Hey everyone. I’d like to go over two questions we had since our last newsletter:
Question:
Please talk more and give more examples of documenting established patients for 99215 based not on risk but on history of multiple medical problems and medical necessity. You spent only a few minutes on this on your first conference but this is 80% of what internist do!
Answer:
I agree, this has always been a difficult issue: determining when the 'complicated chronic patient' moves from a 99214 to a 99215.
3-4 stable chronic problems is usually a 99214. 12 stable chronic problems with 18 meds is a 99215. But where does the break come to turn it into a level 5? That's the hard part. Here's what I tell most people: If a patient has at least 4 chronic problems but your data review doesn't add up to 4 points and your risk is not High, then it comes down to History and Physical. If you need to do a comprehensive H&P in order to adequately address this patient's problems, then you have fulfilled the requirements for a 99215. But don't forget, this means:
Addressing the status of at least 3 problems (which will have been done).
At least 2 parts of Medical, Social, or Family History
10 elements of ROS
8 organ systems of physical exam
If any one of these are lacking, then it is usually a 99214. The biggest thing most people miss in the 'complicated chronic patient' is 10 elements of ROS. And if you really want credit for it, don't state "All other systems reviewed and are negative" unless you actually address 10 systems with the patient. It's safer to list the individual systems underneath the ROS heading in your note.
I will be addressing this topic of the” complicated chronic patient that doesn’t have a High level of risk” at length in the upcoming Advanced Coding Strategies course.
Question:
We too adopted the nursing staff of obtaining the HPI and have used this approach for years. We were recently audited by an outside firm as part of our compliance program and we were not able to use the HPI documented by anyone other than the provider for new patients, because of this our new patient visits were down coded to an established visit. We are looking to change our process now because of this and our nursing staff will only be obtaining the chief complaint at intake. I also had our certified coder do research on this issue as well and she came to the same conclusion. Now, with that being said in the electronic world it will be difficult for an auditor to determine who did what. What are your thoughts?
Answer:
Very interesting. What I do is have the nurse compile the HPI, then I am the one who writes the note. It comes across as simple text in the HPI section of the electronic record. I have the option of changing it or leaving it be. But then I am the one to sign it and it is the progress note as signed by me. I am not considering this the HPI, rather it is starting notes that the nurses have provided.
The coding guidelines do explicitly state that someone other than the provider can collect the past medical, family, social histories and review of systems. However, the provider still must address it in their note and state that it was reviewed on that date and there were no changes (or state the changes).
We would always want to be compliant with the coding/documentation guidelines. I wonder, is this any different from the nurse putting in the Past/Social/Family History in the chart? As long as the provider reviews this with the patient and then signs off on it saying "this is my history that I want in my note." Obviously we would never have the nurse do an HPI and then not do one ourselves; but who does the documentation raises an interesting question.
Don’t forget I’ll be hosting Advanced Coding Strategies in Dallas on October 15th. Over the last several years we have worked to provide the best coding instruction available for physicians. We appreciate the help and support you have given us. Our annual Coding Growth Strategies seminar focuses on how we can quickly and accurately identify the type of patient that we’ve seen then document accordingly.
After every conference and newsletter we release, we have many questions that come our way. Some of these are simple coding chores but often they are a little more challenging to figure out. Over time I have come to call these ‘advanced coding’ topics. These bring up several issues that aren’t covered in our normal day-to-day coding. We have compiled these into a 4 hour session that we know will be helpful to your practice.
The conference will start out with a few minutes of review and ‘touching base’ for those that have attended before (Remember the color-coded Risk sheet?). Please Note: this is not an introductory course! It is expected that the attendees will have already completed our regular 6 hour Coding Growth Strategies course and we will not go back over what we have already learned. You should be comfortable with identifying the patient’s level of risk, medical decision making, and have a certain level of proficiency with coding 99213, 99214, and 99215 codes.
This is the ‘part 2’ of the course. We will immediately dig in to some of our more challenging topics in the day-to-day practice. For more information about the specifics that will be covered, visit our website at www.CodingGrowthStrategies.com.
After becoming familiar with multiple challenging examples, we will then discuss Documentation Short Cuts. While there are no ‘short cuts’, we will talk about several items that can streamline your documentation so that you spend less time writing, and more time seeing patients.
One thing I’m very excited about is our ‘lightning round’. Here, we will have the attendees submit some of their coding challenges ahead of time and we will discuss them as a group. We will identify the patient and first ask ‘what should be the level of service?’ quickly followed by ‘is this note adequate?’. That way instead of using pre-made examples, we will use actual patients seen by you.
This will be an exciting course, hope to see you in October. DVD’s will be available by the end of October.
Sign up for the Advanced Coding Strategies live presentation at www.CodingGrowthStrategies.com
Pre-order the Advanced Coding Strategies DVD/CD at (available October 25)