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Documentation Tip: Vascular Intervention

Posted on Mon, Feb 13, 2017
Documentation Tip: Vascular Intervention

Our recurring series of documentation tips for clinicians.

By Timothy Brundage, MD

“Peripheral Vascular Disease” is a huge, non-specific bucket. Operative notes need specificity for coding purposes.

Vascular interventionalists need to document three things for coding specificity:

1. Specific vessel(s) involved.

a. Anatomical name and laterality (R/L)

  • Artery
  • Vein
  • Previous bypass graft

2. Type(s) of lesion(s) identified and addressed.

a. Stenosis/blockage due to arteriosclerosis, embolus or thrombus. Note: the same area of blockage may have more than one etiology or two different lesions with different etiologies that are corrected in the same operation.

b. Detailed operative note with specificity is necessary for coding.
  • Example #1: The surgeon first removed an embolus from an artery and then they stent the stenosis where the embolus lodged. The embolus and its removal should be documented as should the arteriosclerosis and its stenting.
  • Example #2: The surgeon first stents an arteriosclerotic lesion proximally and then removes a thrombus distally. The surgeon should document a detailed procedure note that would include the specificity listed above in order to capture the accurate code.

3. Consequences of the blockages:
  • Claudication
  • Ulcers
  • Gangrene, dry/ischemic

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Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: CMS Three-Day Rule

Posted on Mon, Jul 25, 2016
Documentation Tip: CMS Three-Day Rule

Our ongoing series of documentation tips for clinicians.

By Timothy Brundage, MD

The Centers for Medicare/Medicaid Services (CMS) 3 day rule necessitates that all outpatient diagnoses and treatments are pertinent to the inpatient admission for 72 hours prior to admission.

The 3 day rule allows for the inpatient diagnosis to be made using data gathered from EMS as well as the ER evaluation.

Case Example:
Patient has documentation to support worsening shortness of breath with respiratory distress and hypoxia (81% on room air) documented in the EMS and ER records. This data supports the pulmonologist’s diagnosis of acute respiratory failure that was documented on the pulmonary consultation, treated with nebs, steroids and oxygen.  
 

  • The diagnosis of acute respiratory failure can be made at the time of the admission using the information obtained up to 3 days prior to admission
  • This is a valid diagnosis and should be coded and included in the inpatient DRG assignment



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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Documentation Tip: Sepsis-3

Posted on Mon, Apr 11, 2016
Documentation Tip: Sepsis-3

Our recurring feature of documentation tips for clinicians.

By Timothy Brundage, MD

New sepsis criteria has been announced by the Society of Critical Care Medicine, as published in JAMA.

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
 

  • Organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%.

Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
 
  • Vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater AND
  • Serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Bedside Quick SOFA (qSOFA):  at least 2 of the following clinical criteria:
  1. Respiratory rate of 22/min or greater
  2. Altered mentation
  3. Systolic blood pressure of 100 mm Hg or less.

Timothy Brundage

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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The Basics of Billing for Critical Care Services: What Physicians May Not Know

Posted on Thu, Dec 17, 2015
The Basics of Billing for Critical Care Services: What Physicians May Not Know

By Mark J. (Jeff) Slepin, MD, MBA, FACEP, and John Coyle, DO

Documentation of professional services that reflect the cognitive (Evaluation and Management – E&M) and procedural services that providers perform is an essential activity in the day-to-day practice of emergency and hospital medicine.

Perhaps you have seen a breakdown of the acuity levels of the services that you render. Do you ever wonder why certain conditions that seemingly require less work than others are assigned the identical E&M code? Does this accurately reflect a comparable amount of work, risk to the patient, generation of Relative Value Units (RVUs – a reflection of the work performed), and revenue for the practice?

Many providers are unaware of some of the nuances of documentation, coding and billing, all of which are essential to the provider getting proper credit for the services rendered and the practice generating the appropriate revenue for medically necessary services. And, do you understand exactly how the revenues are generated to provide the compensation for the work performed?

The Basics of Billing

Getting credit for the work performed and evaluation of the risks faced by the patient are essential for professional services. Most patient encounters by ED physicians and hospitalists result in the generation of a charge for an E&M service, based on the patient’s acuity, medical decision-making, and the elements of the history and physical examination. Critical care services are performed to a greater extent than most physicians realize. So, just what services qualify for classification as “critical care?”

Critical care is defined as a physician’s direct delivery of medical care for a critically ill or unstable patient. A critical illness is one with a high probability of sudden, clinically significant or life-threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently, including direct personal management by the physician, with life and organ supporting interventions that require frequent, personal assessments and manipulation by the physician. Withdrawal of or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration of the patient’s condition.

The following table illustrates examples of conditions and interventions that may qualify for critical care.


 
Critical care services require the physician’s documentation of the cumulative time spent in critical care activities and must include a minimum of 30 minutes attending to the patient, which includes more than just continuous attention at the bedside. Instead, activities considered within “critical care time” include all of the following:
 

  • Time spent at the bedside evaluating and managing the patient
  • Time spent on activities that contribute to the patient’s care, such as reviewing old records, laboratory results, and imaging results
  • Time spent in consultations with other physicians
  • Time spent with family, whether to obtain a history or to discuss treatment options when a patient is not able to participate; and
  • Performing any of the following services:
    • Gastric intubation
    • Interpretation of blood gases
    • Interpretation of cardiac output
    • Interpretation of chest X-rays
    • Interpretation of pulse oximetry
    • Temporary transcutaneous pacing
    • Vascular access procedures
    • Ventilator management

The services listed above cannot be billed for separately when critical care services are provided, but the time spent performing these procedures counts toward the computation of critical care time.

Why It’s Important to Report Time Spent Providing Critical Care Services

The codes for most E&M services, while associated with a usual amount of time spent in their performance in the code descriptor, don’t require the physician to report the amount of time spent (with the exception of inpatient discharge day management services and services in which counseling and/or coordination of care constitute > 50% of the encounter time). Thus, the coder can analyze the problems (diagnoses, signs and symptoms), medical decision-making complexity, and the medically necessary elements of the history and physical examination to assign the appropriate code.

In contrast, critical care service codes can only be assigned if the physician INDICATES THE AMOUNT OF CUMULATIVE TIME SPENT IN THE PERFORMANCE OF CRITICAL CARE ACTIVITIES for a patient whose clinical condition(s) and interventions also are documented and qualify for the definition of a critical illness. Critical care time excludes the time spent in the performance of separately billable procedures (such as intubation, insertion of central line, insertion of thoracostomy tube, etc.)

The Bottom Line

Analysis of the aggregate services performed by a group of providers in an EM or HM program is essential for assuring adequate staffing levels, evaluating the quality of care, and collecting revenues for the practice. In terms of revenues, funds for physician compensation are primarily drawn from these revenues from the billing of professional services following analysis of medical record documentation and assignment of E&M and procedure codes by professionally trained coders and submission of a bill to third-party payers and patients.

Whether in solo or group practice, or working with a larger practice management organization, revenue should be based on the provision and accurate documentation of medically necessary services.

Jeff Slepin

Mark J. (Jeff) Slepin, MD, MBA, FACEP, joined EmCare in 2003 as the regional medical director for EmCare Physician Services (EPS), the EmCare division that manages rural, community and other small-volume hospitals and medical centers. Dr. Slepin is the medical director of NorthStar First Response, a Virginia-based company that provides basic and advanced life support training, as well as public access defibrillation programs for private and public entities. In addition, Dr. Slepin has served as a peer reviewer in emergency medicine for the Agency for Health Care Administration in the state of Florida.

John Coyle
John Coyle, DO, is Executive Vice President of EmCare Physician Services. Dr. Coyle graduated with honors with a Bachelor of Science degree in biology with a minor in sociology from St. Michael’s College in Winooski, Vt. He earned his doctoral degree from the University of New England College of Osteopathic Medicine in Biddeford, Maine. He completed his internship at Southeastern Medical Center in North Miami (Fla.) and later joined that organization’s Department of Emergency Medicine faculty. He completed his emergency medicine residency at Philadelphia College of Osteopathic Medicine. He has held senior management positions with several emergency management companies prior to joining EmCare in 2005.

 

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Documentation Tip of the Week: GI Bleed

Posted on Wed, Nov 25, 2015
Documentation Tip of the Week: GI Bleed

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Choose words carefully to capture the true severity of illness (SOI) for your patient:

 
No SOI Moderate SOI High SOI
Stool with +occult blood
 
GI Bleeding
Melena
GI Bleeding from
DEFINED site (e.g.
PUD)
GERD
Esophagitis
Acute esophagitis
Esophageal ulcer
Esophageal ulcer with
bleeding or Mallory-
Weiss


Did you Know? “BRBPR” does not have a code. Consider documenting “hematochezia” or “Lower GI Bleeding” to effectively reflect SOI in coding language.



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.
 

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