Toward Better Reimbursement: History
Medical Management Specialists (MMS) - http://www.mms.med.pro
As we discussed last month, a group's reimbursement is dependent on a myriad of different factors, from its fee schedule, to its contracts, to its documentation, to the performance of its billing company, to name a few. What we would like to do as we initiate this column is to tease those elements out and focus on different ones each month. Hopefully that will at least give everyone a broad foundation when it comes to evaluating this aspect of their practice. We will begin with some documentation fundamentals, and in this issue our focus will be on the HISTORY.
For the purposes of billing and coding, each patient encounter needs to be broken down into the components of History, Physical Exam, and Medical Decision Making. The History part is further divided into: 1) History of Present Illness, 2) Review of Systems, and 3) Past Medical History, Social History, and Family History. Each one of these categories is further broken down into still smaller units. Sounds really straightforward and easy to use, doesn't it? The truth is that there are some keys which will enable you to record the right amount of information in most cases. Let's first look at the HPI.
There are only two levels of HPI: Brief and Extended. This category looks at the following 7 elements of history: location, duration, quality, severity, timing, context, modifying factors, and associated signs and symptoms. Brief has fewer than 4 of these; Extended has 4 or more. I maintain that any good history for just about any complaint will cover at least four of these elements. You will do yourself a clinical and a billing favor if you endeavor to cover 4 or more of these in every case.
If there is one area in which ED docs have traditionally gotten "dinged" when it comes to charting, it is in the area of the Review of Systems. The reason is that a level 99281 requires no ROS; levels 2 and 3 only require a problem-pertinent ROS, but the whole range from 2-9 systems only qualifies for a level 4. You have to have 10 or more systems to get to level 5. It has been my experience that providers who "free dictate" have a very hard time covering 10 or more systems. What can you do to perform better in this area? I have four suggestions.
1. Use some form of template to document or to help remind you what systems need to be covered.
2. Commit to doing at least a 10-system review on anyone who is sick enough to need an IV and more than two studies.
3. Use a summary statement. As long as you really do it, saying something like, "A full review of systems was done and is otherwise negative," or using a template which allows you to check this option is an acceptable alternative.
4. Use the Level V Caveat. This is a "coding gift" to emergency medicine which allows the physician to determine that the patient is too sick or otherwise unable to provide a full history. As long as the provider documents the reason why, he can use this option to bypass the full ROS and still get credit for it.
Finally, there is the PSFH. This, too, is an area in which the requirements are relatively easy for emergency medicine. All that is required for the highest level is one statement from two of these areas. Something like, "this is an otherwise healthy smoker," would cover it. Again, this is something we should be able to do on all our patients. The one ringer here is that patients who are going to Observation need to have all three areas covered for the highest level observation codes.
Those are the essentials of the history. You will be in good shape if you do at least a four element HPI and 2/3 PSFH on all your patients, and if you do a 10 ROS on all your patients sick enough to need an IV and 2 or more studies.
That's it for this month. Next month we'll look at the Physical Exam and Medical Decision Making.
Robert A. La Fleur, MD, FACEP