E/M Coding Fact And Fiction - AAPC
E/M Coding – Fact and FictionPresented by:Peggy Stilley, CPC, CPMA, CPC-I, COBGCand Deann Tate, MHA, CPC, CPMA, CCC, CEMC1
Overview of Today’s Session This session will cover Facts and Fiction about E/MCoding––––Medical NecessityCoding Guidelines & Payer InsightsPotential “Gray” AreasEvaluation and Management Process Presenting Results Case Studies Recommendations for Future E/M ComplianceE/M Coding – Fact and Fiction2
Disclaimer This course was current at the time it was published. This course was prepared as a tool toassist the participant in understanding how to perform a successful internal audit to protect yourmedical practice. Although every reasonable effort has been made to assure the accuracy ofthe information within these pages the ultimate responsibility all of the information has does notaccept responsibility or liability with regard to errors, omissions, misuse and misinterpretation.Please keep in mind that every insurance company has processing and reimbursingprocedures that are individual to each particular company. Instructions and recommendationsgiven in this booklet should not be interpreted as applying specifically to every insurancecarrier. Please confirm with your carriers coding practices that are applicable to each carrier.The American Academy of Professional Coders (AAPC) employees, agents, and staff make norepresentation, warranty or guarantee that this compilation of information is error-free and willbear no responsibility, or liability for the results or consequences of the use of this course.NOTICESCurrent Procedural Terminology (CPT ) is copyright 2009 American Medical Association.All Rights Reserved. CPT is a registered trademark of the American Medical Association(AMA).E/M Coding – Fact and Fiction3
Medical Necessity What is Medical Necessity?– Medicare defines as services or items reasonable andnecessary for the diagnosis and treatment of illness or injuryor to improve the functioning of a malformed body area Can be determined on a case-by-case basis– Other payers define as: “Reasonable and necessary” or “Appropriate”– Coverage may be limited if: Service is provided more frequently than allowed under either anational or local coverage policy or a clinically accepted standardof practiceE/M Coding – Fact and Fiction4
CMS Guidance FACT:– “Medical necessity of a service is the overarching criterion for paymentin addition to the individual requirements of a CPT code. It would notbe medically necessary or appropriate to bill a higher level ofevaluation and management service when a lower level of service iswarranted. The amount of documentation should not be the primaryinfluence upon which a specific level of service is billed.Documentation should support the level of service reported. Theservice should be documented during, or as soon as possible after it isprovided in order to maintain an accurate medical record.”– Comprehensive Error Rate Testing Program 2009;https://www.cms.gov/certE/M Coding – Fact and Fiction5
In Today’s Regulatory Environment . . . Post payment reviews and audits are increasinglyprevalent Good documentation is the only defense for thephysician The auditor’s motto is “Not documented, notdone!”E/M Coding – Fact and Fiction6
Measuring Medical Necessity What Methods do Payers use to ensure MedicalNecessity when reviewing claims?– Claim edits Ensure payment is made for a specific procedure code orpredetermined diagnosis code– Automated denial/review commands– Diagnosis code is important for supporting MedicalNecessityE/M Coding – Fact and Fiction7
Keys to Demonstrating Medical Necessity in E/M Services Document all diagnoses the provider is managing during thevisit For each established diagnosis, specify if the patient’scondition is stable, improved, worsening, etc. Make sure the rationale for ordering diagnostic tests is eitherdocumented or easily inferred Clearly describe management of the patient, (i.e.,prescription drugs, over the counter medication, surgery, etc)E/M Coding – Fact and Fiction8
Why is it Important? Practice of Medicine has undergone a significant transformationdue to:– Federal regulations– Coding– Reimbursement Medical Coding is a language all its own– Coding is not an exact science– Documentation and Medical Necessity must be supported in themedical record– Coding is subject to intense review by insurance industry Insurance industry uses statistical analysis to recover dollarsspent for fraud, waste, and abuseE/M Coding – Fact and Fiction9
Supporting Medical Necessity Diagnostic codes identifycircumstances of patient’sconditionNature of thepresentingproblem To justify care provided youMUST provide pertinentinformation to the insurance carrierReason forCareFactsregardingSigns/Symptoms orComplaintsE/M Coding – Fact and Fiction10
Top E/M Coding Errors Lack of Medical NecessityOvercoding or UndercodingWrong E/M category chosen– Consult requirements not met– Preventive service should be billed Chief Complaint missing or incorrectAssessment and/or Plan not clearly documentedMissing DocumentationIllegible DocumentationTime not documented correctly– Total time is documented but not that more than 50% was devoted tocounseling and/or coordination of careE/M Coding – Fact and Fiction11
Top E/M Coding Errors Documentation not authenticated Tests ordered & billed but not documented on the patientencounter Incorrect Diagnoses– Signs & Symptoms with Definitive Diagnosis– Incorrect Sequencing Unbundling Missing or invalid modifiers– -24– -25– -57E/M Coding – Fact and Fiction12
Auditing Procedures Performed with E/M Services Accurately translating surgical and medical services into CPT and ICD-9-CM codes is challenging– Auditor must understand the surgery coding guidelines, insurancecarrier rules, Correct Coding Initiative (CCI) edits, and how to code anoperative report– Knowledge of procedural and diagnostic rules, as well as abackground in medical terminology is needed– Specific understanding of the procedure and services performed by thephysician is essential to assign the proper CPT code(s)– Many insurance carriers monitor a physician’s billing practices closelyfor possible inappropriate billing and/or unbundling. It is essential thatthe CPT description accurately describe what actually transpiredduring the patient encounter.E/M Coding – Fact and Fiction13
Billed:Dx:99213-25V13.2957511Audited: E/M is supported EPF/EPF/Lbut lacks medical necessityDx: 622.11 Consented for differentprocedure9/7/2012 Established patient here for cryoHPI: this patient is in for treatment of her abnormal pap. Last colposcopy showed a low-gradesquamous lesion with mild dysplasia. She has a history of irregular pap smears in the past.Informconsent for colposcopy was obtained.Allergies: NonePatient is non-smoker, works as RN in ER. Family history of cancer in GGM and HTN in mother, fatherhas Diabetes. G6P2ROS: Constitutional: negative for fever, Respir: negative for SOB, Cardio: negative for chest pain,GI: negative for N&V, Neuro: negative for HA, Psych: negative for depression, patient is not anxious.Objective:Oriented to time, place, person, head is normocephalic and atraumatic, PEERLA, neck has normal ROM,no thyromegaly, no respiratory distress, no abdominal distension, alert and oriented to time, place,person, skin is warm and dry, normal mood and affect.Assessment: History of abnormal pap, mild dysplasia of cervixPlan: Cryotherapy is performed – return in 4-6 months for test of cure pap smear.E/M Coding – Fact and Fiction14
99213 -252055099213- 2520600-RTJ1100, J0702X2Patient presents with complaint of pain and soreness on the left foot. Has been sore for several months andis getting worse. Also has compliant of painful right great toe.Medical history – negativeMedications – noneAllergies NKDASocial history – no tobaccoExam: Skin temperature of lower extremities is warm to cool on proximal to distal. Pulses palpable bilaterally,no edema, cyanosis or crepitus.Sensations are normal, tenderness with palpation of the right great toe.Tenderness of right 3rd to 4th interspace.Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones,joints, and muscle unremarkable.Impression: Neuroma, CapsulitisPlan: Injection of Lidocaine 20 m/ml, ¾ cc Dexamethasone 1 mg /ml and 4 cc Celestone soluspan 3mg /ml inright great interspace. Patient tolerated injection w/o complications. Discussed exercise - instructed to callwith increased pain or redness.E/M Coding – Fact and Fiction15
AMA Surgery Guidelines The CPT manual describes the surgery package as including:––––––––Subsequent to the decision for surgery, one E/M visit on the date immediately prior to or on thedate of the procedure (including history and physical)Local anesthesia: defined as local infiltration, metacarpal/digital block, or topical anesthesiaIntraoperative services that are normally a usual and necessary part of a surgical procedureand any related supplies, services, procedures normally required for the particular surgeryImmediate post-operative care, including dictation of operative notes, talking with family andother physiciansWriting ordersEvaluation of patient in post-anesthesia recoveryNormal, TYPICAL follow-up careAll additional medical or surgical services required of the physician within 90 days of thesurgery because of complications, which do not require additional trips to the operating room Related follow-up visits made within the postoperative period and post-surgical pain management bythe surgeonNormal, TYPICAL follow-up careE/M Coding – Fact and Fiction16
Modifiers for E/M with Major or Minor Procedures -25– Minor procedures: 0-10 global days Patient presents to her PCP with chest pain. Physician documents aDetailed History, Detailed Exam and Moderate MDM. He orders an EKG,which is performed in the office.– Report 99214-25 and 93000. -57– Major Procedures: 1 day preoperative and 90 days postoperative Patient (non-Medicare) presents to ER with knee pain and is admitted byher PCP. He consults an orthopedic surgeon, who personally reviews herCT, labs and EKG and decides to operate that day. He documents aDetailed History, Detailed Exam and High MDM.– Report 99253-57E/M Coding – Fact and Fiction17
National Correct Coding Initiative (NCCI) 1996 CMS implemented this National Policy–––– Aimed at controlling improper coding and billing practices of Part B claimsMany third party payers rely on CCI for implementing policyNCCI published quarterlyReviews coding combinations and implements correct code editsCode combinations in 2 categories– Mutually exclusive Denies combination that should not be separately reported based on standardsof medical practice If necessary to report modifier 59 should be appended– Modifier 59 reviewed by CMS when claims are submitted for these code pairsthat are normally prohibited– What if this is a private payer?E/M Coding – Fact and Fiction18
Unbundling Similar to coding an incidental procedure Unbundling can result from two problems:– Unintentional results from not having a goodunderstanding of coding– Intentional when practitioners manipulate the coding tomaximize payment Medicare closely monitors physician billing practicesfor possible abuse or fraudulent billing. Private payersalso watch for unbundling.E/M Coding – Fact and Fiction19
Unbundling Prevention Use current code booksEducate yourself on:– CPT guidelines– NCCI– Insurance Carrier Regulations Be specific when using charge tickets for codingCode directly from operative note or chart noteUpdate codes annually– ICD-9-CM in October and CPT in January Avoid fragmented billingMake sure physicians provide complete information and documentationUse modifiers correctlyUse caution when reporting integral proceduresE/M Coding – Fact and Fiction20
E/M LevelsE/M Coding – Fact and Fiction21
How to Select E/M Level Select the appropriate E/M category– New patient, Established patient– Office or other outpatient, Inpatient, Consultation, Observation, Consultation Review Components used to Define Level:– Key Elements Medical Decision Making History Exam CounselingCoordination of CareNature of presenting problemTime as controlling factor– Determine Complexity of MDM Determine Extent of History and Exam ObtainedE/M Coding – Fact and Fiction22
Medical Decision MakingE/M Coding – Fact and Fiction23
Medical Decision Making (MDM) Number of Diagnoses or Treatment Options– Section A on MDM worksheet– Each diagnosis “earns” points Self-limited or Minor: 1 pt (maximum of 2)Established problem, stable or improved: 1 pt eachEstablished problem, worsening: 2 pts eachNew problem, no add’l workup planned: 3 pts (maximum1 prob) New problem, add’l. workup planned: 4 ptsE/M Coding – Fact and Fiction24
Diagnosis/Treatment Options (Section A)Problem Status#Pts Self limited or minor – max of 21Est. prob. (to examiner) stable/improving1Est. prob. (to examiner) worsening2New prob. (to examiner) no add. w/u planned – max1 problem3New prob. (to examiner) add. w/u planned4ResultsE/M Coding – Fact and Fiction25
Medical Decision Making (MDM) Amount and/or Complexity of Data to be Reviewed– 1 point is assigned for: Review and/or order clinical lab tests (max 1 pt)Review and/or order tests in CPT radiology section (max 1 pt)Review and/or order tests in CPT medicine section (max 1 pt)Discussion of test results with performing physicianDecision to obtain old records or obtain additional history– 2 points is assigned for: Independent visualization of image, tracing or specimen (not simply areview of a report) Review and summarization of old records and/or history from someoneother than patient and/or discussion with another healthcare providerE/M Coding – Fact and Fiction26
Amount/Complexity of DataType of DataPtsReview and/or order clinical labs1Review and/or order X-rays1Review and/or order other tests1Discussion of tests with performing MD1Independent review of image, tracing, or specimen2Decision to obtain records and/or obtain History from someone otherthan pt1Review and summarize old records, obtain history from someoneother than pt, discuss case with other MD2TotalE/M Coding – Fact and Fiction27
Medical Decision Making (MDM) Risk of Complications and/or Morbidity or Mortality– Presenting Problem(s) 1 self-limited or minor problem (insect bite) Minimal1 stable chronic illness Low2 stable chronic illnesses Moderate1 chronic illness with mild exacerbation, progression or sideeffects of treatment Moderate Unknown new problem with unknown prognosis Moderate 1 chronic illness with severe exacerbation High Acute or chronic illness or injury that may pose a threat to lifeor bodily function HighE/M Coding – Fact and Fiction28
Medical Decision Making (MDM) Risk of Complications and/or Morbidity or Mortality Diagnostic Procedure(s) Ordered– Chest x-ray, EKG or Ultrasound Minimal– Skin biopsy Low– Diagnostic endoscopy without identified risk factors Moderate– Diagnostic endoscopy WITH identified risk factors High– Cardiovascular imaging study without identified risk factors(cardiac cath) Moderate– Cardiovascular imaging study WITH identified risk factors High– Cardiac EP Test (EP study in lab, not Holter monitor) HighE/M Coding – Fact and Fiction29
Medical Decision Making (MDM) Risk of Complications and/or Morbidity or Mortality– Management Option(s) Selected Rx drug mgt Moderate Elective major surgery without identified risk factors Moderate Elective major surgery WITH identified risk factors High Emergency major surgery High Decision not to resuscitate HighE/M Coding – Fact and Fiction30
Risk of Complications and/or MortalityE/M Coding – Fact and Fiction31
Medications Medications that likely indicateHigh Risk (Risk Table)––––––IV AntihypertensivesIV Anti-arrythmicsIV Controlled substancesIV InsulinCoumadin initiationtPA DrugsDocumentation ReminderBe sure to overtly statewhether the patient’s conditionis MILD vs MODERATE vsSEVERE exacerbation,progression, or side effect oftreatment.E/M Coding – Fact and Fiction32
MDM Facts & Fiction FICTION: Three points may be assigned for anEKG done at the patient visit (one for ordering thetest and two for the interpretation and report FACT: If the physician is billing globally for the EKG(93000), he “earns” one point for the order becausehe is being reimbursed for interpretation as part ofthe CPT codeE/M Coding – Fact and Fiction33
MDM Facts & Fiction FICTION: If a provider plans surgery, today’srisk is high FACT: All surgeries have risk factors.Documentation of identified risk factors (otherthan those inherent to the procedure) make asurgery high risk.E/M Coding – Fact and Fiction34
MDM Example This 77 year old woman returns for further evaluation of her weakness. She was in the hospital in the end ofSeptember, was doing a little better. Steroids worked to improve her weakness, but she has deteriorated in the lastseveral weeks. She had a UTI in November, treating with amoxicillin, is not sure if it has helped.She is restless, up in the night, not using CPAP as well. She is having hallucinations, remembering things poorly,not recognizing family. She has been complaining of abdominal pain as well, no BM since Friday. She is notsleeping well. Her PCP is Dr. Booth.Review of Systems:Constitutional: Negative for fatigue, fever and night sweats.HEENT: Positive for Ringing in earsRespiratory: Positive for-Dyspnea- occurs at rest /activity/laying down. Negative for asthmaCardiovascular: Positive for-Irregular heartbeat/palpitations - Negative for claudicationComments: pacemakerGastrointestinal: Positive for Constipation-Fecal IncontinenceGenitourinary: Positive for Urinary Incontinence Negative for polyuriaReproductive comments: not sexually activeMetabolic/Endocrine: Negative for cold intolerance, excessive diaphoresis, heat intolerance, polydipsia andpolyphagiaNeuro/Psychiatric: Positive for Depression, Difficulty concentrating, Gait Disturbance-Gen. weakness, Hallucinations, Memory Impairment, Mood Swings, Psychiatric Symptoms, -Speech Changes,Tremors, Negative for diff. w coordinationE/M Coding – Fact and Fiction35
MDM Con’t Dermatologic: Negative for acne, change in shape/size of mole(s), excessive sun exposure, frequent skin infections, hairloss, hirsutism, nail changes, photosensitivity, pigment change, pruritus, rash, skin lesion and utricariaMusculoskeletal: Positive for Bone/joint symptomsHematology: Negative for bleeding, bleeding diathesis, cytopenias, easy bruising, hypercoagulability, lymphadenopathy,petechiae and thromboembolic eventsImmunology: Negative for angioneurotic edema, animals at home, animals in work place, bee sting allergies, chemicals athome, chemicals in work place, contact allergy, contact dermatitis environmental allergies, food allergies and hay fever.Exam:NeurologicalAlert, but confused. Only oriented to self, not time or place. Language fluent, but words often times meaningless. Flight ofideas, not making sense. Follows simple commands appropriately. No drift, but weakness in BUE and LE, poor resistancethroughout. Normal heart sounds and lung sounds, no bowel sounds.Assessment/Plan: Myasthenia gravis (358.00) Recurrent pneumonia (486) CHF (congestive heart failure) (428.0)Delirium (780.09)Gradually worsening debility since discharge from the hospital, worse delirium.-steady decline since recent hospitalization-steroids were a temporary measure but helped at the time-admit to hospital for evaluation of possible infection, evaluation to see risk of immunosuppression with her history ofrecurrent PNA, and to get PT/OT/ST to see her, make sure her breathing is ok with PFTs. Repeat UA and culture to makesure UTI adequately treated. -Will follow her in hospital, RTC in 1 month.E/M Coding – Fact and Fiction36
MDM example Weakness, was improving – recently deteriorating Myasthenia gravis –– “She is restless, up in the night, not using CPAP as well. She is havinghallucinations, remembering things poorly, not recognizing family. Shehas been complaining of abdominal pain as well, no BM since Friday”– “Gradually worsening debility since discharge from the hospital, worsedelirium.-steady decline since recent hospitalization” Dx/Treatment options - New problem or exacerbation Data - UA and culture Risk - Abrupt change in neurologic statusE/M Coding – Fact and Fiction37
HISTORYE/M Coding – Fact and Fiction38
History Chief Complaint– Required for Every Service History of Present Illness (HPI) – MUST be performed andrecorded by provider– Location, Duration, Quality, Severity, Timing, Context, ModifyingFactor(s), Associated Sign(s) or Symptom(s)– Some are very similar, i.e. Quality and Severity– Brief: 1-3 descriptors– Extended: 4 or more descriptors– 1997 guidelines: status of 3 chronic conditionsE/M Coding – Fact and Fiction39
History Status of 3 Chronic Conditions Supports a complete HPI under 1997 DocumentationGuidelines (and sometimes under 1995 as well – per payer) Does not have to be stated in the heading under HPI– Often the status can be pulled from other areas ofdocumentation. Will usually require auditor to use 1997 exam guidelines When additional information on chronic conditions isincluded, it can be used for ROSE/M Coding – Fact and Fiction40
History Review of Systems (ROS)– Review of patient’s current or past SYMPTOMS (notchronic conditions)– Problem Pertinent: 1 system reviewed– Extended: 2-9 systems reviewed– Complete: 10 or more systems reviewed– Some payers allow provider to note positives andpertinent negatives, then summarize remaining negativesE/M Coding – Fact and Fiction41
History Past, Family & Social History (PFSH)– PAST HISTORY Meds, allergies, surgeries, chronic conditions, immunizations, etc– FAMILY HISTORY Health status of parents, siblings, children Document if patient does not know his/her family history Some payers do not recognize “FHx noncontributory” or “FHxnegative”– SOCIAL HISTORY Use of alcohol or tobacco, marital status, employment, extent ofeducation, etc. Pediatric social history could include whether patient attends daycare,where patient lives (with grandmother, etc) and/or if there are anysmokers/pets in the homeE/M Coding – Fact and Fiction42
History Facts & Fiction FICTION:– Only symptoms can be used as HPI elements FACT:– If patient is asymptomatic but provider is following chronicconditions, statements about that condition can supportHPI elements– Patient is seen in follow-up for her DM. Blood sugars havebeen running in the 120s. She has modified her diet andis eating less carbs. Severity and Modifying FactorE/M Coding – Fact and Fiction43
History Facts & Fiction FICTION:– Statements about negative symptoms in the HPI sectioncannot be used as ROS. FACT:– ROS does not have to neatly listed in a paragraph with aheading of “Review of Systems” – can be listedanywhere in HistoryE/M Coding – Fact and Fiction44
E/M Coding – Fact and Fiction45
She Has Multiple Concerns ①She is very concerned about the expense involved inavoiding lactose and wants to ask to talk aboutalternatives. She gets ②flare-ups of ③ irritable bowelsymptoms in ④ spite of being careful with lactoseintake. She has significant pain in her feet and she isgetting no relief with topical Voltaren. Her neuropathycontinues to be an issue. Her glucose readings havebeen in the 120-130 range. She is now on a higherdose of thyroxine replacement. She inquires as towhether she uses the right amount.E/M Coding – Fact and Fiction46
She Has Multiple Concerns Patient is status post hospitalization for COPD – he had an① exacerbation. He had been on exercise but stopped it onown. Patient was discharged on ③Levoquin andprednisone which he is currently taking. Has ② occasional④wheezing but has improved significantly. He was admittedfor 2 days at RMC. Patient has cardiomyopathy, gastroesophageal reflux, ischemic heart disease, hypertension,and hyperlipidemia. Patient is accompanied by caregiver.Medications were reviewed in detail with both patient andcaregiver. Patient has had decreased appetite andcontinues to lose weight.E/M Coding – Fact and Fiction47
She Has Multiple Concerns The patient is a 23 year old female. Patientwants to discuss PMS. ①Currently usingOCP. Age of menarche is 12, ② LMP2/10/2012, ③moderate pain/cramping and④ uses 3 pads/tampons per day. She doesperform SBE monthly.E/M Coding – Fact and Fiction48
She Has Multiple Concerns Patient presents complaining of not beingable to move his ①left arm ②when hewas waking up and ③ being off balance.States ④ several days ago, prior to thisepisode, he had left arm weakness thatseemed to resolve and return to normalE/M Coding – Fact and Fiction49
She Has Multiple Concerns Was scratched ①by a cat ②25days ago. Now complains of ④swelling and⑤ redness, ③Rtforearm. No fever, no chillsPMH–SHx-FHx : See problem listROS: negative and as above.E/M Coding – Fact and Fiction50
Exam - 1995 Organ utionalEyesEars, nose, mouth & Hematologic/Lymphatic/Immunologic Body Areas– Head, including Face– Neck– Chest, including breasts &axillae– Abdomen– Genitalia, groin buttocks– Back, including spine– Each extremityE/M Coding – Fact and Fiction
Exam - 1997––––––––––––General Multi-SystemCardiovascularEyeEar, Nose & ThroatGenitourinary (Female)Genitourinary eletalNeurologicalPsychiatricRespiratorySkinE/M Coding – Fact and Fiction52
Exam LevelsPFEPFDetailedComprehensive19951 BA/OS2-7 BA/OS2-7 BA/OS in detail8 OS1997 General MultiSystem1-5 bullets6-11 bullets2 bullets from eachof 6 systems2 bullets from each of 9systems1997 Psychiatric1-5 bullets6-8 bullets9 bulletsAll bullets in shaded boxesand at least one from eachunshaded box1997 other SingleSystem1-5 bullets6-11 bullets12 bulletsAll bullets in shaded boxesand at least one from eachunshaded boxE/M Coding – Fact and Fiction53
Common Exam Statements ConstitutionalVital signsGeneral appearance of patient––––– No acute distressAlertWell developed, well nourished, well groomed (WDWNWGWF)DisheveledPatient appears uncomfortableEyeConjunctivae & lids normalSclera clearLeft eye has purulent dischargePERRLA (pupils equal, round, reactive to light and accommodation)EOM intactE/M Coding – Fact and Fiction54
Sample Exam Statements ENT––––– Hearing normalNasal mucosa pink, moistGood dentitionOoropharynx clearMaxillary sinus tendernessCardiovascular––––––No JVD (jugular venous distention) or carotid bruitsRRR (regular rate & rhythm), no murmurs, rubs or gallopsPMI (point of maximal impact) non-displacedNo abdominal bruitsMild edemaPulses normalE/M Coding – Fact and Fiction55
Sample Exam Statements Respiratory–––––Lungs CTA (clear to auscultation) throughoutNo wheezes, rales or rhonchiNo evidence of respiratory distressThorax symmetrical with good diaphragmatic expansionNo use of accessory muscles, normal effort Gastrointestinal––––Abdomen soft, tender, no massesNo hepatosplenomegalyNo hernia appreciatedBowel sounds normalE/M Coding – Fact and Fiction56
Sample Exam Statements Genitourinary (Male)––––Normal scrotum without significant lesions or rashesNormal size testes descended bilaterally without massesUrethral meatus is normally located and nonstenoticNormal penis without lesions Genitourinary (Female)––––Breasts symmetrical and non-tenderExternal genitalia normalBUS normalBladder without masses or tendernessE/M Coding – Fact and Fiction57
Sample Exam Statements Musculoskeletal–––––– Patient is limpingNo clubbingFull ROM (range of motion) of left lower extremityNormal muscle strengthCrepitusRight knee laxity is appreciatedNeurological––––––Cranial nerves II-VII intactTongue is midlineFace symmetricShoulder shrug normalDTRs (deep tendon reflexes) 4Normal sensationE/M Coding – Fact and Fiction58
Sample Exam Statements Psychiatric––––––Alert & oriented x 3Slightly depressed mood and affectGood judgment and insightRecent memory is goodSpeech slurredLogical reasoning Hematologic/Lymphatic/Immunologic– No adenopathy (cervical, axillary, inguinal, other)E/M Coding – Fact and Fiction59
Sample Exam Statements Integumentary– No rashes or lesions– Male pattern baldness noted– Skin warm & dry– No breast lumpsE/M Coding – Fact and Fiction60
Exam Facts & Fiction FICTION:– Pt WD/WN, PERRLA, Lungs CTA, Heart RRR, Abdsoft & nontender DETAILED exam by 1995guidelines FACT:– Payers have different standards for Detailed Exam Some define as 5-7 Areas or Systems Others define as 2-7 BA/OS with detail in oneE/M Coding – Fact and Fiction61
Exam Facts & Fiction FICTION:– Neck: no JVD or carotid bruits BODY AREA: NECK FACT:– Do not use headings to determine whichAreas/Systems is supportedE/M Coding – Fact and Fiction62
Exam Facts & Fiction FICTION:– A specialist has to use “his” single system specialtyexam under 1997 guidelines FACT:– Use of Multi-system exam or any of the specialtyexams is allowed for any physician/providerE/M Coding – Fact and Fiction63
EXAM – EPF or DETAILED? Constitutional: BP 118/64, P 70, T 98.0. Patient in NAD. HEENT: PERRLA. Neck supple. Lungs CTA. Heart RRR, nomurmurs, rubs or gallops. Abdomen soft, nontender, nomasses.EPF Constitutional: BP 118/64, P 70, T 98.0. Patient in NAD. HEENT: PERRLA. Neck supple, no JVD or bruits. LungsCTA. Heart RRR, no murmurs, rubs or gallops. No edema.Abdomen soft, nontender, no masses.DETAILEDE/M Coding – Fact and Fiction64
EXAM – EPF or DETAILED? VITAL SIGNS: BP 134/89, P 77, R 12, Wt 161.4. GENERAL: Well developed, well nourished in no a
E/M Coding - Fact and Fiction Practice of Medicine has undergone a significant transformation due to: - Federal regulations - Coding - Reimbursement Medical Coding is a language all its own - Coding is not an exact science - Documentation and Medical Necessity must be supported in the medical record
8. In Maya mythology, a god breaking the Sacred Oath is of no consequence. FACT or FICTION 9. Ixtab and Ah-Puch are the best of friends. FACT or FICTION 10. The calendar systems developed by the Maya are still influential today. FACT or FICTION 1. FACT 2. FICTION Ah-Puch is a stinky, skeletal one. 3. FACT 4. FACT 5. FACT 6. FACT 7. FACT 8.
8 Bernd Girod: EE368b Image and Video Compression Introduction no. 15 Outline EE368b n Some fundamental results of information theory n Scalar quantization and vector quantization n Human visual perception n Predictive coding n Transform coding n Resolution pyramids and subband coding n Interframe coding n Motion estimation n Motion compensated coding n Coding standards JPEG, H.261, H.263 and MPEG
Coding ClinicReferences 1 Injury and Poisoning Coding Clinic 4Q 2008 ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Chapter 17: Injury and Poisoning (800-999) Coding of Injuries When coding injuries, assign separate codes for ea
Source Coding Techniques 1. Fixed Length Coding In fixed length coding technique all symbols assigned with equal length because the coding don’t take the probability in account. The benefit of the fixed length code is ease of applied (easy in coding and decoding) Example1: Let x { x 1,x 2, ,x 16} where pi 1/16 for all i , find ζ
1.2 Employment outcomes of coding bootcamp training 2 2 Employment and the coding skills shortage 5 2.1 Background: ICTs and employment 6 2.2 ICT skills shortages 7 2.3 Summary 13 3 Learning to code: Adoption of the coding bootcamp model 13 3.1 Coding bootcamp models in developing countries 14 3.2 Coding bootcamp business models 18
Coding and Payment Guide for the Physical Therapist Optum360, 2017 LLC Getting Started with Coding and Payment Guide — 1 Getting Started with Coding and Payment Guide The Coding and Payment Guide for the Physical Therapist is designed to be a guide to
Coding and Payment Guide for Behavioral Health Services Getting Started with Coding and Payment Guide — 3 1. CPT Codes and Descriptions This edition of Coding and Payment Guide for Behavioral Health Services is updated with CPT codes for year 2023. The following icons ar e used in the Coding and Payment Guide: This CPT code is new for 2023.
influence of ideological values on the policies and practices of America’s criminal justice systems. Recently, however, a trend toward critical analysis of the behavior of police, courts, and corrections has emerged that focuses exclusively on ideology as the analytical tool of choice. For example, Barlow (2000), and Bohm and Haley (2001) include extensive discussion of the influence of .
