Medical Decision Making Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors: **The number of possible diagnoses and/or the number of management options that must be considered by the examiner **The amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed by the examiner **The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner.

A. Problem(s) Status	Points	Results
Self-limited or minor (stable, improved or worsening) (1 point)	Max=2
Est. problem (to examiner); stable, improved (1 point)	Max=2
Est. problem (to examiner); worsening (2 points)	Max=2
New problem (to examiner); no additional workup planned (3 points)	Max=1
New problem (to examiner); additional workup planned (4 points)	Max=1
Bring total to Line A in Final Result for Complexity Total :

B. Amount and/or Complexity of Data Reviewed

The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the encounter, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician.

Review and/or order of clinical lab tests	1
Review and/or order of tests in the radiology section of CPT	1
Review and/or order of tests in the medicine section of CPT	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or obtain history from someone other than the patient	1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider	2
Independent visualization of image, tracing or specimen itself (not simply review of report)	2
Bring total to line B in Final Result for Complexity Total :

C. Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based upon the risks associated with the presenting problem(s), the diagnostic procedure(s) ordered, and the management options selected. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

Level	Presenting Problem(s)	Diagnostic Procedure(s) Ordered	Management Options Selected
Minimal	One self-limited or minor problem	Lab tests requiring Venipuncture Chest or other diagnostic X-ray EKG/EEG Urinalysis Ultrasound KOH prep	Rest Gargles Elastic bandages Superficial dressings
Low	Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury	Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical laboratory tests requiring Arterial puncture Skin biopsies	Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
Moderate	One or more chronic illness with mild exacerbation or progression Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury	Physiologic tests under stress Deep needle or incisional biopsy Diagnostic endoscopies with no identified risk factors Cardiovascular imaging studies with contrast and no identified risk factors Obtain fluid from body cavity	Minor surgery with identified risk factors Elective major surgery with no risk factors Prescriptions drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocations without manipulation
High	One or more chronic illness with severe exacerbation or progression Acute or chronic illness or injuries which pose a threat to life or bodily function Abrupt change in Neurologic status	Cardiovascular imaging studies with contrast with identified risk factors Cardiac Electrophysiological tests Diagnostic endoscopies with identified risk factors Discography	Elective major surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Now, add your numbers from above to get your medical decision making

A	Circle the number in section A	<1 Minimal	2 Limited	3 Multiple	4> Extensive
B	Circle the number in section B	<1 Minimal or none	2 Limited	3 Multiple	4> Extensive
C	Circle the number in section C	<1 Minimal	2 Low	Moderate	High
Complexity Level of Medical Decision Making		Straightforward SF	Low L	Moderate M	High H

Draw a line down the column with 2 or 3 circles and circle decision making level OR draw a line down the column with the center circle= level of MDM.

Time

If the physician documents total time and suggests that counselling or cordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential disgnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.

Documentation reveals total time? Time: Face to Face outpatient setting. Unit/Floor in inpatient setting	Yes	No
Documentation describes the content of counselling or coordinating care	Yes	No

If both answers are “Yes” you may select the level based on time.

PHYSICAL EXAM

There’s a couple basic things you need to know about the bullets in the exam portion of the E/M tool. Once you know what each of the bullets stand for then you will be able to place them accordingly. The definition of the bullets are as follows:

Constitutional-Measurement of any 3 of the following 7 vital signs: BP(sitting, supine or standing), Pulse, Respiration, Temperature, Height, Weight and general appearance of the patient(development, nutrition,body habits, deformities, grooming)

Eyes-Inspection, examination or ophthalmoscopic exam(conjunctivac, lids, pupils, irises)

ENT(Ears, Nose, Throat, Mouth)-External inspection ears, nose, auditory canal, tympanic membrane. Inspection of nasal, mucosa, septum, turbinates, lips teeth, gums. Examination of oral mucosa, salivary glands, hard & soft palates, tongue, tonsils, and posterior pharynx.

Neck-examination of neck and thyroid

Respiratory-assessment of respiratory effort, percussion of chest, palpitation of chest, auscultation of lungs.

Cardiovascular-palpitation of heart, auscultation of heart, carotid artery pulse and bruit, abdomianl aorta bruits, femoral artery pulse and bruits, pedal pulses, and extermity edema and/or varicosities.

Chest(Breasts)-inspection and palpitation of breasts.

Gastrointestinal(GI)(Abdomen)-examination of abdomen, liver, spleen, hernia, when indicated anus, perineum, rectum, hemorrhoids, rectal masses.

Genitourinary(GU)-any part of the male or female.

Lymphatic-palpitation of lymph nodes in neck, axillae(armpit), groin…etc

Musculoskeletal-examination of gait/station, palpitation of digits(clubbing, cyanosis, petechiae, ischemia, infection, nodes), examination of bones, joints, muscles, deformities, stability, range of motion, muscle strength.

Skin-inspection and palpitation of skin

Neurologic-test cranial nerves, deep tendons, sensation

Psychiatric-description of patient’s judgement/insight, brief assessment of mental status, orientation to time, place, person, recent/remote memory, mood and effect.

Now let’s look at the exam chart in detail below:

Limited to affected body area or organ system (one body area or system related to problem)	PROBLEM FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s) (additional systems)	EXPANDED PROBLEM FOCUSED EXAM
Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 ( more depth and elaboration than above)	DETAILED EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system (Body areas do not count)	COMPREHENSIVE EXAM

Body area: †Head, including face Chest, including breasts and axillae Abdomen †Neck Back, including spine Genitalia, groin, buttocks †Each extremity OR Organ systems: †Constitutional † Ears, nose, Respiratory † Musculoskeletal †Psych (e.g., vitals, gen app) mouth, throat Gastrointestinal Skin †Hem/lymph/imm †Eyes †Cardiovascular GU † Neuro	1 body area or organ system	2 – 4 body areas or organ systems	5 – 7 body areas or organ systems WITH MORE DEPTH	8 or more organ systems or comprehensive single organ system exam
	PROBLEM FOCUSED	EXPANDED PROBLEM FOCUSED	DETAILED	COMPREHENSIVE

Physical Exam– This is the second part of the patients note from the History.

Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal  ulcerations;auditory canals patent with pearly TMs normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12

Physical Exam

Using the 1997 E/M guidelines, this example qualifies as a Comprehensive Physical Exam which requires two bullets in EACH of nine organ systems.  The following bullets and systems were used(*sidebar 1995 guidelines would only require one bullet in each system):

Constitutional

• 3 vital signs
• general appearance

Eyes

• inspection of conjunctiva and lids
• examination of pupils and irises (PERRLA)

Ears, Nose, Mouth, and Throat

• external appearance of the ears and nose (NC/AT)
• examination of oropharynx:

Neck

• examination of neck (e.g., masses, symmetry, tracheal position)
• examination of thyroid

Respiratory

• assessment of respiratory effort (e.g., intercostal retractions)
• auscultation of the lungs

Cardiovascular

• auscultation of the heart with notation of abnormal sounds and murmurs
• assessment of lower extremities for edema and/or varicosities

Gastrointestinal (Abdomen)

• examination of the abdomen with notation of presence of masses or tenderness
• examination of the liver and spleen

Lymphatic (palpation of lymph nodes two or more areas)

• neck
• other (extremities)

Skin

• inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
• palpation of the skin and subcutaneous tissue (temperature and turgor)

Psychiatric

• orientation to time, place, and person
• mood and affect

A total of 10 systems with two bullets each were included, even though the requirement is only for nine systems with two bullets each.

Now, just count how many systems the physician assessed.

1. Constitutional, 2. Eyes, 3. ENT, 4. Neck, 5. Respiratory, 6. Cardiovascular, 7. Gastrointestinal(Abdomen), 8. Lymphatic, 9. Skin, and 10. Psychiatric

After careful review, the physician assessed 10 systems and would make the exam portion COMPREHENSIVE according to the exam chart above.

COMPREHENSIVE EXAM

The extent of history of present illness (HPI), review if systems (ROS), and past medical, family, and/or social history (PFSH) obtained and documented is dependent upon clinical judgement and the nature of the patient’s presenting problem(s).

Basic understanding on how to use an E/M tool with theses simple need to know tips.

History of Present Illness (HPI)- Description of illness or injury by the patient or person giving the information:

·        Location-where it hurts (LT leg, stomach)

·        Quality– descriptive (throbbing, productive, red)

·        Severity– level of pain (pain scale, temps to 102)

·        Duration -how long it’s been hurting/going on (5 days) (don’t mixup w/timing)

·        Timing– when it hurts (in the pm, intermittent, worse at night) (don’t mixup w/duration)

·        Context– how you got hurt/sick (falling, exposure at work/school)

·        Modifying factors– what helps or not(Motrin reduced fever, ice, heat)

·        Associated signs and symptoms– cough, fever, etc…..

Past, Family, & Social History (PFSH)

*Past History– The patient’s past experiences w/illnesses, operations, injuries, treatments, medications & allergies.

*Family History-review medical events in the patient’s family including diseases which are hereditary or put the patient at risk.

*Social History-an age appropriate review of past and current activities(drink,smoke,….)

If one column contains three circles, draw a line down that column to the bottom row to identify the type of history.

If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history.

After completing this table which classifies the history, circle the type of history within the appropriate grid below.

	PROBLEM FOCUSED	EXP.PROB. FOCUSED	DETAILED	COMPREHENSIVE
HPI: Status of chronic conditions: 1 condition, 2 condition, 3 condition OR		Status of 1-2 chronic conditions		Status of 3 chronic conditions
HPI: (history of present illness) elements: _Location, _Severity, _Timing, _Modifying factors, _Quality, _Duration, _Context, _Associated signs and symptoms	Brief (1-3)	Brief (1-3)	Extended (4 or more)	Extended (4 or more)
ROS (review of systems): _Constitutional (wt loss, etc), _Eyes, _Ears, nose, mouth, throat, _Gastrointestinal (GI), _Genitourinary (GU), _Integumentary (skin, breast), _Endocrinology, _Hem/lymph, _Card/vasc, _Musculo, _Neuro, _All/immuno, _Resp, _Psych, _All others negative	None	Pertinent to Problem (1 system)	Extended (2-9 systems)	* Complete (10 or more) Some systems + statement “all others negative”
PFSH (past medical, family, social history) areas: _Past history ( the patient’s past experiences with illnesses, operation, injuries and treatments) _Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk) _Social history (an age appropriate review of past and current activities)	None	None	Pertinent (1 history area)	** Complete (2 or 3 history areas)

Example part I A Patient with a history of CHF who presents with shortness of breath CC : “ Shortness of breath.” HPI: Patient is a 68 year old male with a history of CHF who presents with SOB. He states this problem began about two weeks(duration) ago. The shortness of breath may occur at rest or with exertion(context). The timing is described as intermittent(timing). His breathing is worse when laying flat(modifying factors). He has noticed his shortness of breath is often associated with worsening lower extremity swelling(assoc signs & symptoms). He states he has a history of heart disease, but had a negative nuclear stress test approximately one year ago. Medications Atenolol 25 mg PO QD Glyburide 5 mg PO BID Lisinopril 10 mg PO BID Atorvastatin 20 mg PO QD PMH: per HPI, plus osteoarthritis and dyslipidemia FH: Mother died in her 80s of “old age”; father at age 72 of pneumonia.  The patient has three grown children in good health.   SH: The patient has been married for 45 years.  He denies tobacco or alcohol abuse and continues to drive himself around. ROS: Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising.  HPI has 5 elements: duration, context, timing, modifying factors, and associated s&s ROS-Complete which it states complete PFSH-Complete due to talking about histories HISTORY -Comprehensive

Coding for the Treatment of “Abortions”

Pregnancy chapter codes are very complicated to use in coding. If you are medical coder, you would surely understand how difficult it is to find a correct ICD or CPT code in pregnancy chapter. I have made very big errors in past in ICD and CPT code while coding pregnancy medical reports. The major topic in this chapter is to discuss about coding ABORTION. I have learnt coding Z codes, pregnancy complication codes, Injury encounter codes but still I am struggling to code the Abortion ICD and CPT codes. Today, I would just share few tips for coding abortion procedures. 

The definition of “abortion” is the premature expulsion from the uterus of the products of conception, the embryo or a non-viable fetus. However, for the lay person, the coding or labeling of the medical record or report as “spontaneous abortion” may be somewhat problematic. The CPT codes properly use the medical term abortion. If you are want to be perfect in surgery coding, you have to understand every term related to abortion.

On the basis of the cause, abortions may be categorized as either spontaneous and induced. Spontaneous abortion, also known as Miscarriage and Pregnancy loss, is the natural death of an embryo or fetus before it is able to survive independently. Some use the cutoff of 20 weeks of gestation, after which fetal death is known as a stillbirth. Induced abortion is the intentional termination of a pregnancy before the fetus can live independently.

Different medical terms for Abortion

Abortion, threatened

Abortion, spontaneous

Abortion, incomplete

Abortion, missed

Abortion, septic

Ovum, blighted

Abortion, induced

Threatened Abortion

A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy. The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of “routine” obstetric care of the patient who successfully delivers.

In the event that the patient being treated for a threatened abortion requires additional visits, these should be coded separately using evaluation and management services codes, according to the services the physician provides.

Read also: Coding tips for Maternity Care and Delivery Procedure codes

Coding for Spontaneous Abortion (Miscarriage)

Complete Abortion: All of the products (tissue) of conception leave the body.

When a spontaneous abortion, that is complete (any trimester),  of the products (tissue) of conception leave the body. occurs and the physician manages the patient medically, with no surgical intervention, the physician should assign the appropriate level of evaluation and management code, dependent on the place where the patient is seen (99201-99233).

Incomplete Abortion : Only some of the products of conception leave the body

An incomplete abortion occurs when the uterus is not entirely emptied of its contents. Fragments of the products of conception may remain within the uterus, protrude from the external os of the cervix, or can be found in the vagina. Some fragments of the products of conception may have spontaneously passed out of the vagina. Code 59812 is used to report the dilation and curettage (either sharp or suction curettage) for the surgical management of an incomplete abortion. However, if the patient is septic and is diagnosed as experiencing an incomplete abortion, do not use code 59812.

59812 – Treatment of incomplete abortion, any trimester, completed surgically

Read also: When to use Hospice Modifiers GV and GW 

Blighted Ovum

The advent of diagnostic tools that aid in the very early detection of pregnancy such as beta subunit HCG and ultrasound, have clouded the clinical coding picture as to when early “abortion” occurs. In the instance of a positive pregnancy test, with a blighted ovum identified on ultrasound (a pathologic ova in which the embryo was degenerated or absent) raises the question of whether a code for treatment of abortion should be selected or a code for dilation and curettage, since there was not any (viable) product of conception present.

In many of these cases, women who did not seek medical attention for early diagnosis of pregnancy would not have previously identified a delayed menstrual cycle as the loss of a pregnancy nor have been aware that any conception had occurred. However, if a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the physician services related to the abortion.

Modifier 59 is the most discussed topic every year. With the introduction of X-{EPSU} modifiers the confusion for using 59 modifier has increased more medical coders. The X modifiers were added to give more specificity than 59 modifier for distinct procedures.

Recently, their has been an update on the proper and correct use of modifier 59, because their has been lot of errors done by medical coders with use of 59 modifiers. So, let us checkout the recent updated information about this modifier.

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

1.Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers –that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ.However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. Modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. For example:
• Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site. 
• Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site. 
• Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site. 

2. Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.
Another common use of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers – i.e., 24, 25, 27, 57, 58, 78, 79, or 91.  As noted in the CPT definition, modifier 59 should only be used if no other modifier more appropriately describes the relationship of the two procedure codes.

3. Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.
One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be “separate and distinct.” The provider should not use modifier 59 for such an edit based on the two codes being “different procedures.” However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures on that date of service. Additionally, there may be limited circumstances sometimes identified in the National Correct Coding Initiative Policy Manual for Medicare Services (available in the downloads section at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html) when the two codes of an edit pair may be reported together with modifier 59 when performed at the same patient encounter or at the same anatomic site.

4. Other specific appropriate uses of modifier 59 

There are three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe nonoverlapping services even though they may occur during the same encounter, i.e.:
A. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.

B. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention.  If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

C. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of Modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.
Modifiers XE, XS, XP, and XU are effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more specific modifier is appropriate.)

Get all information with examples on this topic in the below reference:

Click to access SE1418.pdf

Again in the coming year 2020, we will be seeing lot of new addition, deletion and revision of CPT codes. There are 394 code changes in the 2020 CPT code set, including 248 new codes, 71 deletions, and 75 revisions.

New CPT category I codes will be effective from January 1st, 2020. 

I have already shared some the important changes for E/M codes for 2021 previously. Let us checkout the new CPT code changes for 2020. 

Their are around six new codes to report online digital evaluation services or e-visits. These codes describe patient-initiated digital communications provided by physician or other qualified health care professional (99421, 99422, 99423), or a non-physician health care professional (98970, 98971, 98972).

Two new CPT code (99473, 99474) is used to report self-measured blood pressure monitoring. The goal of these codes is to expand reporting pathways for physicians across the country who take care of a diverse set of patients that have varying degrees of access to care.

Moving on the medical coders will have some more new CPT codes for health and behavior assessment and intervention services (96156, 96158, 96164, 96167, 96170 and add-on codes 96159, 96165, 96168, 96171).

These codes replace six older codes to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.

References:

https://www.ama-assn.org/practice-management/cpt/6-new-telehealth-cpt-codes-you-should-know-about

Upcoding, as the name suggest, is coding a higher dollar value medical code which is not actually performed or documented in the report. Downcoding is exactly opposite of upcoding, in which the medical coder assign a medical code, which has less dollar value than the actual procedure performed in the medical report. Let us learn both of them with an example.

Suppose, in a medical report a physician has performed a Ultrasound, abdomen limited exam (CPT code 76705). But, while coding the medical coder has reported an Ultrasound complete exam (CPT code 76700). Now, when you see the RVU (Relative value units) of these codes below, you will know how much upcoding affect the medical billing or payment.

RVU for 76705 – 0.59

RVU for 76700 – 0.81

Now for downcoding, the same procedure if performed as complete ultrasound abdomen 76700, and reported by medical coder as limited 76705, will be considered as downcoding.

RVUs includes physician productivity, expense and malpractice expense. RVUs value varies for Facility and Non-Facility setting.

Consequences of Upcoding and Downcoding

Upcoding and Downcoding can directly be called a FRUAD. Yes, these things can be done to earn extra money or dollar using these malpractices. The main consequnce of upcoding & downcoding will be denial of claims. Yes, medical claims can be denied as well if medical codes are not reported correctly.

Incorrect coding can create a problem in medical billing as well. The services that you claimed are reimbursed in lower rates. You won’t receive any explanation for lower reimbursement. To detect downcoding errors, you must be familiar with the fee schedule and compare that to the amount mentioned on the EOB form.

Same goes with upcoding errors as well, you must be familiar with the NCCI edits and mutual exclusive elements. If a minor procedure is completely included in a major exam then, only the major procedure should be billed. For example, the barium swallow procedure code (74220) is included in modified barium swallow (CPT code 74230) procedure. Below are the NCCI results for this code pair.

NCCI Edit Results:

Edit exists with 74230.  74220 is a Column 2 code.

If both 74230 and 74220 are submitted, only 74230 will be paid.
– NO modifiers associated with the CCI are allowed to be used with this code pair.
– Rationale: More extensive procedure

How to avoid Downcoding & Upcoding

These errors can be avoided with a healthy knowledge about modifiers, CPT codes & ICD 10 codes. Moreover, the NCCI (National Correct Coding Initiative) should be used whenever it is applicable between two or more medical codes.

Always audits all the coding files before sending them to medical billing. Do not depend on software completely for coding and auditing.

CMS has provided ICD-10-CM coding updates for the fiscal year beginning Oct. 1, 2019, and ending Sept. 30, 2020.

Five takeaways:

1. The updated ICD-10-CM codes are for discharges and patient encounters taking place in fiscal year 2020.

2. There are 72,184 ICD-10-CM codes for fiscal year 2020 compared to 71,932 for fiscal year 2019, according to the American Health Information Management Association.

3. For fiscal year 2020, 273 codes were added, 21 were deleted and 30 were revised.

4. Among the added codes for fiscal year 2020 are:

• Adenosine deaminase deficiency, unspecified
• Severe combined immunodeficiency due to adenosine deaminase deficiency
• Adenosine deaminase 2 deficiency
• Other adenosine deaminase deficiency
• Pressure-induced deep tissue damage of left elbow
• Chronic embolism and thrombosis of right calf muscular vein

5. Among the deleted codes for fiscal year 2020 are:

• Congenital metatarsus primus varus
• Congenital pes cavus
• Ehlers-Danlos syndrome
• Congenital malformation syndromes predominantly associated with short stature

Each section of a SOAP note requires certain information, including the following:

Subjective: SOAP notes all start with the subjective section. This refers to subjective observations that are verbally expressed by the patient, such as information about symptoms.

It is considered subjective because there is not a way to measure the information. For example, two patients may experience the same type of pain. One patient may report it as the worst pain of their life while another may say it was only moderate pain.

When considering what to include in the subjective section of your SOAP notes remember the mnemonic OLDCHARTS. Each letter stands for a question to consider when documenting symptoms. Consider the following:

– Onset: Determine from the patient when the symptoms first started.

– Location: If pain is present, location refers to what area of the body hurts.

– Character: Character refers to the type of pain, such as stabbing, dull or aching.

– Alleviating factors: Determine if anything reduces or eliminates symptoms and if anything makes them worse.

– Radiation: In addition to the main source of pain, does it radiate anywhere else?

– Temporal patterns: Temporal pattern refers to whether symptoms have a set pattern, such as occurring every evening.

– Symptoms associated: In addition to the chief complaint, determine if there are other symptoms.

Objective: The second section of a SOAP note involves objective observations, which means factors you can measure, see, hear, feel or smell. This is the section where you should include vital signs, such as pulse, respiration and temperature. Information from a physical exam including color and any deformities felt should also be included. Results of diagnostic tests, such as lab work and x-rays can also be reported in the objective section of the SOAP notes.

Assessment: The next section of a SOAP note is assessment. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong. There may also be other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment.

Plan: The last section of a SOAP note is the plan, which refers to how you are going to address the patient’s problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work.

A psychiatrist double, triple and even quadruple booked patients at his Virginia Beach practices in order to over bill insurance companies by more than $460,000, according to court documents.

Udaya Shetty, of Behavioral & Neuropsychiatric Group and more recently Quietly Radiant Psychiatric Services, pleaded guilty Wednesday to one count of health care fraud. The Virginia Beach resident is set to be sentenced Jan. 16 in U.S. District Court in Norfolk.inRead invented by TeadsADVERTISING

Shetty’s attorney, Brian Whisler, said last week his client “voluntarily separated” from Quietly Radiant in July 2018 and has not practiced elsewhere since. While the doctor’s medical license remains in good standing, Whisler said Shetty “does not plan on returning to any form of practice in Virginia in the future.”

Assistant U.S. Attorney Joseph Kosky declined to comment on the case, as did a spokeswoman for the Virginia Department of Health Professions.

“Complaints and investigations are confidential by law,” Diane Powers said in response to questions about his license.

She said Virginia law requires a doctor’s license to be suspended if he is convicted of a felony, but Shetty’s conviction will likely not be finalized until his sentencing.

A graduate of Karnatak University in India, Shetty has been licensed in Virginia to practice psychiatry since 1991. He has held a certification for the sub-specialty of child and adolescent psychiatry since 1994, court documents said.

The scheme stretched from at least 2013 through 2018. At first, Shetty owned and operated Behavioral & Neuropsychiatric Group. He subsequently closed that practice in November 2017 and joined Quietly Radiant as a staff psychiatrist.

The former owner of Quietly Radiant, Bethanie Simmons-Becil, said Shetty had expressed plans to retire when he joined her practice, and that she believed he was “taking steps to ensure continuity of care for this clients.”

In the wake of the FBI investigation, Simmons-Becil shuttered Quietly Radiant.inRead invented by TeadsADVERTISING

The fraud scheme involved Shetty’s misuse of various codes employed by the American Medical Association. Insurance companies use the “Current Procedural Terminology” codes to determine the nature and complexity of medical services and procedures doctors perform.

So-called “upcoding” is a common type of healthcare fraud that can often go undetected, experts said. Patients are generally unaware the extent of services they received, and for which they and their insurance companies are billed.

At BNG, Shetty typically worked three days a week, seeing patients from 11 a.m. to 5 p.m. The documents said he would generally spend no more than 5 or 10 minutes with each patient, renewing their prescriptions and then moving on.

He would then instruct his staff to bill Medicaid, Medicare, and Tricare like he provided each patient two medical services that would have required a minimum 38 minutes to complete.

“In this way, Dr. Shetty was able to fraudulently over inflate his hours and receive payment from government health care benefits programs for services not adequately rendered,” the statement of facts said.

The fraud continued at Quietly Radiant even though the company was now in charge of Shetty’s billing. According to court documents and Simmons-Becil, Shetty instructed Mary Otto, an employee who came with him from BNG, to log into the billing system and upcode his appointments.

Medical and billing experts reviewed Shetty’s records as part of a federal investigation. They concluded none of his patient files supported the use of the codes for which they were billed.

“In fact, the records were so poorly maintained, they did not support Dr. Shetty billing for the … services rendered,” the statement of facts said.

As a result of the fraud, Medicare lost $169,860, Medicaid lost $161,710, Tricare lost $72,405 and Anthem Blue Cross Blue Shield lost $61,967, documents said.

Simmons-Becil said she was unaware of the FBI investigation until agents arrived at her practice in April 2018 to serve a subpoena. She said she dismissed Otto when she learned of her involvement in the scheme.

Otto, the former office manager at BNG, pleaded guilty earlier this year to one count of making false statements relating to health care matters. According to court documents, she filled out several prescriptions for Shetty’s BNG patients while he was on vacation. Otto, who lacked a medical license, used used a blank, but pre-signed, prescription pad Shetty left behind.

A sentencing hearing is set for Nov. 5 in U.S. District Court in Norfolk.