Hospitalist’s guide to Code Green Lida Fatemi, DO, MPH 4/19/17

Objectives Key Components of Documentation Key Components of Coding Streamline – Pro Fee + Facility Fee Communication Patient Care Needs

Documentation  Coding  Billing Overall picture Documentation  Coding  Billing E&M = Pro Fee = Professional Fee – Individual Physician Facility Coding – How facility gets paid

Components of Pro Fee E&M = Pro Fee = Professional Fee – Individual Physician History Physical Exam Medical Decision Making Looks at components of each note

Facility Fee How the hospital gets paid Facility Coding High specificity in diagnosis Severity of illness Comorbid conditions The entire hospital stay

H&P

Need 10 Systems Need 8 Systems Missing Family History

Key Components for H&P Pro Fee Chief Complaint ROS – 10 systems – don’t have to reiterate the HPI Past Medical, Social Hx, Family Hx, Surgical Hx PE: 8 systems Medical Decision Making – usually the first problem (up to 4) If spent >100 minutes = Prolonged Service

Key Components for H&P Facility coding Specificity Providing evidence Use “treat” New vs. old – acute/chronic/acute on chronic/subacute Severity of illness Laterality

Progress Note

Need 10 Systems Need 8 Systems

Key Components Progress note = subsequent visit Pro Fee – 2 out of 3 components Need 10 ROS Need 8 for PE Prolonged Service = If spent >65 minutes Critical Care Time >30 minutes

Prolonged Service

Why is it good? “All criteria met - Total time in minutes, indication that time dominated visit by greater than 50% and substantiating details.”

“What's missing? Time is specified, but no indication that over 50% of visit was dominated by counseling/coordination of care. The details, by provider, is excellent though!”

DC Summary

DC Summary Components Pro Fee – “Face-to-Face” and > or < 30 Minutes Facility – Diagnosis and specificity

Take Away… H&P: History ROS – 10 Systems PE – 8 systems PMHx, Fam Hx, Social Hx, Surgical Hx If spent >100 min = Prolong Service Specificity regarding diagnosis – evidence

Take Away… Progress Notes If >65 min = Prolonged Service ROS 8 systems PE 8 systems

All notes Be very specific regarding diagnosis – provide evidence Accurately capture the severity of illness of your patient Communicate patient care Critical care time >30 minutes – for all notes Use status for every diagnosis (acute, chronic, acute on chronic, improving, stable, worsening) Use: suspected, likely, questionable, possible, still to be ruled out, probable

Thank you!