continuity clinic coding patient encounters ii episode 2 determining the “level” of the...
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Continuity Clinic
Coding Patient Encounters II
EPISODE 2
Determining the “level” of the encounter
Continuity Clinic
Objectives
• Understand the basic rules:– Physician payment rules– Basic CPT and ICD coding rules
• Be familiar with the 3 criteria for selecting the correct EM Code
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The “Art” of CPT Coding
• First select the code based on the “feel” of the visit (not check-up) – how complex, how much time
• Then validate your code using a E/M tool (E/M = evaluation and management)
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The “Art” of CPT Coding
• The “Feel”– 99211 = nurse visit– 99212 = easy, brief problems– 99213 = average, usual problems– 99214 = “oh no!”– 99215 = after visit you think “I just ran a
marathon”
• Why should you care?– > $40 difference between level 3 and 4!
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99212 Typical Scenarios
• Diaper rash
• OM recheck and resolved
• Otitis externa
• Thrush
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99213 Typical Scenarios
• Fever and pharyngitis
• UTI-cystitis
• URI and Otitis
• Mild LRI’s
• Moderate Injury
*Most acute uncomplicated problems
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99214 Typical Scenarios
• Chronic or Multiple problems– Headaches, abdominal pain– Fatigue, anorexia– Asthma, diabetes
• School and Behavioral Problems– ADHD return visits
• Acute Complicated Illnesses– Fever without focus– Influenza
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99215 Typical Scenarios
• Diabetes complicated by illness
• Headaches with vomiting
• Disabling abdominal pain
• Fatigue and anorexia in adolescent
• Fever without focus for more than 60 days
• Initial evaluation for ADHD
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The Science of Coding
• Three Criteria for selecting the correct E/M Code:– History– Physical Examination– Medical Decision Making
• For established patients, must have 2/3 areas at same level to qualify (3/3 for new patients)
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Levels of HistoryLevel of History Chief Complaint HPI ROS PFSH
Problem Focused
-level 2-
Required 1-3 elements Not required Not required
Expanded Problem Focused
-level 3-
Required 1-3 elements 1 system Not required
Detailed
-level 4-
Required 4+ elements or 3+ chronic elements
2-9 systems 1 element
Comprehensive
-level 5-
Required 4+ elements or 3+ chronic elements
10 systems 2 or 3 elements
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What Constitutes the Elements of the History?
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSHI)
Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms
Constitutional, eyes, ENT, CV, respiratory, GI, GU, musculoskeletal, integumentary (includes breast), neurological, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic
Past – experience with illnesses, operations, injuries and treatments, allergy hx, medications taken prior to visit
Family – medical history including hereditary diseases, current illness in family
Social – age appropriate review of activities, drug use, education, sexual history, day care status
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Levels of Physical ExamLevel of Physical
Exam1995 Guidelines 1997 Guidelines
Problem Focused
-level 2-
1 body area or organ system
1-5 bullets in 1 or more organ systems
Expanded Problem Focused
-level 3-
2-4 body areas/organ
systems including affected area
6-11 bullets in one or more organ
systems/body areas
Detailed
-level 4-
5-7 body areas/organ
systems including affected area
12 or more bullets in two or more organ
systems/body areas
Comprehensive
-level 5-
8 or more organ systems
General multi system exam: 2 bullets from
9 different organ systems
Either the 1995 guidelines or 1997 guidelines may be used, but most general pediatricians use the 1995 guidelines as the 1997 guidelines were written with specialists in mind.
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Body Areas/Organ Systems in the PE
1995 Guidelines 1997 Guidelines
Body Areas: abdomen; back including spine; chest, including breast and axillae; GU/groin/buttocks; head, including face; each extremity; and neck
Organ Systems: CV, constitutuional; ears/nose/mouth/throat; eyes; GI; GU; hematologic/lymphatic/ immunologic; musculokeletal; neuro/psych; respiratory, skin
General multi-system exam: CV; chest/breasts; constitutional; ears/nose/throat; eyes; GI; GU; hematologic/lymph/immuno; respiratory, musculoskeletal; neck; neuro; psychiatric; skin
Single system exam: constitutional; CV; GI; GU; lymphatic; neck; neuro; psych; respiratory; skin
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Criteria for Selecting the Correct EM Code
• History and Physical form the 1st two of the key criteria in coding. In the next set of slides and the conclusion of the trilogy “Coding”, we will discuss medical decision making as the third component.