Medical Decision

Making

Michael Nauss MD FACEP

Senior Staff

HFH Dept. of Emergency Medicine

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

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

Downcoding

Focus on 10% of patients

Can increase charges by 20%

Why do you care ?

You will…in less than 3 years

What is good for the dept. affects you

Revenue = power

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

“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

“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….

“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

MDM

In talking with coding…this is our #1

issues….

Because we often don’t do it

And please….Fill out the boxes….

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

MDM: Risk

Diagnostic procedures

Minimal• Labs (no IV), CXR or EKG

Low• X-rays (mult.), ABG

Moderate• CT AND x-rays

High• emergency surgery

MDM: Risk

Management Options

Minimal• RICE, bandage, gargle

Low• RICE

Moderate• PO meds

High• IV meds

MDM

Level 1 or 2 Level 3 Level 4 Level 5

Critical Care

Can be billed by staff only

Do not click “CC” in your notes

Medical Decision Making

Arguably the most important piece of

the medical chart

HPI “paints a picture”

MDM “plays art critic”

Common Mistakes

Missed information on

triage/EMS/nursing notes (general ED

notes)

“worse HA of life”

“slurred speech”

Common Mistakes

Unanswered abnormal VS

Unanswered abnormal VS

Unanswered abnormal VS

Unanswered abnormal VS

Unanswered abnormal VS

Unanswered abnormal VS

Unanswered abnormal VS

Common Mistakes

Lack of patient reassessment

VS

Pain

Symptom relief

• CP

• Abd. Pain

• Vomiting

• Wheezing

Common Mistakes

Poor consult documentation

Who did you talk to and when

• Make consultant aware of charting

“curb-siding”

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)

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.

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

Community Experience

How this is done

12 charts (3 per CC)

3-4 months after hire

Sit down evaluation with Risk

Management physician

HFH Experience

Charting metric

Twice a year for PGY-2 and above

Yearly for PGY-1’s

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…

How to Put it Together

Just put it somewhere

MDM section

• Reassessment (.now phrase)

• Diff Dx.

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

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

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

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

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.

Most Common Dx 1998-2012

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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.

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

Coming to a ED near you:

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