At ERx, we believe our physicians, NPs & PAs, and other staff must remain current in all aspects of their designated specialties, as well as be up-to-date in developing trends. Our regular training sessions, webinars, and other training programs are set in place to insure we stay in compliance and within hospital and state and federal guidelines.
BASIC T-SYSTEM REMINDERS
1. Designed to use at bedside
2. Write legibly
3. Use Regular ballpoint pen
4. Utilize specific template based on presenting problem.
5. Circle or Check Affirmatives
6. Backslash Negatives
7. Avoid Group Circling
8. Avoid using one backslash through multiple components
9. Include Clinical Impression
10. Sign & date (Be sure if MLP signs the attending physician also signs and dates)
There are two scenarios for coding and billing Intermediate Repairs. Remember to document all steps so that we can code the appropriate CPT code for wound repairs; especially as it relates to the second scenario.
First scenario: Intermediate repairs requires layered closure of one or more of the deeper layers of the subcutaneous tissue and superficial (non- muscle fascia, in addition to the skin (dermal or epidermal ) closure.
Second Scenario: When documenting a single layer closure of heavily contaminated wound, if it requires “extensive” cleaning and/or debridement and/or removal of particulate matter as it qualifies for intermediate repair document specifically when applicable: Contaminated wound was “extensively” irrigated, “extensively” debrided,“extensively” cleaned plus your single layer closure procedure note.
Pointers on History and Physical Documentation–
Provided below is information on documenting the H&P and also included are 3 attachments that may help. The 1st attachment is PEARLS for MDM , the 2nd attachment is key components for E/M services and the 3rd attachment is HPI elements and descriptions.
As of July 15, 2017 dates of service (DOS) and forward we can no longer accept “all other relevant/pertinent systems are negative” as an acceptable ROS statement for a complete ROS .
Unfortunately we cannot defend “All other relevant/pertinent systems are negative” as the accepted attestation per Centers for Medicare and Medicaid Services (CMS) 1995 documentation guidelines (See excerpt below).
Please “free text” one of the options listed below or document 10 individual ROS.
Recommend requesting your IT department add one of the acceptable ROS options listed below.
Clarification: There has been some confusion that documenting “ as per HPI” was acceptable and please note this only allows us to credit any systems documented in the HPI, not a 10 point ROS. For example if the HPI has Musculoskeletal and Skindocumented and you document “as per HPI”, we will only credit those 2 systems towards ROS.
ROS options that are compliant for you to consider implementing are:
All other systems are negative (Published in CMS 1995 DG)
All other ROS are negative
All other systems reviewed & otherwise negative
A 10 point ROS is conducted and negative except as noted
ROS: All systems negative/normal except as noted.
Complete ROS otherwise negative.
CMS excerpt for a complete ROS when medical decision making supports a 99285.
A complete ROS inquires about the system(s) directly related to theproblem(s) identifiedintheHPI plus all additional body systems.
Documentation Guideline (DG): At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
For purposes of ROS, the following systems are recognized:
1. Document: 4 HPI + 10ROS + 2 PFSH + 8 Organ System Exam for Admits/Transfers andtypically Discharged Patient’s with 3+ diagnostic test/studies.
2. HPI- Distinctly identify 4 or more elements of the following: what the affected bodyLocation is -how Severe the problem is- describe environmental/situational Context- theDuration of the problem whether the Timing was acute or gradual-use adjectives todescribe Quality -what Modifying Factors had a positive/negative effect- Any AssociatedSign/Symptoms. (Level 99284 and 99285 require 4 HPI elements)
3. ROS-Acceptable to document patient pertinent positive and negative responses anddocument “ALL systems negative: except asmarked”. In the absence of this notationdocument one comment for 10 ROS of 14 ROS:
4. Document Allergies under HPI. (allergies can be used for past hx or immuno for ROS)
5. Document I have reviewed available ancillary/nursing notes. ( This is very important as it allows us to use allergies if documented by nursing to give credit for Past hx or immuno in ROS.)
6. Past Medical/Surgical, Family, and Social-Document at least one comment for any 2of 3 histories. Best practice is to document one comment of past medical or past surgical (documenting allergies also counts as past history), and one comment for family hx or social hx. Ex: document allergies for past hx and “non smoker” for social hx and in the case of a minor it is acceptable to document “no exposure to second hand smoke”.
7. Document one finding for each organ system. 99285 requires eight organ systems -99284 requires 3 organ systems-99282 and 99283 requires 2 organ systems.
History limited/unobtainable? Document the reason why. Example: History limited due toAMS or unobtainable due to acuity/clinical condition. Avoid using history limited/ unobtainable due to age or language barrier as these are not acceptable.
Be specific on measuring wound repairs and to document lengths. If you document approximately 2.5 cm your coders round down.
If lengths are not documented and repair note is documented your coders will not send back but will code as less the lowest length laceration (typically 2.5 cm or less).
Document a single layer closure of heavily contaminated wound if it requires “extensive” cleaning and/or debridement and/or removal of particulate matter as it qualifies for intermediate repair.
I & D: be detailed on your procedure notes so that your coders may make the correct code choice based on your documentation.
Note: Any insertion of a drain, packing, probing to break up loculations, send for culturing, deep abscess requiring US guidance or multiple simple I & D = Complex
Routinely document when a splint is applied to include:
Type of splint (short arm, long leg, finger, etc.)
Who applies splints (by me, by nurse, by ortho tech, by EDP (Emergency Dept. Provider)
Post splint assessment include note “Placement check & NV intact”
Note: Most splints are separately billable unless there is a reduction and would be included in the procedure except Medicare requires the physician/mid-level personally apply the splint to code and bill separately.
Document type of cast, who applied and post splint assessment.
Recommended documentation: “short leg cast applied by me” when ED physician/mid-level applies.
Note: We only charge for casting if the physician/mid-level personally applies
If you remove impacted cerumen using irrigation/lavage, unilateral document : Removal of impacted cerumen using irrigation or lavage “performed by me.” CPT 69209-RVU’s 0.36. Do not charge if nursing does.
If you remove impacted cerumen using a curettes, hooks, forceps to break up and remove, unilateral document: Removal of cerumen impaction with curette, hook, forceps. CPT 69210-RVU’s 0.94
Note: If the physician or mid-level determines there is ear wax, but it is not impacted, the removal (if any) is not separately reportable and is considered bundled into the evaluation and management service for that day.
Foreign Body Removal from Eyes, Ears, Nose:
Document use of instruments in procedure note when used to remove foreign bodies as there is a separate procedure codes coders will add in addition to the visit level.
i.e. currettes, forceps, katz extractors, fine gauge needle, etc.
Note: Removal of foreign body with irrigation or air pressure does not qualify for separate procedure code and will be part of medical decision making in the visit level.