Home Forums Discussions General Discussion Delimiters

How does using delimiters in your HPI, ROS and PE increase coding accuracy?

Bump

Bert,

I am ignorant, and have no idea of what you are asking. I talked to Dr Google; this thread is listing #1, and all I could come up with is page 14 here:

http://www.speechrecsolutions.com/assets/Dragon10MedicalGuide.pdf

Could you expand your question so I don't feel so stupid. Still won't be able to help though.

Bert,

If you are referring to "bullet points" or similar, I think it just makes it easier for an auditor to find the number of items in HPI/etc. So I don't think it make you more accurate, but it might make an auditor more accurate!

If these are not what you are asking about, nevermind.

Gene

Thanks Gene,

Sorry, I should have been more specific.

I am referring to the information on the E & M coding helper in AC. You may be right. Maybe it pertains to a bullet. But, you would think it would say that. Like use a bullet: > * - () #

Bert.

Basically, what Gene said. It is a bullet point that helps count the number of items in a specific field. In the case of the E&M coding helper, it lets the program count the number of items in each relevant field (HPI, ROS, and PE)and lets the Coding Helper figure out what office visit code to use for that visit.

Thanks Mark,

OK. That sounds too good to be true. I have used EMRs that will figure out your code for you or tell you what you are missing for a certain code.

Are you saying that AC has the capacity to parse the number of items and, therefore, figure out codes for a particular visit?

Somewhat, but it is not perfect. In simple terms, it will count the number if delimiters in those specific fields, plus look at if you entered CC and will generate a code. So ideally you would have a delimiter ("<" by default in the program)in front of every item in that field and that is what the program counts. Without the delimiter it will usually default to 99213.

Sorry to take up your time. I am trying to understand this. Especially your last two sentences.

Is there a white paper on this? An instruction sheet of some sort? Am I the only one who didn't know this was available?

So, if I wrote:

Patient presents with fever, cough, runny nose and rash, that may be considered one or none? But, if I wrote: (and I think in the E & M Coder Helper it used ( > )

Patient presents with:

> Fever times three days
> Cough
> Runny nose times two days
> Rash starting today

the program would count that as four? Bear in mind, when looking at E & M, it counts Fever to 102.3 for three days as three things due to the descripters (unless I am wrong about that).

Also, if it gives a 99214, where would it show that and how accurate is it?

I would definitely count "fever 102.3 grade Fahrenheit x3days" as a single element. EDIT: THIS IS WRONG

The window would show it where it shows the 99213. Under the "Your likely code" text to the right. How accurate the tool is depends on how well you use your delimiters. And how well you use your delimiters depends on your knowledge of coding. Ultimately, the E/M Coding Helper is just that, a helper/tool. I wouldn't recommend using it if you don't know the ins and outs of coding.

At least that's my impression of it after reviewing it for a few minutes. The doctor doesn't use the E/M coding helper.

I'd recommend that all physicians learn more about coding. How deep you get into it will depend on whether or not you have someone to worry about that kind of stuff for you. There is a doctor named Paul Firth that holds a conference about medical coding called Coding Growth Strategies. He sells a DVD of his talks along with an accompanying 100+ page power-point booklet that you can complete while watching the DVD. It's very informative.

Gosh, I hate being wrong, but it appears that I am. I am wrong about the fever example you brought up.

Straight from the 1995 guidelines on the CMS website.

Thanks Mario,

I very much appreciate your going into so much detail. I didn't feel comfortable going completely by the E & M Code Helper. Besides, I think it would end up taking longer than its worth.

It is the "drill down" EMRs like Centricity, where you click eye, then sclera red, then bilateral, then spares limbus, etc. where each click is tallied by the program. It will give a fairly accurate code. But, in AC, one is typing, so it seems as though it would be tougher for the program to parse the data.

Thanks again.

I found this article very helpful on level IV visits:

http://www.aafp.org/fpm/2006/0200/p34.html

The 'examples' page is very helpful, on the back of this:

http://www.aafp.org/fpm/2006/0200/fpm20060200p34-rt1.pdf

I don't think there is anything available to all moral physicians that can be as profitable as spending the extra little time making sure you have recorded enough history to justify a 99214 charge, if the rest of the visit can support it. If an EHR can change a physician from always charging 99213 to prevent audits over to doing 99214s half the time, the difference is a lot of profit. AC can help us make some money with meaningful use, and maybe an integrated PM could minimize staff time, but nothing compares to billing exactly what you did.

As we all know and have been trained by CMS for 18 years, a 99214 charge requires 2 out of 3 of a detailed history (required CC, extended HPI as per Mario, extended ROS, pertinent Past, Family, Social History), a detailed exam (at least 6 organ systems/body areas or 12 elements of one organ system/body part), and moderate complexity of decision making (2 out of 3 for multiple diagnoses, moderate data to be reviewed, and moderate risk of significant complications).

Moderate complexity of decision making is subjective, so you can probably get this for an acute illness or more than one chronic disease, starting a new treatment, etc.. This is where we have to think that not every visit is either a 99213 or a 99214. It is the ratio that will leave money on the table or trigger an audit.

A detailed exam is probably the element that doesn't get recorded fully, even if it was done.

So the detailed history is the tie breaker. EHRs make it a lot easier to record a detailed history. Some offices even use a nurse for most of this.

I hope AC will make this area very robust in future versions.

I never want to trust a program to do more than help me know if I have recorded enough bullet points, elements, etc in the history and exam. If we get too confident in letting the program decide our visit charge, eventually the insurance companies will be choosing it for us.

Chris, I haven't had a chance to look over your sites. I will soon.

@Dan,

Thanks for the well written and very studious, detailed information on coding. I don't know if I have ever seen it done that well.

Unfortunately for me, I find E & M coding a necessary evil and find it impossible to document all my visits not only thoroughly but in a way where I can put the bullets in all the right places. I do think that a poorly documented note can lead to poor care or even lessen the chance of a good defense if sued. But, I don't think the abundance of a lack thereof should affect how I am paid. Once again, medicine does things differently than nearly every other profession. An attorney will charge you the same price for an hour's worth of work and a golf pro will always charge you $75.00 for that same 45 minute lesson whether he/she is teaching you the driver or the putter. I am sure there are many other examples of professionals charging a certain fee for a certain amount of time.

I saw 32 patients today, partly because I must see volume to make a profit and partly because most of them needed to be seen. My 3:00 patient which ended up being seen at 3:30 pm. This particular patient presented with wheezing, decreased air movement in the LLL and a left acute otitis media. Sats were 86%. After three Xopenex 1.25 mg nebs and 60 mg of Prednisone, they were up to 93%. His RR was down, his pulse rate was down and fever down from 103 to 99.9 with Tylenol and Motrin. His CXR did show a lobar pneumonia, and he was diagnosed with pneumonia, asthma exacerbation and otitis media. Given the amount of time the patient required, my note was not as thorough as it could have been. It was difficult to not charge a 99214, but technically it wouldn't meet the E & M coding requirements. On the other hand, I am sure I could turn a conjunctivitis into a 99214 if I tried hard enough. Maybe it is the only way to do it, but I just find myself throwing my hands up in the air and charging 99213s 80% of the time, if not more.

As a side note, our ED simply dictates all ten review of systems were normal.

Thanks Bert,

You will get your reward for the 3 pm patient in karma or the hereafta. Sounds like you kept a child out of the scary hospital, when a lot of docs would have been happy to do that for the time savings and the higher charges.

I think the future of history taking is going to be the portal, a kiosk, or a tablet cheap enough to drop. Patients are going to have to enter their problem, pertinent positive and negative symptoms, and the related elements into the computer before they even get an acute care appointment or get put into the exam room for a follow-up appointment.

When they get to the exam room, an experienced nurse is going to review the responses, verify the patient understands the questions and choices made, and flesh out the sparse areas.

You will come in to review a granular 99214 expanded HPI, listen to their story, and go thru the differential with other questions while you examine them.

Patients want to tell the story of their problems, because they want to connect to us, and we should listen to it. But, rather than interrupting constantly to try to get the bullet points, we just have to edit them if necessary.

Better care for the public is in granular data used to prevent physicians from making mistakes of omission and commission. Unfortunately, we are not even in the training wheels phase.

This kind of programming needs to be a part of every portal and EHR. We have to do this to become more productive and effective. I think every specialty or subspecialty should create the guidelines to make this programming successful.

I agree. Thanks. But, I read the PDFs from Chris (thanks), and I would have failed that in medical school.

That was the most confusing thing I ever read.

Can you clear ONE THING up for me?

It says something about bringing up something new or whatever from PMH, PSH, and FH (or SH?). But, on the E & M helper, it's a box not a radio button. I can get a 99214 (playing around in it) without it. I am confused. Especially in pediatrics where broken left arm in 2010 doesn't change much.

Oh, also, I won't lie that when I am in the room trying to get a deserved 99214, the degree of decision making is also difficult for me. I am not sure how I would do that quickly.

One thing I have asked for the program for ten years is to have a necessary screen or option where when you sign the chart and enter the CPT code, you HAVE to select a degree of decision making. Because now when you select it, it tends to stay the same, and you end up with a moderate instead of straightforward for canker sore, because it stays the same and you don't remember to change it.

What I do for PMHx, FHx, SHx is look at what I have in AC, make sure it's complete, and ask the patient (Mother?) if there is any family history of similar difficulties. If it's a longwinded mother of a patient with a common infection , you could save time by asking, "Are there any family members with infection problems, like AIDS?" This is why I don't treat distressed mothers for a living.

What I record for the histories is, "Reviewed ... for pertinent information." before the facts in those histories. At least it meets the letter of the law I think.

Two things about charging 99214. First the danger of it. You can induce patients to go to another physician that doesn't charge too much and you can induce payment problems or audits. I'm sure you know or have a feeling for which patients might deserve 99213 prices for 99214 care, so be generous to them. As to the insurance companies, the only gorilla out there is Medicare, which isn't your problem, so fight the good fight.

Second, changing your 99213/99214 ratio is like changing your weight, you have to watch it. Have someone keep a tally for you, remind you, and you will change your behavior. Just like the drug reps trying to keep their product in your mind so you don't go back to old habits.

To make the decision easier when you have time to do proper documentation, be prejudiced and ask yourself, What kind of doctor could have handled this visit? With all respect to midlevels and FPs(I'm trying to help Bert here), if an average FP office midlevel could of handled the visit, maybe it's a 99213. If it would have taken the average FP instead to handle the visit, possibly/probably it's a 99214, and a lot of these should be 99214s, like 50% at least. If it would have taken a pediatrician to do the job right most of the time, it's definitely a 99214. There you go, better quick n dirty billing thru prejudice.

Dan and Bert,

This thread

http://amazingcharts.com/ub/ubbthreads.php/topics/38424/Maximizing_billing#Post38424

from about a year and a half ago was very useful to me.

Specifically

www.emuniversity.com

which is free was extremely useful.

Dan,

About 7 years ago I heard a speaker (family doc), at a Pa. AFP seminar, reporting that virtually every visit of his was a 214. He got paid for all of them, and had no problems with the occasional audit that he was subject to.

In my experience, the only potential problem based on percentage of visit coding, was a Medicare letter received by an ENT. He was flagged for coding all office visits as 213s, the norm for that specialty was about 5% 212, 70% 213, 25% 214. They suggested that he review his coding procedures.

He never heard back from them afterward.

Gene

Dan, thanks again. Very helpful.

And, Gene, gotta get back to you. Too busy with my 99213.5s.

Not sure which guidelines you are using (1995 vs 1997), but I know that with the 1995 guidelines there are 7 "dimensions" of an OV. These are:
1. history
2. physical examination
3. medical decision making
4. counseling
5. coordination of care
6. nature of the presenting problem
7. time

Typically, coders/physicians use the first 3 dimensions to determine the level of a visit. However, the last 3 can override what would be determined by analysis of the typical 3 (history, pe, decision making). For your patient, exacerbation(depending on the severity of the exacerbation) could have made it an automatic 99214. It sounds to me like that patient was in pretty bad shape, you might have even been able to charge a 99215.