Any billing gurus?

I have some homework on coding for NPs. We got a case study and with the elements of HPI/ROS/exam had to decide what level of visit to code for.

I've done the homework, but I'm getting confused the more I look at it! I keep second-guessing it and I think I'm messing it up.

Anyone willing to look it over and give me some pointers?

I teach PA billing which is very similar. I would be happy to look at it. Or you can post it and we can all learn (if that is allowed).

For those that are new to coding I recommend the MPECS workshop book and pocket coder (no business relationships to declare):

http://www.mpecs.org/consultations

Of course if you are a PA I recommend the AAPA billing course.

David Carpenter, PA-C

Good idea re posting. Any clarification would be most appreciated. Thanks for looking!

Case Study (New Patient, Office)

History: 22 year old female with complaint of 36 hours of urinary frequency, urgency, and dysuria. Denies chills, fever, flank pain or gross hematuria, Past history of recurrent urinary tract infection, Is sexually active using effective contraception and condoms. Denies lady partsl symptoms. Past history is otherwise not remarkable.

Physical exam: appears in no acute distress. Afebrile, No CVA (costovertebral angle) tenderness, Abdomen is nontender, without masses. Slight suprapubic discomfort on palpation, No lady partsl discharge, Urine reveals 4-6 RBCs and 20 WBCs per high power field, positive for leukocytes, nitrites and blood. Urine sent for culture and sensitivities.

Diagnosis: cystourethritis (UTI)

Plan: Bactrim DS BID X 3 days, Pyridium 100 mg TID p.c.

Adequate fluid intake

Will contact with results of urine C&S

1. How many elements are in the HPI (location, quality, severity, duration, timing, modifying factors (what makes it better or worse), associated symptoms)?

Three elements:

• Duration: 36 hrs

• Location: dysuria

• Associated symptoms: frequency, urgency

2. How many elements of past medical, family and social history are included?

Two elements:

• Past medical history (prior recurrent UTI, no other relevant)

• Social history (sexually active using contraception & condoms)

3. How many systems in the ROS (review of systems) are included?

Three systems:

• Constitutional – denies chills, fever

• Abdomen – denies flank pain

• Genitourinary – denies lady partsl symptoms or gross hematuria

4. What level of visit can be coded based on history?

Expanded problem-focused

5. How many elements are included in the physical exam?

Three elements:

• Constitutional

• GU

• abdomen

6. What level of visit can be coded based on physical exam?

Expanded problem-focused

7. How many diagnoses/problems does she have?

One: UTI

8. Is/are the problem(s) acute or chronic/complicated or uncomplicated/minor or major?

- acute

- uncomplicated

- minor

9. Amount of data to review is limited or moderate or extensive?

Limited (labs)

10. Risk of complication is minimal or low or moderate or high?

Moderate (prescription drug management)

11. What level of medical decision-making do the above indicate?

Low complexity (labs to review)

12. What is the CPT code for this patient?

99201

**Things I'm somewhat stuck on:

- The levels of visit that can be coded based on physical exam

- Level of decision making required

- Whether physical exam is problem-focused or expanded problem-focused

- Anything else you can see that is wrong!

Good idea re posting. Any clarification would be most appreciated. Thanks for looking!

Case Study (New Patient, Office)

History: 22 year old female with complaint of 36 hours of urinary frequency, urgency, and dysuria. Denies chills, fever, flank pain or gross hematuria, Past history of recurrent urinary tract infection, Is sexually active using effective contraception and condoms. Denies lady partsl symptoms. Past history is otherwise not remarkable.

Physical exam: appears in no acute distress. Afebrile, No CVA (costovertebral angle) tenderness, Abdomen is nontender, without masses. Slight suprapubic discomfort on palpation, No lady partsl discharge, Urine reveals 4-6 RBCs and 20 WBCs per high power field, positive for leukocytes, nitrites and blood. Urine sent for culture and sensitivities.

Diagnosis: cystourethritis (UTI)

Plan: Bactrim DS BID X 3 days, Pyridium 100 mg TID p.c.

Adequate fluid intake

Will contact with results of urine C&S

1. How many elements are in the HPI (location, quality, severity, duration, timing, modifying factors (what makes it better or worse), associated symptoms)?

Three elements:

* Duration: 36 hrs

* Location: dysuria

* Associated symptoms: frequency, urgency

2. How many elements of past medical, family and social history are included?

Two elements:

* Past medical history (prior recurrent UTI, no other relevant)

* Social history (sexually active using contraception & condoms)

3. How many systems in the ROS (review of systems) are included?

Three systems:

* Constitutional - denies chills, fever

* Abdomen - denies flank pain

* Genitourinary - denies lady partsl symptoms or gross hematuria

4. What level of visit can be coded based on history?

Expanded problem-focused

5. How many elements are included in the physical exam?

Three elements:

* Constitutional

* GU

* abdomen

6. What level of visit can be coded based on physical exam?

Expanded problem-focused

7. How many diagnoses/problems does she have?

One: UTI

8. Is/are the problem(s) acute or chronic/complicated or uncomplicated/minor or major?

- acute

- uncomplicated

- minor

9. Amount of data to review is limited or moderate or extensive?

Limited (labs)

10. Risk of complication is minimal or low or moderate or high?

Moderate (prescription drug management)

11. What level of medical decision-making do the above indicate?

Low complexity (labs to review)

12. What is the CPT code for this patient?

99201

**Things I'm somewhat stuck on:

- The levels of visit that can be coded based on physical exam

- Level of decision making required

- Whether physical exam is problem-focused or expanded problem-focused

- Anything else you can see that is wrong!

So what you have is

HPI - 3 elements

ROS - 3 elements

Hx 2 elements

You really only have two ROS elements (flank pain is part of GU). However again that is enough for detailed (2 bullet points in 2-9 systems).

So I agree that you have an expanded problem focused history. If you had one more element of HPI you could make it detailed. The simple addition of continuous or moderate would allow you to do this (defining timing or severity).

Detailed requires 4 elements of an HPI, 2-9 elements of ROS and 1 of 3 elements of PMHx, Social or family hx. You can see here that one missed word costs you money.

Also if you were a student you would get dinged for no CC.

Now look at physical exam. I divided it by system using the 1997 guidelines:

Constitutional:

• appears in no acute distress.
  
• Afebrile,

GU

• No lady partsl discharge,
  
• No CVA (costovertebral angle) tenderness,
  
• Slight suprapubic discomfort onpalpation,

GI

• Abdomen is nontender,
  
• without masses.

So what you have here is three systems with two bullets except that you cannot count afebrile under constitutional since you need 3 vital signs. However you also have 6 bulleted items. Therefore you can call this an expanded problem focused physical exam. The difference between problem focused and expanded problem focused is that problem focused requires 1-5 elements and expanded problem focused requires 6-11. If you want to do detailed it would require 12 or more bullets or 2 bullets in 6 areas.

• Labs: Urine reveals 4-6 RBCs and 20 WBCs per high power field, positive for leukocytes, nitrites and blood. Urine sent for culture and sensitivities.

Medical decision making revolves around number of diagnosis, amount of data to be reviewed and morbidity/mortality.

In the case of a new patient you do not have an established diagnosis. Therefore until you have a diagnosis you discuss this as a differential.

For this case you have UTI, realistically you should put this as cystitis (although everyone will write this as UTI;)). For this my differential would be something like:

• Cystitis
  
• Renal stones
  
• Pyelonephritis (unlikely without CVA tenderness)
  
• Urethitis (unlikely in females)
  
• PID (no tenderness documented)
  
• Pregnancy (hmm no BCG)

For labs reviewed you have the UA

Risk is very complex here. Casual purusal of the literature is all over the place. Mortality appears low but morbidity can be high.

The definition of low severity is low risk of morbidity or mortality with full recovery expected. Moderate severity is defined as moderate risk of mortality or morbidity without treatment. You have limited data to review and limited differential diagnosis (really one system)

I would probably say this is low complexity based on although a case could be made for straight forward.

So overall what you have is (level)

Expanded problem focused history (2)

Expanded problem focused Exam (2)

Low complexity decision making (3)

Overall you have two level 2 and one level 3 elements so you would code this as a level 2 visit based on the history and the exam. So this would be a 99202. Remember that less than 2% of new visits are coded as 99201 so this should hardly ever be used. Also this demonstrates that if there was a better exam and one more descriptor on the HPI it could have been coded as a 99203.

Medical decision making is the area most often undercoded. Its because you don't realize the amount of decision making that goes into the analysis and underestimation of morbidity.

Here is an good cheat sheet:

http://www.ackdoc.com/Forms%20and%20Templates/SUPERBILLS/coding%20documentation%20requirements.pdf

Anyone else want to have a try?

David Carpenter, PA-C

Wow, you're very good at this! Thankyou so much for the detailed rationales - it's much clearer! It is scary to see how the documentation can so easily cost you money.

Do you agree that the "risk of complication" comes out as moderate due to drug therapy?

Edit: That cheat sheet is awesome, really made things a lot more simple for me.

Thanks again for your tremendous help!

Wow, you're very good at this! Thankyou so much for the detailed rationales - it's much clearer! It is scary to see how the documentation can so easily cost you money.

Do you agree that the "risk of complication" comes out as moderate due to drug therapy?

Edit: That cheat sheet is awesome, really made things a lot more simple for me.

Thanks again for your tremendous help!

The risk of complication refers to the overall risk for the disease and the treatment. There is a published table of risk management that outlines the risk involved in three areas. The presenting problem, diagnostic procedures and management options. Some coders advocate using the highest risk category while others advocate an average. The table can be found here on page 23:

http://www.cms.hhs.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf

If you follow along with the table you will actually see that all of your elements are here. The three elements:

Presenting problem - Acute uncomplicated illness - ie cystitis Low

Diagnostic procedures - U/A - Minimal

Management options - prescription drugs - Moderate.

So you are correct that in isolation prescription drugs carry a moderate risk of complications according to the chart. However in totality you have one Minimal, one Low and one Moderate. I would err on the side of caution and say this is low level of risk. If you are audited you have one element (the risk) that is discongruous from the others. You only need Low level of risk to code 99203 (you only need minimal to code 99202). Barring 45 minutes of counseling over a UTI you are not going to turn this into a level 4. If you call this moderate risk you have one element of a level 4 visit and all the other levels are a level 2 or 3. It looks odd like you are trying to upcode. This is another reason why this fits firmly in the 99203 category if the the exam and history had been done correctly.

An example of a 99202 would be a viral URI which only requires supportive therapy. An example of a 99204 would be pylenephritis which requires bloodwork an U/S as well as the UA and has significant morbidity, mortality and complex medical decision making.

Good luck

David Carpenter, PA-C

Thanks, David.

Which link, he posted more than one.

They are different sites, so it must be your computer. Do you have adobe acrobat to read pdfs? If not you may need to download it as those files are pdfs. Even if I emailed them to you, you won't be able to see them if you don't have acrobat.

Update - I got 19.5/20 for this assignment. I don't have the paper back yet to see what I missed. Thanks again for your help - it really made it clear for me.

Cheers.

Actually, better news - got the assignment back today, and challenged the one she called wrong. I said three elements of physical exam, with 7 bullet points. She agreed and paid me the point, so I got 100%. Yay!