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Archive for January, 2007

TB Isolation Rule

2+ of the following:

Abnormal CXR
Temp >101
Lives in Homeless Shelter
Hx of TB/PPD+

Written by phil

January 30th, 2007 at 1:30 pm

Posted in ID


1. Medical Decision Making: Coders look for MDM first… They use a point system that adds up based on how many tests you order AND documentation of your gathering of information and analysis of information. In other words use the “DOCTORS NOTES” section. The more boxes you check in this section, (greater that 4 is “high”) the more MDM points you get. Below in addendum A is the coding specialist discussion of this topic

2. We document Critical Care on 1.38% of our patients. The national average is 2-4%. In order for our coders to bill out a case as critical care you need: (for those of you who wanted “the written definition”)

a. Clinical Condition Criterion-There is 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. (An acute allergic reaction, or severe asthma attack, or bad CHF, or Acute MI, or CNS bleed, etc… all count…..)
b. Treatment Criterion-Critical Care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these intervention on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.

One of the keys to remember is that the provider has to be immediately accessible to the patient. (We are always in the Department!) Critical Care is not time spent exclusively at the bedside of the patient, but time spent in work directly related to the patient’s care

Critical Care time cannot be requested if the patient is not yet in the ER, such as en-route in the ambulance or if the patient is deceased as the Critical Care time ends when the patient is no longer alive. The patient does not have to be admitted to a CCU or ICU in order to request Critical Care, and can in rare instances be sent home with Critical Care performed during the patient’s ER course.

PLEASE NOTE: Our billing company is unable to return charts for provider documentation of Critical Care when none is requested in the cases where the documentation would have supported it. That means: please respond to Tiffany’s imail request to review a case for potential critical care documentation. She reviews that charts of all patients that physically went to the resus room, every day. If it was not a potentially life, limb or organ if danger… just imail her back “no”. If it may have been critical care, review the chart, “buff it if needed, choose the drop down for critical care and imail her back.

CPR: When CPR is performed the time requested for Critical Care must be time not spent in the direction of the CPR as this is a separately billable procedure which needs to be subtracted from the Critical Care time. Finally, if the provider documentation does not support the requested Critical Care time an EM level will be assigned in place of the Critical Care.

3. IV Hydration: In order for a coder to bill out a separate charge for hydrating a patient they need to see:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient

HINTS: If you use the box in the attending note section you can cover b and c. If your primary or secondary diagnosis is dehydration, then a is covered. If your condition is “improved” then d is covered…..

I supervised the administration of IV hydration which required minutes to completely infuse.

(see addendum B for further explanation)

4. Procedures: All procedures performed should be fully documented so that they can be billed separately as appropriate. Intubations, Central Lines, Chest Tubes, etc are separately billable, however they have to be documented in order to bill separately. USE THE TEMPLATES (addendum C)

a. Splints- use the ORTHO SPLINTING template even if the ortho resident applied the cast or splint!

5. . Medical student documentation is considered invisible with the exception of Review of Systems and/or Past, Family, Social Histories. The ROS and PFSH may be used to supplement the attending’s documentation when the attending checks the appropriate boxes in the ATTENDING NOTE section.

6. ROS: Our billing company considers the statement “All relevant systems reviewed and all negative except for the above” unacceptable. One or two ROS need to be documented and then the statement “All other systems reviewed and negative” if reviewed or at least 10 of the 14 systems listed in order to support High MDM or EM level 99285. This means that you need to make yourself a macro that says “All other systems reviewed and negative”, use this with 2 other systems OR you need to document at least one element (or negative) in 10 systems.

7. RVU’s. An RVU is a numeric ranking assigned to a CPT procedure relating it to other CPT procedures in terms of the time, work and costs associated with the procedure. If you document high levels of care and many procedures then you will have higher RVU’s. More RVU’s is good!

I hope that helps…. Feel free to contact me if you have any questions or concerns. If you would like to speak directly to our billing companies coding specialist, email her (Deb Grieve) at the email below. and


Medical Decision Making is determined by the documentation of the Data, Risk and Problem Categories. In order to have consistency with our coders, we utilize a coding tool based on a tool created by the Marshfield Clinic in Wisconsin that has been approved by CMS. In this system, the Data elements, Risk and Problem Categories are assigned points and those points are added together to come up with the EM level
a. Data- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. The data points are as follows: 1-Review and/or order lab tests, 1-Review and/or order radiology tests, 1-Review and/or order tests from the Medicine section of CPT (EKG, EEG, etc.), 1-Discussion of test results with performing physician (ex. review radiology report with radiologist), 1-Decision to obtain old records and/or obtain history from someone other than patient, 2- Review and summarize old records and/or history from someone other than patient and/or discussion of case with another health care provider, 2-Independent visualization of image tracing or specimen. Please note that 4 or more points scored for data equates to High Medical Decision Making for the Data sub-component.

b. Risk-The CMS table of risk is used to help determine the level of MDM by the Nature of Presenting Problem(s), Diagnostic Procedure(s), Possible Management Option(s). 1-Minimal risk is usually one self-limited or minor problem such as cold or insect bite with management options such as rest and gargles or superficial dressings, 2-Low risk is two or more self-limited or minor problems, one stable chronic illness, or acute uncomplicated illness or injury with management options such as over the counter drugs, IV fluids without additives, 3-Moderate risk is one or more chronic illness with mild exacerbation, progression or side effects of treatment, two or more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, or acute complicated injury with management options such as prescription drug management, IV fluids with additives or closed treatment of fractures/dislocations, 4-High risk is usually one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status with management options such as Parenterally controlled substances given IV, IM or SubQ, drug therapy requiring intensive monitoring for toxicity or decision not to resuscitate or to de-escalate care because of poor prognosis. Please note that the highest level of Risk is chosen based on documentation.

c. Problem Categories-Points are assigned based on the outcome of the patient’s status or the work up performed in the ED. 1/2-Self limited or minor (stable, improved, worsening)(max 2), 1-Established problem to examining physician/group;stable, improved, 1/2- Established problem, worsening, 3-New problem (to examining physician/group), no additional work-up planned (max 1), 4-New problem (to examining physician/group), additional work-up planned. Please note that additional work-up planned includes admitting a patient to the hospital, transferring to another facility, making an appointment for the patient with date and time documented, and/or the amount of diagnostic tests being performed in the ED.

In order to establish the Medical Decision Making based on the providers documentation, Data, Risk and Problem Categories are added up and then 2 of the 3 must meet or exceed to support the appropriate level of EM.

IV Hydration service codes 90760 – 90761 are intended to report a IV Hydration infusion which consists of a fluid and/or electrolyte solution (i.e., normal saline, 30mEq KC1/liter) but are not used to report infusion of drugs or other substances. There is no doubt that start and stop times for each IV infusion, piggyback, etc., should be documented in order to bill the most appropriate code(s) as these are time based codes and would require distinct start and stop times should the procedure be performed greater than 1 hour, since the initial code description is “up to one hour”. Poorly documented accounts (where the hydration was greater than one hour) and no stop times are documented – the code may default to the lowest code for the range. It should also be noted that concurrent infusions may occur during an encounter, and this is another indication of the importance of being able to separate out the services as documented. IV Hydration for hydration of prepackaged fluid and electrolytes – not for infusion of drugs or other substances, typically require direct supervision for purposes of consent, safety oversight, or intrasupervision of staff. Documentation should clearly indicate:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient
The CPT codes that are assigned when documentation supports billing of IV Hydration:
a. 90760 – intravenous infusion – initial – up to one hour
b. 90761 – each additional hour up to 8 hours


In order to accurately assign CPT codes for procedures, the documentation must clearly state what type of procedure was performed, if applicable the location and length and the description of the procedure performed. When a procedure has to be repeated, documentation of the additional steps should be documented as a procedure may be billed separately every time it is performed. An example is the chart we reviewed that had documentation of the patient who was intubated once and then when the ET tube came out, the attending had to re-intubate the patient. Both of the intubations are billable. Attendings should clearly document their supervision of procedures when performed by Residents in order to bill separately for the procedures. When a Medical Student is involved, the attending must re-document the entire procedure in order to bill separately for the procedure. If a PA performs a procedure and the attending documents a face to face encounter with the patient, the PA will be credited with the procedure and the attending with the EM level.

Splinting documentation must support that the splint was placed by the ER provider if the patient has a governmental insurance such as Medicare. For all other insurances, the ER provider can document a post splint placement examination when applied by a nurse or tech and the splint can be billed separately. This can be as simple as a statement such as “splint placed by tech in good alignment with neurovascular status intact”.

Written by phil

January 18th, 2007 at 1:25 pm

Posted in IBEX,Pearls