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Hospital Medicine > Billing, Coding, and Documentation > Flashcards

Billing, Coding, and Documentation Flashcards

1
Q

Functions of the medical record

A
  • Historical vehicle that promotes excellence in care
  • Faciliates care coordination
  • Transcends communication barriers
  • Financial, legal, and administrative functions
  • Documentation for professional and facility fee reimbursement, quality and safety assessments
  • Malpractice litigation and disability determinations
  • Community-based care and public health initiatives
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2
Q

What is the purpose of computerized provider order entry?

A
  • Replace paper based ordering systems
  • Originally for improved safety of medication orders
  • Now allows electronic ordering of tests, procedures, and consultations
  • Maintain administration record
  • Review changes to order by successive personnel
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3
Q

What are CPOE systems generally paired with? What is the purpose of this?

A
  • Clinical Decision Support System
  • Prevent errors at medication ordering and dispensing stages
  • Improve safety
  • Suggests default doses, routes of administration, and frequency
  • May include drug safety features such as drug allergy checking or drug-drug, drug-laboratory interactions
  • Some prevent errors of commission and omission
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4
Q

What are some unintended consequences of CPOE?

A
  • Users often use workarounds to bypass safety features
  • Excessive and nonspecific warnings can lead to alert fatigue, users ignore even critical warnings
  • More or new work for clinicians
  • Unfavorable workflow
  • Never-ending system demands
  • Problems related to persistence of paper orders
  • Unfavorable changes in communication patterns and practices
  • Negative feelings toward new technology
  • Generation of new types of errors
  • Unexpected changes in institution’s power structure, organizational culture, or professional roles
  • Overdependence on technology
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5
Q

What are advantages to written patient records?

A

No computer delay

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6
Q

What are disadvantags to written patient records?

A
  • Penmanship and misunderstanding of wording
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7
Q

What are templated notes?

A
  • Preprinted paper progress notes with check boxes or electronically constructed click boxes
  • Appropriate documentation tools
  • Enhance legibility and facilitate efficient documentation
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8
Q

What is one con of templated notes?

A
  • Cut and past errors
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9
Q

How do you avoid cut and paste errors

A
  • Make each note specific to the patient on that encounter date
  • Modify information and language brought forward from any previous encounters so current documentation demonstrates distinct clinical service of today
  • Do not include excessive data or repetitious information that is not relevant to current service
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10
Q

How does medicare pay for inpatient services?

A

Using inpatient prospective payment system, which relies primarily on diagnosis in order to group the services delivered to an inpatient into a medicare severity-adjusted diagnosis related group

Some non-medicare payers still reimburse hospitals and facilities with a fixed payment for each day, commonly described as a per diem rate

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11
Q

What is the most common system used to report provider services?

A

American Medical Association Current Procedural Terminology
* Lists descriptive terms and identifying codes to report medical services and procedures
* Provides uniform language to accurately describe all medical, surgical, and diagnostic services and procedures

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12
Q

What are the 3 key components of selection of an evaluation and management level

A
  • History
  • PE
  • Medical Decision Making
  • Time considered a fourth component but only affects E/M when counseling and/or coordination of care dominate more than 50% of physician’s total visit time
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13
Q

Elements of history

A
  • Chief complaint
  • HPI
  • ROS
  • PFSHs

can all be included in narrative format, do not need to be separate bulleted segments

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14
Q

History

A
  • Conveys information about CC, from either origin or interval between sequential patient encounters
  • Eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms
  • Quantified as brief (one to three elements) or extended (four or more elements)
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15
Q

chief complaint

A
  • Reason for visit in patients own words
  • Always document in progress note, even absent an acute complaint ie pneumonia follow up
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16
Q

ROS

A
  • Fourteen systems: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic
  • Problem pertinent, extended, or complete
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17
Q

What is a problem pertinent ROS

A
  • Documents one system
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18
Q

What is an extended ROS

A

Documentation of two to 9 systems

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19
Q

What is a complete ROS

A

10 or more individual systems

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20
Q

Components of past history

A
  • Documentation of previous illnesses, hospitalizations, surgeries, medications, allergies, and immunizations
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21
Q

What is a pertinent PFSH

A

Comment in any one of the three histories

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22
Q

What is a complete PFSH

A

Comment in each history (ie past, family, and social)

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23
Q

How PFSH changed if obtained during a previous encounter?

A

Does not need to be rerecorded if provider documents review and updating of previous information

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24
Q

What happens if unable to obtain history from the patient?

A
  • Record should describe patient’s condition or the circumstance that precludes obtaining a history, and what attempts the provider has made to obtain the information
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25
Q

What is considered complete PFSH if new patient encounter vs subsequent or ED encounters?

A
  • New: need all 3
  • Subsequent: need 2/3
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26
Q

Can you document generalized PE exam such as HEENT normal?

A

Discouraged but yes
If abnormal, must specifically document

27
Q

How is PE documented?

A
  • Problem-focused
  • Expanded problem-focused
  • Detailed
  • Comprehensive
28
Q

What is considered a problem focused PE?

A

1 organ system with 1 comment

29
Q

What is considered an expanded problem-focused PE?

A

2-7 organ systems with at least 1 comment

30
Q

What is considered a detailed PE?

A

2-7 organ systems with more than one comment in one or more organ systems

31
Q

What is considered a comprehensive PE?

A

> /- 8 organ systems with at least 1 comment in each

32
Q

How is medical decision making categorized?

A
  • Straightforward
  • Low
  • Moderate
  • High
33
Q

What categories must be considered to determine level of MDM complexity?

A
  • Number of diagnosis
  • Amount and complexity of data
  • Risk to patient
34
Q

How is number of diagnosis determined?

A
  • Number of diagnosis and/or management options in encounter
  • Only receive credit for issues considered in care plan. DIagnosis merely listed in assessment and plan without elaboration of the care or simply ascribing care to others are considered part of problem list
  • Self-limited/minor problem - 1 point per problem (stable, improved, or worsening)
  • Established problem (stable or improving) - 1 point per problem
  • Established problem (worsening) - 2 points per problem
  • New problem, without additional workup - 3 points per problem (max one problem)
  • New problem, with additional workup planned (4 points per problem)
35
Q

What is data considered?

A
  • Amount and/or complexity of data reviewed or ordered by the provider during the patient encounter
  • Both type and source considered are valued
  • Ordering and/or reviewing of pathology/laboratory, radiology, and medicine data each provide separate but equal credit (but only one point allocated per category)
  • Chart note should refer to all data reviewed or ordered to capture all of the provider work
36
Q

What are point values for amount and/or complexity of data ordered/reviewed?

A
  • 1 review and/or order of clinical tests
  • 1 review and/or order of tests in pathology/laboratory section of CPT
  • 1 review and/or order tests in radiology section of CPT
  • 1 review and/or order of tests in medicine section of CPT
  • 1 Decision to obtain old records and/or history (non-healthcare provider) from someone other than the patient
  • Review and summarize old records, obtain additional history, or discuss case with another health care provider = 2 points
  • 2 independent visualization of actual image, tracing, or specimen
37
Q

What is the third MDM category?`

A

Risk to the patient

38
Q

Components of risk to patient

A
  • Risk of complications, morbidity, and mortality with respect to presenting problem, diagnostic procedures ordered, or management options chosen
39
Q

Levels of risk to patient

A
  • Minimal
  • Low
  • Moderate
  • High

consider comorbidities as well as plans of care
Also, diagnostic studies or alternatively, procedures under consideration or excluded based on excessive risk

40
Q

What is considered minimal risk?

A
  • One self-limited or minor problem
  • Diagnostic procedures ordered: lab tests requiring venipuncture, CXR, ECG/EEG, UA, US, KOH prep
  • Management options: rest, gargles, elastic bandages, superficial dressings
41
Q

What is considered low risk?

A
  • Two or more self-limited or minor problems
  • One stable chronic illness (well controlled hypertension, noninsulin dependent diabetes, cataract, BPH)
  • Acute uncomplicated illness or injury (cystitis, allergic rhinitis, simple sprain)
  • Diagnostic procedures ordered: physiologic tests not under stress, noncardiovascular imaging studies with contrast, superficial needle biopsies, clinical lab tests requiring arterial puncture, skin biopsies
  • Management: over the counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy, IV fluids without additives
41
Q

What presenting problems are moderate risk?

A
  • One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
  • Two or more stable chronic illnesses
  • Undiagnosed new problem with uncertain prognosis
  • Acute illness with systemic symptoms
  • Acute complicated injury (ex head injury with brief loss of consciousness
42
Q

What diagnostic procedures ordered are moderate risk?

A
  • Physiologic tests under stress
  • Diagnostic endoscopies with no identified risk factors
  • Deep needle or incisional biopsy
  • Cardiovascular imaging studies with contrast and no identified risk factors (arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity (lumbar puncture, thoracentesis, paracentesis)
42
Q

What management options are considered moderate level of risk?

A
  • Minor surgery with identified risk factors
  • Elective major surgery with no identified risk factors
  • Prescription drug management
  • Therapeutic nuclear medicine
  • IV fluids with additives
  • Closed treatment of fracture or dislocation without manipulation
43
Q

What presenting problems are considered high risk?

A
  • One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
  • Acute or chronic illnesses or injuries that pose a threat to life or bodily function (such as multiple trauma, acute MI, PE)
  • Abrupt change in neurologic status
44
Q

Diagnostic procedures ordered considered high risk

A
  • Cardiovascular imaging studies with contrast with identified risk factors
  • Cardiac electrophysiological tests
  • Diagnostic endoscopies with identified risk factors
  • Discography
45
Q

Management options considered high risk

A
  • Elective major surgery with identified risk factors
  • Emergency major surgery
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate or to de-escalate care
46
Q

How is MDM complexity categorized?

A
  • Problem-focused
  • Low
  • Moderate
  • High
47
Q

The final result of MDM complexity hinges on what?

A
  • Two highest valued categories
  • Two of the three categories must meet or exceed the requirements assigned to a specific level of complexity to select that level
48
Q

Problem focused MDM complexity

A
  • </- 1 diagnosis or treatment option points
  • </- 1 data points
  • Minimal risk
49
Q

Low MDM complexity

A
  • Diagnosis or treatment options = 2 points
  • 2 data points
  • Low risk level
50
Q

Moderate medical decision making complexity

A
  • 3 diagnosis or treatment options points
  • 3 data points
  • Moderate risk level
51
Q

High medical decision making compexity

A
  • 4 diagnosis or treatment option points
  • 4 data points
  • High risk level
52
Q

What do initial patient encounters require?

A

Consideration of all three key components

53
Q

What do subsequent hospital visits require?

A

Consideration of only two of the key components
Lowest component of the two or three key components required determines visit level

54
Q

code 99221

A

Initial hospital care
* History detailed or comprehensive
* Exam detailed or comprehensive
* MDM straightforward or low
* Time: 30 min

55
Q

Code 99222

A

Initial hospital care
* Comprehensive history
* Comprehensive exam
* Moderate MDM
* Time: 50 mins

56
Q

code 99223

A

Initial hospital care
* Comprehensive history
* Comprehensive exam
* High MDM
* Time 70 mins

57
Q

Code 99231

A

Subsequent hospital care
* Problem-focused history
* Problem-focused exam
* MDM straightforward or low
* Time: 15 min

58
Q

Code 99232

A

Subsequent hospital care
* Expanded history
* Expanded examination
* Moderate MDM
* Time 25 min

59
Q

Code 99233

A
  • Subsequent hospital care
  • Detailed history
  • Detailed exam
  • High MDM
  • Time 35 min
60
Q

How to determine level of service for time counseling/coordinating care?

A
  • CPT assigns typical time to render service, but doesn’t need to last that long
  • Inpatient: time accrues as unit or floor time in addition to face-to-face time
  • When more than 50% of service time involves counseling and/or coordination of care, may select code reflecting total time spent with patient, rather than 3 key components
  • TIme and corresponding counseling details must be documented in medical record as well as patient responses and all relevant history, exam, and MDM
  • Amount of CCC time may be estimated at round total visit to closest average total visit time
  • Tasks that count toward counseling patient include discussions of the plan, evaluation, procedures, prognosis, treatment options, risk factor reduction, and patient and family education
61
Q

In order to bill for time counseling/coordinating care, what time must be documented

A
  • Two different amounts: total visit time and portion of total visit time that was spent CCC
  • Need brief description of what was discussed during time in order to prove medical necessity

Hospital Medicine (7 decks)

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