Briefing: Coding, Documentation and

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• Briefing Coding, Documentation and
• Relative Value Unit (RVU) Impact
• Date 09 Aug 2007
  

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Objectives

• This presentation will provide an overview of the
  following
• The importance of coding accuracy
• Why good documentation is necessary
• RVU impact
• Common Outpatient Coding Errors

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Clinical Coding
Clinical coding is the transforming of written
descriptions of diseases, injuries, and
procedures into numeric or alphanumeric
codes Originally performed to classify -
Mortality Later broadened to also classify
- Morbidity - Procedural data Today -
Coding is being used throughout medical
facilities from the administration office
to the billing office
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Importance of Coding Accuracy

• The clinical data is used for a multitude of
  purposes
• Population Health studies
• Business Planning
• Managed care decisions (Resource Sharing
  Agreements)
• Global War On Terrorism (GWOT) tracking

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How Clinical Codes Relate
The complete picture of the encounter
Procedure Code (CPT-4/HCPCS) What was performed
Diagnosis code (ICD-9-CM) Why the service was
necessary
EM code Case complexity
RVU weights
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ICD-9-CM Codes

• V Codes (V01-V82)
• - Factors Influencing Health Status Contact
  with Health Service
• Identify reasons for an encounter other than
  disease or injury
• E Codes (E800-E999)
• - Classification of External Causes of Injury
  and Poisoning
• Used to support environmental cause of injury,
  poisoning or war
• related casualties (including adverse
  drug reactions)

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Evaluation and Management Services

• Evaluation and Management Services
• 99201-99499
• Reflect the amount of resources that went into
  the provision services
• Key Components
• Patient history
• Patient examination
• Medical decision making
• Contributory factors
• Nature of presenting problem
• Counseling
• Time

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CPT-4 Codes

• Five digit codes
• Evaluation and Management 99201-99499
• Anesthesiology 00100-01999,99100-99140
• Surgery 10021-69990
• Radiology 70010-79999
• Pathology and Laboratory 80048-89399
• Medicine 90281-99569
• The codes get modifiers in some instances for
  example, a procedure
• is bilateral.
• Dont code laboratory or radiological procedure
  codes if they are
• performed in the ancillary department.

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The Need for Detailed Documentation

• Detailed and concise documentation is critical
  for the following
• Continuity of patient care
• JCAHO compliance
• Support of billing
• For example, an appeal for duplicate claim
  denial missing the bilateral modifier
• Clinical research
• Case-mix analysis (severity and complexity)

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Documentation Dos and Dont

• Simply selecting the name and CPT/HCPCS code for
  a procedure
• Does Not constitute enough documentation to
  support coding the
• Procedure.
• Documentation must detail the procedure no matter
  how minor the
• procedure including
• Indications
• Findings
• Condition of patient upon completion
• Type of anesthesia (if any)
• Injection (route, dosage, med)

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Documentation Dos and Dont contd

• Per the DoD guidelines (section 3.1.5.1)
• Time is NOT a dominant factor for assigning the
  appropriate EM
• Code in most scenarios.
• Time is a determining factor when counseling or
  coordination of
• Care consumes more than 50 percent of the time a
  provider spends
• Face-to-face with the patient, family, or both.
• Documentation must indicate
• Why the additional time was necessary
• What occurred during that time
• How much time was spent counseling

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RVU Types

• Three basic types
• Work RVU Provider effort and costliness
• Practice Expense RVU Overhead (supplies,
  bookkeeping)
• Malpractice RVU Paying malpractice premiums
• RVU assignment is designed to be based on the
  procedure code,
• location, modifiers and units of service.

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RVU (MHS Table)

• The MHS focuses on work RVUs
• They are used to explain costliness of provider
  labor
• MHS RVU table is different than the civilian
  weight table
• MHS RVU table incorporates values for things
  not generally
• covered, such as telephone consultations
• MHS RVU table adjusts global procedure codes to
  accommodate
• DoD coding rules

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RVU (MHS Table)contd

• DoD policy for assigning RVUs is determined by
  Health Affairs
• Modifiers and units of service can not
  currently be considered in
• RVU assignment, they are not available
  in the Standard
• Ambulatory Data Record (SADR)
• - They are collected, but are not
  forwarded on the SADR
• - They are included on the CAPER
  (SADR-redesign) layout

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RVU Impact contd
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Documentation/Coding TipRVU impact
It is important to verify the following fields in
the Disposition Module Patient Status- If the
system improperly selects Existing Patient
and the field is not corrected by the provider
the system generated EM code may result in
under-coding and lost RVUs. Service Type-
Inaccurate bookings may result in over-coding in
cases where the service type is not corrected and
the system generated EM code is accepted.
For example, an acute visit is booked into a well
appointment slot.
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Documentation/Coding TipRVU Impact contd

• Per DoD Guidelines (section 4.8)
• In AHLTA, using the MEDCIN module, to code the
  consult correctly
• instead of a referral, the provider must switch
  the SERVICE TYPE
• from OUTPATIENT VISIT to OUTPATIENT CONSULT.

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Coding Tip RVU Impact
Per the DoD guidelines (section 6.14) If an
additional problem or issue is identified and
treated, an additional office EM may be
warranted. If the encounter intent is preventive
(e.g., a physical, code the Preventive EM
encounter first, even though problems or
issues addressed constitute an additional
problem-oriented EM code (e.g., 99212) based on
the separate problem-oriented documentation. Appe
nd modifier -25 to the problem-oriented EM
(e.g., 99212-25).
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Coding TipRVU Impact contd

• When is it appropriate to document inpatient
  consultations in the
• outpatient clinic? What is the criteria for
  answering the
• question Is this related to the inpatient
  visit?
• For capturing consults to inpatients use the
  appointment type walk-in.
• Answer No to the question to ensure credit is
  given to the appropriate
• B MEPRS code. For example
• Dr. Orthopedics, an orthopedic surgeon, requests
  a pulmonary consult
• on a high-risk patient. There was no
  recommendation for the patient
• to be transferred to pulmonary services. The
  inpatient consult by Dr.
• Pulmonary the consulting physician, will be
  entered in under the
• B MEPRS along with the appropriate diagnosis, EM
  and procedures.
• Per DoD Guidelines (section 9.5.1)

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Some EM code RVU examples
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Common Outpatient Coding Errors

• Common coding errors
• New vs. Established patient visit
• Routine office visit vs. Preventive Medicine
  Service
• Incorrect/Missing ICD-9-CM diagnosis code
• Lack of code specificity
• Chronic conditions affecting care not reported
  
• Incorrect modifier use
• Missing CPT/HCPCS procedure code
• Procedure performed in the clinic but not
  reported

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Getting Help on Coding Issues

• Updates to coding guidance are on the UBU website
  at
• http//www.tricare.mil/ocfo/bea/ubu/index.cfm
• Submit questions on coding issues and review the
  FAQs at
• https//dq.med.navy.mil/default.htm

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Summary

• Medical record documentation and coding form
  the basis for the
• data in the MHS data repositories.
• The quality of that data depends on how well
  providers are trained,
• document and code.

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Questions?