscious sedation This is good news! 85 REMEMBER Moderate Sedation begins with the administration of the sedating agent, requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation. 99143 under 5 years - same physician performing the procedure 99148 under 5 years - different physician performing the procedure 99144 over 5 years - same physician performing the procedure 99149 over 5 years different physician performing the procedure In addition to 99143 & 99144 you can report 99145 for each additional 15 minutes beyond the first 30 minutes In addition to 99148 & 99149 you can report 99150 for each additional 15 minutes beyond the first 30 minutes 86 43

CORRECT ORTHO CODES FOR FRACTURE/DISLOCATION CARE DEPEND ON EXTENT OF TREATMENT Coders apply orthopedic codes for the treatment of fractures, sprains and other orthopedic injuries only when the ED delivers definitive care, sometimes also called restorative care. Definitive care aims to repair, rather than simply stabilize the injury. Along with casting, definitive care may also include splinting, strapping and/or pain management. 87 FRACTURE VS. SPLINTING/STABILIZATION CARE CHART Scenario: The emergency department physician s role in fracture care. He or She Report Code For: Fracture and/or Dislocation Care (21300-28675) Stabilization Care (29000-29590) Assumes fracture care responsibility Yes No Applies cast/splint for stability; refers patient to specialist for fracture care No Yes Replaces damaged or inadequate cast during or after the global follow up No Yes 88 44

BILLABLE NOTE FOR FRACTURE CARE 89 DEFINITIVE FRACTURE CARE IN THE ED Many ED physicians provide definitive fracture care for fractures such as: Finger Fractures 26720, 26750 Toes Fractures 28490, 28510 Clavicle Fractures 23500 Rib Fractures 21800 Nasal Fractures 21315 These are high RVU procedures and should not be overlooked. 90 45

SPLINTS If a splint is applied and checked by the ED physician this level of care usually does not meet the requirement for definitive or restorative care but a splinting code can be billed for stabilizing the fracture. Common splinting CPT codes include: Finger 29130 Short Arm 29125 Long Arm 29105 Short Leg 29515 Long Leg 29505 91 92 PQRS MEASURES IN THE ED 46

Suggested PQRS Measures in the ED Number Measure ICD-9 Codes CPT II Code 54 12-Lead Electrocardiogram 413.0, 413.1, 413.9, 3120F (ECG) Performed for Non- 786.50, 786.51, 786.52, Traumatic Chest Pain - Age 786.59 > 40 yrs. Reporting Modifier 1P Reporting Modifier 2P Reporting Modifier 3P Reporting Modifier 8P Documentation of medical Documentation of Patient 12-Lead ECG Not performed, reason(s) for not performing reason(s) for not reason not otherwise specified a 12-Lead ECG performing a 12-Lead ECG 55 12-Lead Electrocardiogram 780.2 G8704 Documentation of medical Documentation of Patient 12-Lead ECG Not performed, (ECG) Performed for reason(s) for not performing reason(s) for not reason not otherwise specified Syncope - Age > 60 yrs. a 12-Lead ECG performing a 12-Lead ECG 56 Community-Acquired 481, 482.0, 482.1, 2010F Pneumonia (CAP): Vital 482.2, 482.30, 482.31, Signs - Age > 18 yrs. 482.32, 482.39, 482.40, G8546 or G8550 if all four 482.41, 482.41, 482.42, Community Acquired 482.49, 482.81, 482.82, Pneumonia (CAP) Measures 482.83, 482.84, 482.89, have been performed 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0 57 Community-Acquired 481, 482.0, 482.1, 3028F Pneumonia 482.2, 482.30, 482.31, (CAP):Assessment of Oxygen 482.32, 482.39, 482.40, Saturation - Age > 18 yrs. 482.41, 482.41, 482.42, G8546 or G8550 if all four 482.49, 482.81, 482.82, CAP Measures have been 482.83, 482.84, 482.89, performed 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0 Documentation of medical reason(s) for not documenting and reviewing oxygen saturation Vital signs (temperature, pulse, respiratory rate, and blood pressure) not documented and reviewed Documentation of Patient Documentation of system Oxygen Saturation not reason(s) for not reason(s) for not Documented and Reviewed, documenting and documenting and Reason no Specified reviewing oxygen reviewing oxygen saturation saturation 58 Community-Acquired 481, 482.0, 482.1, 2014F Mental Status no Assessed, Pneumonia (CAP): - 482.2, 482.30, 482.31, Reason not Specified Assessment of Mental Status 482.32, 482.39, 482.40, - Age > 18 yrs. G8546 or 482.41, 482.41, 482.42, G8550 if all four CAP 482.49, 482.81, 482.82, Measures have been 482.83, 482.84, 482.89, performed 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0 59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic - Age >18 yrs. G8546 or G8550 if all four CAP Measures have been performed 481, 482.0, 482.1, 4045F 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.41, 482.42, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0 Documentation of medical Documentation of patient Documentation of system Appropriate empiric antibiotic reason(s) for not prescribing reason(s) for not reason(s) for not not prescribed, reason not appropriate empiric prescribing appropriate prescribing appropriate otherwise specified antibiotic empiric antibiotic empiric antibiotic 93 PQRS PNEUMONIA MEASURES Community Acquired Pneumonia PQR's measures 56, 57, 58, 59 Medicare Patients ONLY 18 or older CAP if all 4 measures are done (VS, PO, Mental status. ABX) - G8550 CAP if all 4 measures are not done G8546 VS done 2010F PO Done 3028F Mental Status done 2014F ABX NOT given 4045F Modifier indicating why (1P, 2P, 3P, 8P) CAP if all 4 measures are not done G8546 VS done 2010F PO Done 3028F Mental Status NOT done 2014F Modifier indicating why (1P, 2P, 3P, 8P) ABX given 4045F CAP if all 4 measures are not done G8546 VS done 2010F PO NOT Done 3028F Modifier indicating why (1P, 2P, 3P, 8P) Mental Status done 2014F ABX given 4045F CAP if all 4 measures are not done G8546 VS NOT done 2010F Modifier indicating why (1P, 2P, 3P, 8P) PO Done 3028F Mental Status done 2014F ABX given 4045F 94 47

REFERENCES 95 REFERENCES AMA CPT Professional Edition ICD-9-CM For Physicians https://www.cms.gov/transmittals/downloads/r178cp.pdf http://www.cms.hhs.gov/transmittals/downloads/r1548cp.p df http://www.cms.hhs.gov/mlnmattersarticles/downloads/m M5993.pdf http://www.acep.org/ http://www.acep.org/clinical---practice- Management/Ultrasound/ http://www.acep.org/content.aspx?id=30428 http://www.cms.gov/ http://www.ahima.org/ 96 48