Transcript Psychiatry Coding Tips

Provider Evaluation &
Management Training
Christi Wesson, Assistant Director
Misty Skelton, Assistant Director
VMG Coding and Charge Entry
1
NP Billing
There are separate rules for billing Nurse
Practitioner’s and nonbilling Nurse
Practitioners.
Non Billing Nurse Practitioners can not bill for any
services. The attending can only reference their
ROS, Past, Family and Social history in order to bill.
2
Non Billing Acknowledgement
3
NP BILLING
NP billing for the admission service (this includes
admission H&P’s)
According to the Vanderbilt Bylaws NP’s can not bill
without the attending provider seeing the
patient(except for CNM).
 Prior to billing the attending will need to document his own
note or countersign stating that he saw the patient and
agrees with the NP’s note.
The preceptor will also need to review 20% of NP
charts.
See next slides for appropriate Countersignature.
4
NP Countersignature
• For Reviewing 20% of the NP’s notes.
• For billing a shared visit and then documenting Key
findings.
5
NP Billing cont.
Nurse Practitioners can bill and see patients for
consults and consulting subsequent visits.
 The attending does not have to attest or document a note
prior to billing for these services.
These services are not shared visits.
If the attending and NP both document a note
these can not be combined in order to bill.
Billing Nurse Practitioners can bill for
procedures if it is within their scope of
practice.
Critical Care cannot be a shared service.
6
Evaluation & Management Coding
 3 Key Components in an E&M service
 History
 Exam
 Medical Decision Making
 The level of service selected is based on the extent of the
history &/or exam, and the complexity of the medical
decision making required and documented by the provider.
7
Elements of History
Chief Complaint (CC)
History of present illness (HPI)
Review of systems (ROS)
Past medical, family, social history (PFSH)
8
History of Present Illness
 Location – Where is the pain/problem?
 Quality – What type of pain? (throbbing, constant, improving, worsening, acute,
chronic)
 Severity – How bad is the pain? (scale of 1-10, functional status, compared to
other types of pain)
 Timing – When did you first experience the problem?
Specific time of day?
Nocturnal?
 Duration – How long do the symptoms last? (Onset 3 days ago, since last Monday,
yesterday)
 Context – What are you doing when the problems occurs?
Associated with meals,
exercise, or stress?
 Modifying factors – What have you tried to alleviate the problem?
Medications? What changes/alters the complaint?
 Associated signs and symptoms – What else is bothering you when this
occurs? (Fever w/ chills, headache w/ blurry visions, diaphoresis w/ chest pain)
9
History of Present Illness cont.
Tip – 4 HPI needed for admits & consults
levels 3-5
Tip – If any part of the history is unobtainable,
you can document history unobtainable due
to ______ (state the reason)
Ex: pt intubated & sedated
10
Review of Systems (ROS)
An inventory of body systems obtained through questions
seeking to identify signs and/or symptoms which the patient
has or has had.
 Constitutional symptoms (e.g.
fever, weight loss)
 Eyes
 Ears, Nose, Mouth, Throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Genitourinary
 Musculoskeletal
 Integumentary (including breasts)
 Neurological
 Psychiatric
 Endocrine
 Hematologic/Lymphatic
 Allergic/Immunologic
Review of Systems (ROS)
May be recorded by ancillary staff or on a form completed
by the patient
 Provider must document that he/she reviewed and
confirmed information recorded by others.
If unable to obtain, document why
Pertinent positives and negatives must be referred to in the
notes
Unacceptable (ROS) statements
 Review of system: negative
 Review of system: None
 Review of system Non-contributory
 Review of system: unremarkable
 Review of system: Full ROS was notable only for the findings
listed in the HPI
 10 point review of systems was completed and is negative unless
otherwise stated
 Review of systems per HPI otherwise negative
Acceptable (ROS) statements
 Review of systems are obtained based on medical
necessity. Systems with pertinent positive or negative
responses must be individually documented.
 Example:
 Review of (# of systems reviewed) system is negative except
for: MSK: chronic back pain that is flaring, no HSM
 Review of (# of systems reviewed) system is negative except
as discussed per HPI
 Document all pertinent positive and negative findings
and document “All other systems reviewed and
negative”
Past, Family & Social History
 Past (past illness, injuries, operations, treatments,
current medications, allergies)
 Family (medical events of patient’s family,
hereditary disease)
 Social (living arrangements, level of education)
Tip: DON’T use “noncontributory”
Can use negative, but must document negative for
what
15
Physical Exam Findings
Body Areas (7)
Organ Systems (12)
 Head including face
 Neck
 Chest, including breast
 Abdomen
 Genitalia, groin
 Back including spine
 Each extremity
 Constitutional
 Eyes
 ENMT
 Cardiovascular
 Respiratory
 GI
 GU
 Musculoskeletal
 Skin
 Neuro
 Psych
 Hem/Lymph/Immo
Physical Exam Findings
 Examples of Organ system exam:
 Constitutional: Vital signs and general appearance
 Eyes: Pupils: size, shape, equality, reaction to light &
accommodation
 ENMT: Sinus tenderness, pharynx, tonsils
 Cardiovascular: Thrill, Rhythm, Sounds, Murmur, Edema
 Respiratory: Breath Sounds, Wheeze, Spoken or Whispered voice.
 GI: Hepatomegaly, Splenomegaly, Bowel sounds, bruits, rubs
 GU: Examination of Bladder, Palpation of kidney -enlargement, CVA
tenderness
Physical Exam Findings
Examples of Organ system exam:
 Musculoskeletal: ROM (range of motion), Strength, Stability, Gait
 Skin: Color, texture, lesions, moles, birthmarks, rashes, dermatitis,
dermatoses, hyperhidrosis, actinic damage, ulcers
 Neuro: Sensory examination, Reflex Examination
 Psych: hallucinations, delusions, obsessions, compulsions, Time, place,
person
 Hem/Lymph/Immo: Palpable cervical, axillary, inguinal nodes
18
Medical Decision Making
2 of the 3 elements must be met or
exceeded
 Number of Diagnoses/Treatment Options
 Amount & Complexity of Data
 Level of Risk
19
Number of Diagnoses/Treatment Options
Each encounter should have an
assessment/plan and diagnosis that is
documented
 Self limited/minor
 Est problem: stable/improved
 Est problem: worsening
 New problem: no work-up
 New problem: add work-up
=1
=1
=2
=3
=4
20
Amount & Complexity of Data
 If a diagnostic service is ordered, planned, reviewed, or performed at the
time of the E/M encounter, the type of service should be documented
 Lab Test (80000 series)
= 1
 X-Ray (70000 series)
= 1
 Medical Test (90000 series)
= 1
 Discuss test with performing physician
=1
 Independent review of images, testing or specimen = 2
 Decision to obtain old records and/or hx from
someone other than patient
=1
 Review/summarize old records and/or obtain hx from someone other
than patient
=2
21
Table of Risk
Highest level of risk in any category
determines the level of risk
 Presenting Problem
 Diagnostic Procedure
 Management Options
22
Score Sheet – Table of Risk
23
Score Sheet – Type of Decision Making
To qualify for a given type of decision making, 2 of
the 3 elements in the table must be either met or exceeded.
Type of
Decision
Making
Str. Forward
Low
Moderate
High
# of Dx or
Mgmt Options
0 or 1
2
3
4+
Amount &
Complexity of
Data
0 or 1
2
3
4+
Overall Risk
Minimal
Low
Moderate
High
24
Evaluation & Management
Services
Inpatient Consultation (3 out of 3)
Level
HX
PE
MDM
Time
99251
Problem Focused
Problem Focused
Straightforward
20
99252
Expanded PF
Expanded PF
Straightforward
40
99253
Detailed
Detailed
Low
55
99254
Comprehensive
Comprehensive
Moderate
80
99255
Comprehensive
Comprehensive
High
110
Initial Hospital Care (3 out of 3)
99221
Detailed/
Comprehensive
Detailed/
Comprehensive
Straightforward/
Low
30
99222
Comprehensive
Comprehensive
Moderate
50
99223
Comprehensive
Comprehensive
High
70
Subsequent Hospital Care (2 out of 3)
99231
Problem Focused
Problem Focused
Straightforward/
Low
15
99232
Expanded PF
Expanded PF
Moderate
25
99233
Detailed
Detailed
High
35
25
Questions
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