Coding Growth Strategies

Well let's get to it! Many of you have asked what we will be learning this year in Coding Growth Strategies that is new or better. I'm going to show you several of the things right now. Let's take the example we had last week. I'm going to write a 'simple' note and then discuss a few things.

A Good Note

History of Present Illness:
41yo male with stable HTN controlled with Diovan comes in with complaints of 12 hours of severe vomiting and diarrhea that resolved yesterday morning. He states that he lost approximately 16# in 24 hours but drank a little over a gallon of Gatorade and today in clinic is still down 6#. He was febrile to 101.2 yesterday but no fever in clinic today. Remainder of history is negative.

Past Medical History:
Problem List:

  1. BENIGN ESSENTIAL HYPERTENSION (401.1)

Medications:

  1. Diovan 160 mg tablet TAKE 1 EVERY DAY(S).

Allergies: No Known Allergies

Physical Exam:
Vitals: BP: 118/76
Constitutional: Normal/Negative.
ENT: Normal/Negative.
Cardiovascular: Normal/Negative.
Respiratory: Normal/Negative.
Gastrointestinal: Normal/Negative.

Diagnoses:

  1. FEVER (780.6)
  2. GASTROENTERITIS-NONINFECTIOUS (558.9)
  3. BENIGN ESSENTIAL HYPERTENSION (401.1)

Treatment Plans:

  1. Medication continued: Diovan 160 mg tablet TAKE 1 EVERY DAY(S).
  2. Take tylenol or motrin as needed.
  3. Will weigh daily at home. If weight does not return to normal, will return to clinic in 1-2 days. Otherwise return to clinic in 3 months.
  4. Encourage fluids.
  5. Return to clinic immediately or call for blood in stool.

Signature(s):
Signed Electronically: Great and Powerful Oz, MD

Let's talk about coding. First let's do Medical Decision Making. Risk would be moderate due to having an Acute Illness with Systemic Symptoms. Number of diagnoses is 3. Treatment plans at least 4. Data Review is zero. But your auditor may state that you did not seem to address the hypertension in the note. So maybe number of diagnoses is two. You'll have to fight it out with her and see.

Now let's talk about Physical Exam. Do we have a limited exam of the affected organ system (Expanded Problem Focused) or an extended exam of the affected organ system (Detailed). When we are audited, will she agree?

History: We have 5 elements of HPI (location, duration, severity, associated symptoms, modifying factors). We have one element of PFSH (past medical history). No review of systems ("Remainder of history is negative" is a meaningless sentence as far as coding is concerned).

So that means if our auditor decides that we did a limited exam, then this is a 99213, not a 99214.

Now let me show you the kind of note we will by aiming for. And if you use a reasonable EMR, it literally takes an extra 2-3 seconds to get this note:

A Better Note

History of Present Illness:
41yo male with stable HTN controlled with Diovan comes in with complaints of 12 hours of severe vomiting and diarrhea that resolved yesterday morning. He states that he lost approximately 16# in 24 hours but drank a little over a gallon of Gatorade and today in clinic is still down 6#. He was febrile to 101.2 yesterday but no fever in clinic today. Denies other Constitutional, Cardiovascular or Gastrointestinal symptoms (ROS). He states his BP has been stable at home with no side effects reported.

Past Medical History:
Problem List:

  1. BENIGN ESSENTIAL HYPERTENSION (401.1)

Medications:

  1. Diovan 160 mg tablet TAKE 1 EVERY DAY(S).

Allergies: No Known Allergies

Physical Exam:
Vitals: BP: 118/76
Constitutional: Normal/Negative.
ENT: Normal/Negative.
Cardiovascular: Normal/Negative.
Respiratory: Normal/Negative.
Gastrointestinal: Abdomen: Soft, nontender, no masses. Hyperactive bowel sounds.
Liver: No hepatomegaly.
Spleen: Nonpalpable.

Diagnoses:

  1. (780.6) (Acute Illness w/Systemic Symptoms)
  2. GASTROENTERITIS-NONINFECTIOUS (558.9) (Acute Illness w/Systemic Symptoms)
  3. BENIGN ESSENTIAL HYPERTENSION (401.1) (Stable)

Treatment Plans:

  1. Medication continued: Diovan 160 mg tablet TAKE 1 EVERY DAY(S).
  2. Take tylenol or motrin as needed.
  3. Will weigh daily at home. If weight does not return to normal, will return to clinic in 1-2 days. Otherwise return to clinic in 3 months.
  4. Encourage fluids.
  5. Return to clinic immediately or call for blood in stool.

Signature(s):
Signed Electronically: Great and Powerful Oz, MD

So what is different? In History, our meaningful use prompts remind us to get the patient's smoking status, which gives us one more item for PFSH. Also, we now have 3 clearly marked systems that have been reviewed. We also added one sentence to show that we did in fact address his hypertension. This moves our level of history up to Detailed.

By including the multiple negatives in the GI system, we now have assurance that our Physical Exam also meets the criteria for Detailed.

In Decision Making, we simply added descriptors to the diagnoses in order to clarify risk. Now our auditor knows why we said our level of risk is moderate.

We will be talking at length this year about many of these coding and documenting shortcuts. Or as I like to call them: 'insurance policies'. You know I'm not one to overly 'pad' the chart because I feel it is a waste of time. But literally it took me about 7 extra clicks of the mouse to convert the first note to the second. We're talking about an extra 3 minutes per day over 30 patients. And now our notes are much 'safer' when it comes to being audited.

I hope you have a chance to attend this year! Look forward to seeing and hearing from you all. Good luck with your practices.