Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss...
Transcript of Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss...
![Page 1: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/1.jpg)
Medical Decision
Making
Michael Nauss MD FACEP
Senior Staff
HFH Dept. of Emergency Medicine
![Page 2: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/2.jpg)
Billing 101:
Down coding
Compared to national benchmark:
• HFH -1% on critical care
• When compared to Level 5 billing:
• Loss of $220 professional charges/pt
• Loss of $765 facility charges/pt
• HFH -9% Level 5 charts
• When compared to Level 4 billing:
• Loss of $215 processional charges/pt
• Loss of $494 facility charges/pt
![Page 3: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/3.jpg)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
99281 99282 99283 99284 99285 99291 99292 Other
DEM Mean
FSPC Mean
July-Dec 2013
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
99281 99282 99283 99284 99285 99291 99292 Other
DEM Mean
FSPC Mean
Jan-June 2013
![Page 4: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/4.jpg)
Downcoding
Focus on 10% of patients
Can increase charges by 20%
![Page 5: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/5.jpg)
Why do you care ?
You will…in less than 3 years
What is good for the dept. affects you
Revenue = power
![Page 6: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/6.jpg)
What can you do to help?
Improve documentation
To reflect what we actually see and do
To reflect the complexity of our
patients and our workup’s
To capture the appropriate revenue
![Page 7: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/7.jpg)
“Level 5 Chart”
HPI: Four
location, quality, severity, timing,
associated sx, duration, context,
modifying factors
ROS: Ten
• Constitutional, Eyes, ENMT, CV,
Respiratory, GI, GU, MSK,
Integumentary, Neuro, Psych,
Endocrine/Metabolic,
Hematologic/Immunological
![Page 8: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/8.jpg)
“Level 5 Chart”
ROS
“Do you have any fever, chills,
nausea, vomiting, cough, sore throat,
rashes or bruises, pain in your head,
back, belly, chest, or burning when
you urinate ?”
There is your 10 in once phrase….
![Page 9: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/9.jpg)
“Level 5 Chart”
PMHx, Family Hx, Social:
Three: Epic does this for you (mostly)
PE
8 systems
• Constitutional, Eyes, ENMT, CV, Resp.,
GI, GU, MSK, Skin, Neuro., Psych,
Heme/Immun.
MDM
![Page 10: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/10.jpg)
MDM
In talking with coding…this is our #1
issues….
Because we often don’t do it
And please….Fill out the boxes….
![Page 11: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/11.jpg)
![Page 12: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/12.jpg)
![Page 13: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/13.jpg)
MDM: RISK Presenting Problem
Minimal
• one self limited minor problem
Low
• 1 stable chronic prob. , 2 minor problems, or acute
uncomplicated illness/injury
Moderate
• Mild exacerbation, 2 chronic stable problems, new
problem/uncertain dx, acute illness
High
• Severe exacerbation, MS changes, Life threat
![Page 14: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/14.jpg)
MDM: Risk
Diagnostic procedures
Minimal• Labs (no IV), CXR or EKG
Low• X-rays (mult.), ABG
Moderate• CT AND x-rays
High• emergency surgery
![Page 15: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/15.jpg)
MDM: Risk
Management Options
Minimal• RICE, bandage, gargle
Low• RICE
Moderate• PO meds
High• IV meds
![Page 16: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/16.jpg)
MDM
Level 1 or 2 Level 3 Level 4 Level 5
![Page 17: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/17.jpg)
Critical Care
Can be billed by staff only
Do not click “CC” in your notes
![Page 18: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/18.jpg)
Medical Decision Making
Arguably the most important piece of
the medical chart
HPI “paints a picture”
MDM “plays art critic”
![Page 19: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/19.jpg)
Common Mistakes
Missed information on
triage/EMS/nursing notes (general ED
notes)
“worse HA of life”
“slurred speech”
![Page 20: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/20.jpg)
Common Mistakes
Unanswered abnormal VS
Unanswered abnormal VS
Unanswered abnormal VS
Unanswered abnormal VS
Unanswered abnormal VS
Unanswered abnormal VS
Unanswered abnormal VS
![Page 21: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/21.jpg)
Common Mistakes
Lack of patient reassessment
VS
Pain
Symptom relief
• CP
• Abd. Pain
• Vomiting
• Wheezing
![Page 22: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/22.jpg)
Common Mistakes
Poor consult documentation
Who did you talk to and when
• Make consultant aware of charting
“curb-siding”
![Page 23: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/23.jpg)
Common Mistakes
Discharge Instructions
Ambiguous
No information on what to watch for or
why to come back
Lack of follow up instructions (and
time course to do so)
![Page 24: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/24.jpg)
Common Mistakes
Non Documentation
Procedures and failed attempts etc.
• Also hurts from a billing standpoint
Information from old chart/OSH
Repeat EKG’s (order and document)
Adverse events
• Itching after med. etc.
![Page 25: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/25.jpg)
Community Experience
Regional Group
Risk Management Audit
• Abdominal Pain
• Chest Pain
• HA
• Fever in Child
CC’s represent 75% of dollars lost in
ED suits
![Page 26: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/26.jpg)
Community Experience
How this is done
12 charts (3 per CC)
3-4 months after hire
Sit down evaluation with Risk
Management physician
![Page 27: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/27.jpg)
HFH Experience
Charting metric
Twice a year for PGY-2 and above
Yearly for PGY-1’s
![Page 28: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/28.jpg)
Building a Chart
EMR dependent
Typing is not ideal (…job seekers)
Be aware of templates/macros
• LE Amputees with +2 DP/PT pulses
bilaterally are unusual and hard to find
• preformatted discharge instructions…
![Page 29: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/29.jpg)
How to Put it Together
Just put it somewhere
MDM section
• Reassessment (.now phrase)
• Diff Dx.
![Page 30: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/30.jpg)
How to Put it Together
Summarize
Presentation• This is a patient who presented with
cough and SOB
ED Course• Pt. was given nebs/steroids and labs/cxr
were obtained
Studies • Labs unremarkable (.edlabs)
• CXR showed no pna
![Page 31: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/31.jpg)
How to Put it Together
Summarize
Patient Response to Tx:
• Pt states she felt better after tx
• Eating/Up and ambulatory in ED
• Asking for to go home
![Page 32: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/32.jpg)
How to Put it Together
Evaluate the Differential Dx.
Based on…. I doubt ….
• EKG unchanged, no exertional
component to symptoms I doubt ACS
• No leg swelling/pain, no travel or recent
surgery I doubt PE
Given …. I favor ….
• Pt. has hx of COPD, improved with nebs
and steroids I favor COPD exacerbation
![Page 33: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/33.jpg)
How to Put it Together Case for Discharge/Treatment Plan
Why is this COPD exacerbation going home?
• Given pt. does not desat. during ambulation, is afebrile, feels improved, I feel they can be d/c with oral steroids and abx as well and increase home neb. use
Follow up
Phone call Ability to obtain timely f/u
• iPhone etc.
• Document the call/attempt
![Page 34: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/34.jpg)
How to Put it Together
Discharge Info.
Spell out exactly what to watch for and
reasons to seek further care
Follow up (did you talk with PMD)
“…return if worse or if concerned”
Incidental findings: document in chart
and on d/c Instructions
• Need for repeat cxr in 6 months etc.
![Page 35: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/35.jpg)
Most Common Dx 1998-2012
0
5
10
15
20
25
30A
ppy
CA
Card
iopulm
onary
Arr
est
CV
A (
ischem
ic)
Ecto
pic
FB
FX
R
ICH
Infe
ction/S
epsis
Epid
ura
l A
bscess
Menin
gitis
Card
iac/M
I
Mis
sed M
I
Respirato
ry A
rrest
Dis
section/A
neury
sm
(not
intr
a-c
rania
l) PE
Bow
el Is
chem
ia
To
tal
#
0
2
4
6
8
10
12
14
16
Perc
en
t
Total
%
![Page 36: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/36.jpg)
How to Put it Together
(finally)
Case for Admission
Medical Necessity
Important for billing (ATMO/IPAS too)
Why is this COPD exacerbation being
admitted ?
• Increased O2 requirement
• Abnormal CXR
• Need for serial cardiac markers etc.
![Page 37: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/37.jpg)
Coding Queries
As of 7/31
$ 55,000 waiting on resident charting
(queries only) to be billed
Finish carts same day/next day
Respond to queries ASAP (even off
service)
Ask me if ?’s
![Page 38: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/38.jpg)
Coming to a ED near you:
![Page 39: Medical Decision Making - Emergency Medicine Residency ... · Medical Decision Making Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine . Billing 101: Down coding](https://reader034.fdocuments.in/reader034/viewer/2022042709/5f517ff7f2729c040209ec05/html5/thumbnails/39.jpg)
Summary MDM
Needs to play a larger role in
documentation
Should reflect disposition thought
processes and data
Must include commonly missed items
• Abnormal VS, reassessments etc.
Follow up and discharge instructions
ought to be viewed with increased
importance