evaluation and management coding e&m coding - university of 評估和管理編碼e &amp；m編碼-大學(xué)

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1、PowerofthePenIyadG.Houshan.M.D.AssistantProfessorofMedicineChief,DivisionofHospitalMedicineUniversityofNevadaSchoolofMedicineICD-9codes40y.o.malewithPMHxof250.4,272.4,496,herefor491.21exacerbationandpossible410.Howdoyoutreatthispatient?40y.o.malewithPMHxofDM(renalmanifestations),dys

2、lipidemia,COPD,hereforCOPDexacerbationandpossibleMI.EvaluationandManagementCoding“E&MCoding”WhyI’mIhere?CanIpaysomeonetodothatforme?Whatismyincentivetolearnthis?INCENTIVEDefinitionsICD-9:InternationalClassificationofDiseases.(250.00,272.4,…)CPT:CurrentProceduralTerminologyCMS:Cente

3、rsforMedicareandMedicaidServicesDefinitions,Cont’dE&Mcodes,LikeCPTcodesarecompromisedoffivedigits.E&Mcodesspecificallybeginwith99.E&MsubsequentnumbersdependonthetypeofE&M.Definitions,Cont’dAlevel1(lastdigita1)istheleastAlevel2(lastdigita2)isgreaterThehighestcodelevelwillendina3(anin

4、patienthospitaladmission),ora5(Outpatientorconsultations).E&MCodingEachindividualcodelistedhasthreecomponentsthatqualifyphysicianstoworkforthespecificcode:1)History2)Physical3)medicaldecisionmakingMDME&Mcoding,cont’dToaddadegreeofconfusiontoourcodingdilemma,thereareactuallytwosetsof

5、theFederalDocumentationGuidelinesforEvaluationandManagementServices.E&Mcoding,cont’dTheoriginalset,1994,affectedprimarilythehistorycomponentofthephysiciandocumentationThesecondset,1997,usesthesamehistorysegmentbutaddsphysicalexamdocumentationguidelines,featuringthenowinfamous“bullet

6、”points.Besttousethe1997guidelines.(weusethe1994guidelines)E&Mcoding,cont’dIntheCPTbook,whenlookingupaspecificE&Mcode,thethreelistedqualifiers:History,Physical,andMDMarefoundPhysiciansdon’tthinkcodefirst.Wethinkclinicalmatters,diagnoses,labsandtests,andhistoryandphysical.Takingcareo

7、fthepatientsfirstbeforethecodes.TheGameDocumentationCodingLevelTheGameDocumentationCodingLevelMedicalNecessityMedicarewillnotpayforanythingunless“MedicalNecessity”ismetMedicalNecessityisnotclinicalatallitisfinancialtermCodeQualifiersEachCodeMDMHistoryPhysicalExamRiskDataDiagnosisHPI

8、ROSPMFSHElementsino