1.  Lecture 1

2. "All politics is local."

3. “Ask not what your country can do for you - ask what you can do for your country.” -U.S. President John F. Kennedy Inaugural address on January 20, 1961

4. What can correct billing and coding “do for you”? ?

5. Well, you have to.

6. If you don’t….

7. Fraud

8. “I have a trust fund and will just under-bill everything…”

9. Fraud That’s fraud too!

10. As you’ll see, correct documentation associated with correct coding is efficient

11. … and even improves our note!

12. Medical Education  Complex procedures  Specialized knowledge  Tailor treatment plan to individuals  4 years of education o Basic sciences o Pathophysiology o Clinical sciences o Electives Coding and Billing  Laymen’s procedure  No specialty knowledge required  “Arbitrary” rules  Template/check-box mentality How can this work so well? We’ll see at the end.

13. Billing and coding should really be coding and billing Coding = Diagnosis

14. ICDcodes International Statistical Classifications of Diseases World Health Organization  alphanumeric designations o Diagnosis o Symptoms o Cause of death o Inpatient procedures (PCS) CPT codes Current Procedural Terminology (owned and operated by) American Medical Association  numeric designations o Diagnostic “services“ o Therapeutic “services“

15.  Last update was 1979  140,000 codes in ICD-10 (vs 20,000 codes in ICD-9)  There is a code for that! o 9 codes for parrot injuries o 3 codes for flaming water-ski burn injuries  ICD-11 already on the way

16. Billing follows Medicare guidelines, which almost all insurance companies also follow “gold standard”

17. Their Ball. Their Bat.

18. (1) History (2) Physical Exam (3) Medical Decision Making

19. New Established History Physical Exam New & Established Med Decision Making Level 1Level 1 / 2 Problem Focused Level 1 Straightforward Level 2Level 3 Expanded Problem Focused Level 2 Straight-forward Level 3Level 4 Detailed Level 3 Low Complexity Level 4Level 5 Comprehensive Level 4 Moderate Complexity Level 5 High Complexity

20. New Established History Physical Exam New & Established Med Decision Making Level 1Level 1 / 2 Level 1 Level 2Level 3 Level 2 Level 3Level 4 Level 3 Level 4Level 5 Level 4 / 5 Level 4 Level 5

21. New Patient Document all 3 elements All 3 elements must meet the level Else, pick lowest level Established Patient Document >=2 elements 2 of 3 elements must meet the level Else, pick middle level

22. Let’s give it a quick try!

23. 1)Level 1 2)Level 2 3)Level 3 4)Level 4 5)Level 5 Countdown 10 HistoryPhysical ExamMed Decision Making Level 1 Level 2 Level 3 Level 4 / 5 Level 4 Level 5

24. 1)Level 1 2)Level 2 3)Level 3 4)Level 4 5)Level 5 HistoryPhysical ExamMed Decision Making Level 1 Level 2 Level 3 Level 4 / 5 Level 4 Level 5 Countdown 10

25. New Established History Physical Exam New & Established Med Decision Making Level 1Level 1 / 2 Level 1 Level 2Level 3 Level 2 Level 3Level 4 Level 3 Level 4Level 5 Level 4 / 5 Level 4 Level 5

26. 

27. Level 1 (Problem Focused) Level 2 (Expanded Problem Focused) Level 3 (Detailed) Level 4 / 5 (Comprehensive)

28. Four Components: 1. Chief complaint (CC) 2. History of Present Illness (HPI) 3. Review of Systems (ROS) 4. Past Medical, Family, Social History (PMFSH)

29. Level 1Level 2Level 3Level 4 / 5 CCrequired HPI1-3>=4 ROSnone12-9>=10 Medical Family Social none1 3 for new 2 for established -- pick lowest of 3 columns -- Histories

30. 1. Quality 2. Timing 3. Location 4. Context 5. Duration 6. Severity 7. Modifying factors 8. Associated symptoms Character Location Onset Duration Intensity Exacerbation Remission Symptoms

31. 1. Quality: aching, burning, stabbing, etc 2. Timing: constant, intermittent, crescendo 3. Location 4. Context: trauma, travel, position 5. Duration: hours, days, months, etc 6. Severity: scale 1 to 10 7. Modifying factors: relieving/exacerbating factors 8. Associated symptoms

32. 1. Constitutional 2. Eyes 3. ENT 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic

34.  Medical/Surgical History  Social History o Smoking o Alcohol o Recreational drugs o Occupation  Family History : Same/Related conditions o Education o Marital status o Living arrangements o Pets/Hobbies/Travel

35. 

36. “Doctor, my left knee is killing me!”

37. What is the chief complaint?

38. What questions do you want to ask in the History of Present Illness?

39. 1. Quality 2. Timing 3. Location 4. Context 5. Duration 6. Severity 7. Modifying factors 8. Associated symptoms Level 1Level 2Level 3Level 4 / 5 CCrequired HPI1-3>=4 ROSnone12-9>=10 PMFSHnone1 3 for new 2 for established

40. What questions do you want to ask in the Past Medical, Social, & Family History?

41.  Medical/Surgical History  Social History o Smoking o Alcohol o Recreational drugs o Occupation  Family History : Same/Related conditions o Education o Marital status o Living arrangements o Pets/Hobbies/Travel

42. What questions do you want to ask in the Review of Systems?

43. 1. Constitutional 2. Eyes 3. ENT 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 5. Musculoskeletal 6. Skin 7. Neurologic 8. Psychiatric 9. Endocrine 10. Hematologic/Lymphatic 11. Allergic/Immunologic Level 1Level 2Level 3Level 4 / 5 CCrequired HPI1-3>=4 ROSnone12-9>=10 PMFSHnone1 3 for new 2 for established

44. “Urg! My chest!”

45. What is the chief complaint?

46. What questions do you want to ask in the History of Present Illness?

47. Countdown 15 Quality _____??_____ Timing Context Duration Severity Modifying factors Associated symptoms

48. 1. Quality 2. Timing 3. Location 4. Context 5. Duration 6. Severity 7. Modifying factors 8. Associated symptoms

49. What questions do you want to ask in the Past Medical, Social, & Family History?

50. 1)Past Medical History 2)Social History 3)Allergy History 4)Family History Countdown 5

51.  Medical/Surgical History  Social History o Smoking o Alcohol o Recreational drugs o Occupation  Family History : Same/Related conditions o Education o Marital status o Living arrangements o Pets/Hobbies/Travel

52. What questions do you want to ask in the Review of Systems?

53. 1)8 2)10 3)11 4)12 5)13 6)14 Countdown 10

54. 1. Constitutional 2. Eyes 3. ENT 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 5. Musculoskeletal 6. Skin 7. Neurologic 8. Psychiatric 9. Endocrine 10. Hematologic/Lymphatic 11. Allergic/Immunologic Level 1Level 2Level 3Level 4 / 5 CCrequired HPI1-3>=4 ROSnone12-9>=10 PMFSHnone1 3 for new 2 for established

55. “Owwwww!”

56. What is the chief complaint?

57. What questions do you want to ask in the History of Present Illness?

58. 1. Quality 2. Timing 3. Location 4. Context 5. Duration 6. Severity 7. Modifying factors 8. Associated symptoms

59. How many elements are in a Level 3 History of Present Illness? Countdown 10

60. What questions do you want to ask in the Past Medical, Social, & Family History?

61.  Medical/Surgical History  Social History o Smoking o Alcohol o Recreational drugs o Occupation  Family History : Same/Related conditions o Education o Marital status o Living arrangements o Pets/Hobbies/Travel

62. How many elements are in a Level 3 Past Medical Family Social History? Countdown 10

63. What questions do you want to ask in the Review of Systems?

64. 1. Constitutional 2. Eyes 3. ENT 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 5. Musculoskeletal 6. Skin 7. Neurologic 8. Psychiatric 9. Endocrine 10. Hematologic/Lymphatic 11. Allergic/Immunologic

65. How many elements are in a Level 4 / 5 Review of Systems? Countdown 10

66. 

67. What can correct billing and coding “do for you”? ?

68. Correct Billing & Coding Incorrect Billing & Coding Really Big Picture Fraud Necessity

69. Billing and coding should really be coding and billing Coding = Diagnosis

70. Billing follows Medicare guidelines, which almost all insurance companies also follow “gold standard”

71. (1) History (2) Physical Exam (3) Medical Decision Making

72. New Established History Physical Exam New & Established Med Decision Making Level 1Level 1 / 2 Level 1 Level 2Level 3 Level 2 Level 3Level 4 Level 3 Level 4Level 5 Level 4 / 5 Level 4 Level 5

73. Four Components: 1. Chief complaint (CC) 2. History of Present Illness (HPI) 3. Review of Systems (ROS) 4. Past Medical, Family, Social History (PMFSH)

74. Level 1Level 2Level 3Level 4 / 5 CCrequired HPI1-3>=4 ROSnone12-9>=10 Medical Family Social none1 3 for new 2 for established -- pick lowest of 3 columns -- Histories

75. 1. Quality: aching, burning, stabbing, etc 2. Timing: constant, intermittent, crescendo 3. Location: where? 4. Context: trauma, travel, position 5. Duration: hours, days, months, etc 6. Severity: scale 1 to 10 7. Modifying factors: relieving/exacerbating factors 8. Associated symptoms: anything else?

76. 1. Constitutional 2. Eyes 3. ENT 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic

77.  Medical/Surgical History  Social History o Smoking o Alcohol o Recreational drugs o Occupation  Family History : Same/Related conditions o Education o Marital status o Living arrangements o Pets/Hobbies/Travel

78. 

79. How many guesses are needed to find a number between 1 to 1 million, if you are given the hint of "higher" or "lower" for each guess?

80. Linnaean taxonomy Hierarchical & Exponential elimination