EHR Coding and Reimbursement

EHR Coding and Reimbursement
CHAPTER TWELVE THREE EHR Coding and Reimbursement

Guided Exercise 70: Calculating E&M for a More Complex Visit
In this exercise, you are going to add findings to existing encounter to study effects on E&M coding. Step 1 If patient encounter used in previous exercise is displayed on screen, proceed to step 2.

Step 1 (cont.) If not, start Student Edition software. From Select menu, click Patient; from Patient Selector window select Mary Williams. From Select menu, click Existing Encounter; from Encounter Selector window select 5/28/ :45 AM Office Visit.

Step 2 Recall from Guided Exercise 69 that this patient encounter note produces calculated E&M code of “99212 Established Outpatient Focused H&P—Straightforward Decisions.” You do not need to run E&M calculator yet. Because this encounter note was for an URI, and was created using List feature, you are going to load Adult URI list.

Step 2 (cont.) Locate and click on button labeled “List” on Toolbar at top screen. When Lists Manager window displayed, select Adult URI and click button labeled “Load List.” In following steps, you are going to use the list to add findings and study their effect on levels of E&M codes.

Step 2 (cont.) History level is determined by relationship between HPI, ROS, and PFSH.

Step 2 (cont.) If you refer back to table in Figure in the textbook, you will see the following: Increase in number of findings for HPI will only affect level of history if ROS and PFSH contain data as well. Increase in number of body systems in ROS will only affect level of history if HPI contains at least four findings; PFSH contains at least one.

Step 2 (cont.) If you refer back to table in Figure in the textbook, you will see the following (cont.): Adding even one finding for PFSH will only affect level of history if HPI contains at least four findings; ROS contains at least two body systems. “Complete” level of PFSH will only affect overall history level when HPI contains at least four findings and ROS has at least 10 systems.

Step 3 Scroll encounter note, displayed in pane on right, upward to view History section (circled in red in Figure 12-23). Note that there is only one type of History, Review of Systems; HPI or PFSH findings are not present in encounter. This means that there is only one of the three History elements in current E&M calculation.

Figure 12-23: Upper portion of encounter note with Review of Systems section circled in red.

Step 3 (cont.) Locate and click on following symptom finding: Nasal passage blockage (stuffiness) (red button) This symptom describes presenting problem.

Step 4 Locate and click on button labeled “ROS” on Toolbar at top of screen. Verify it is “on” (orange). Locate and click on following symptom findings: Fever (blue button) Chills (blue button) Nasal discharge (red button) Sore throat (blue button)

Step 4 (cont.) Compare your screen to Figure (scroll right pane upward if necessary to see full history). These symptoms are in systems related to presenting problem. Figure shows, circled in red, that two types of history are now in encounter note.

Figure 12-24: Encounter with both History of Present Illness and Review of Systems sections.

Step 5 Click on Hx tab to add PSFH. Locate and click on following History finding: Current smoker (red button) In Entry Details section at bottom of screen, type “6 years” in field labeled “Duration” (circled in red in Figure 12-25).

Step 5 (cont.) Compare your screen to Figure Note that you now have findings in all three History sections: HPI, ROS, and behavioral history (PFSH).

Figure 12-25: Social (behavioral) history—smoker for 6 years.

Step 5 (cont.) Exams provide most direct, but not easiest means to reach a higher level code. More systems examined, more bullet points that are met, represent more work has been done and higher level of code should be justified.

Step 5 (cont.) In general multi-system examination, six or more elements with bullet are required to reach second level. Third level is reached when you have at least two elements in six or more systems/body areas. Fourth level requires all of bulleted items in at least nine systems/body areas.

Step 6 Click on Px tab. Locate and click on following Physical Exam findings: Wheezing (blue button) Rhonchi (blue button) Compare your screen to Figure

Figure 12-26: Added findings on physical exam.

Step 7 Click Forms button on Toolbar; select “Vitals” form. Enter Mary's vital signs in corresponding fields. Click on Encounter tab at bottom of screen. Mary's vital signs: Temperature: 97.7 Respiration: 25 Pulse: 65 BP: 128/90 Height: 64 Weight: 155

Figure 12-27: Vital signs for Mary Williams.

Step 8 Click on E&M button in Toolbar at top of screen. When Problem Screening checklist window appears, click OK button without checking any boxes. Evaluation and Management Calculator window should now display code

Step 8 (cont.) If it does not, locate section labeled Patient Status in upper right corner of calculator window. Click on circle next to label “Existing;” then click on button labeled “Calculate E&M Code.” Figure shows E&M code generated as result of additional findings you added.

Figure Recalculated E&M code.

Step 8 (cont.) New code is “99213: Estab Outpatient Expanded H&P - Low Complexity Decisions.” Refer back to Figure 12-7 in your textbook. The previously calculated E&M code:

Step 8 (cont.) Compare grid at bottom of your E&M calculator window to Figure 12-7. Note that History sections HPI and PFSH now have bold levels listed in them.

Step 8 (cont.) Although only ROS history element moved to level 2, Overall History level changed from 1–Problem Focused to 2–Expanded Problem Focused. Look again at grid at bottom of E&M calculator window. Notice level of Exam has increased to level 2, Expanded.

Step 8 (cont.) This was result of addition of vital signs and two Physical Exam findings. Why, if none of key components changed to level 3, did E&M code change from a level 2 code (99212) to a level 3 code (99213)? Refer back to chart in Figure 12-21; you will notice that for established patient, CPT-4 requirement for is that two of three key components are at least level 2.

Step 8 (cont.) Because Overall History and Exam are now level 2 (Expanded), encounter justifies a higher level E&M code. Medical decision-making components did not change levels. Level of MDM is determined by two out of three elements in table shown in Figure

Step 8 (cont.) Risk table in Figure indicates that managing prescribed medications raises risk to Level 3. MDM level for any patient on medications will usually be determined by number of diagnosis and amount or complexity of data reviewed during visit.

Step 9 Click on button labeled “Cancel” to close E&M calculator window. Click on E&M button in Toolbar at top of screen to restart E&M calculator. Enter data in Problem Screening checklist window before proceeding to E&M calculator. When you click mouse on check boxes in Problem Screening For E/M window, check mark appears.

Step 9 (cont.) Locate and click the boxes for following:  Active  New Problem Compare your screen to Figure Click OK button at bottom of checklist window.

Figure 12-29: Problem Screening window with Active and New Problem checked.

Step 10 Locate column labeled “Dx/Mgt.” You will recall that Dx/Mgt stands for Diagnosis and/or Management. Compare Figure and Figure Notice that Dx/Mgt column has changed from level 2, Limited, to level 3, Multiple. This change in level was caused by addition of data from Problem Screening checklist window concerning diagnoses.

Figure 12-30: Dx/Mgt level changed to Multiple.

Step 10 (cont.) Time can be a factor when more than 50% of face-to-face time is spent counseling patient. Both face-to-face time and counseling time must be documented.

Step 11 It is a good idea to record face-to-face time in encounter note. The software allows you to do this when you record E&M code even if you are not using time as a factor in E&M calculation. Face-to-face time is total time you spent on visit before, during, and after patient exam. It is not just time spent counseling patient.

Step 11 (cont.) Click on button with down arrow in field labeled “Total Face-to-face or Floor time” and select 15 minutes (Figure 12-31). Recalculate E&M code by clicking on button labeled “Calculate E&M Code” again. Note that time did not change calculated code, which is still

Figure 12-31: Setting the face-to-face time.

Step 12 When clinician is satisfied with E&M code that has been calculated, it is posted to note. Locate and click on button labeled “Post To Encounter” (highlighted with orange in Figure 12-31). E&M Calculator window will close and E&M code will be added into your note.

Step 12 (cont.) Compare your screen with Figure Notice that procedure and face-to-face time (circled in red) have been added to bottom of encounter note.

Figure 12-32: Encounter note with E&M code and face-to-face time circled in red.

Step 13 Click on Print button on Toolbar at top of screen to invoke Print Data window. Be certain there is check mark in box next to “Current Encounter;” click on button to either print or export a file. Compare your printout or file output to Figure in the textbook. Do not close or exit encounter until you have completed step 14. Proceed to step 14.

Critical Thinking Exercise 71: Understanding How Procedures Are Posted to the Billing System
EHR systems that are integrated with practice management or billing software can transfer Procedure and Diagnosis codes from the EHR directly into practice management billing system. In most healthcare facilities codes that are transferred from the EHR do not post automatically to billing system.

Most systems hold these as “pending” charges until reviewed by billing or coding expert. Certain procedures are considered part of another procedure (bundled). Under certain conditions coding specialist may need to add procedure modifier codes. Certain codes may represent supply or sample for which doctor does not wish to charge patient.

Step 14 Locate and click on tab on top of right pane labeled “Outline View.” Locate and click small plus signs next to folders “Assessment” and “Practice Management.” Compare your screen with Figure Notice that Assessment Acute Sinusitis displays ICD-9-CM code in this view.

Step 14 (cont.) Notice that text beneath Practice Management folder not only displays description information of calculated E&M code, but CPT-4 code as well. Your version of Student Edition is not interfaced to billing system and does not transfer codes automatically.

Step 14 (cont.) It does post codes to patient encounter. You can view codes that would be transferred in Figure

Figure 12-34: Outline View with E&M code and description circled in red.

Figure illustrates typical method of posting charges from an EHR to a practice management billing module; these steps include: Clinician documents encounter at point of care. EHR calculates E&M code. Clinician clicks button labeled “Post To Encounter.”

Figure illustrates typical method of posting charges from an EHR to a practice management billing module; these steps include: EHR adds procedure codes to encounter note and transfers CPT-4 and ICD-9-CM codes to the practice management system. A billing or coding specialist reviews the “pending” charges, adds modifiers or other information, and posts them.

Figure 12-35: Flow of procedures posted from EHR to billing.
Critical Thinking Exercise 71: Understanding How Procedures Are Posted to the Billing System Figure 12-35: Flow of procedures posted from EHR to billing.

Figure shows practice management billing screen used to post charges transferred from the EHR after being reviewed by billing or coding specialist.

Figure 12-36: Practice management system posting E&M code from EHR (Courtesy of Medisoft).

EHR Coding and Reimbursement

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