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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin/Breast
• Neurological
• Psychiatric
• Endocrine
• Heme/Lymph
• Allergy/Immunology
The PFSH contains information pertaining to past medical, family and
social history. To meet the higher level initial visit codes (99222 and
99223), all three must be documented.
Physical Exam
There are two options for documentation of the physical exam as set forth
by CMS: the 1995 rules and the 1997 rules. In both sets of rules, the physical exam can be documented using 12 body systems. The 1995 rules are
often more easily applicable to a general exam. Although there is much
variation, most compliance departments agree that the highest level exam
(comprehensive exam) includes at least eight body systems. The body
systems are:
• Constitutional (Vital Signs, general)
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
144
S. Sigworth, and I. M. Helenius
• Neurological
• Psychiatric
• Heme/Lymph/Immunology
Medical Decision Making
There are three elements of Medical Decision Making, but only two of the
three need to be achieved to reach each Medical Decision Making level:
• Diagnoses: Number of diagnoses or treatment options
• Data: Amount/complexity of reviewed information
• Risk: Morbidity/mortality
The diagnosis element is the number of documented diagnoses. New and
worsening problems are given two or more points, whereas existing or
stable problems count as one point. A problem is considered new for
billing purposes if it is new to the hospitalist’s group, even if the diagnosis is not new to the patient. This is important when determining the code
for admission notes. For example, when patient is admitted for cellulitis,
stable congestive heart failure would be considered a new diagnosis and
count as three points.
The data element pertains to the number of data points reviewed or
ordered.
Data Points
• Laboratory (includes pathology)
• Radiology
• Cardiopulmonary diagnostics
• Independent interpretation of diagnostic/radiology test
• Communication with other MD regarding the patient
• Obtaining history from someone other than the patient
• Summarizing old records
The overall risk is determined by the highest level of risk in one of three
categories (Table 1) and is assigned a level of Low, Moderate or High.
CMS has published a comprehensive risk table.
1
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Inpatient Documentation and Coding
One can argue that most hospitalizations are the result of a severe
medical condition that may be a threat to life, therefore most initial inpatient visits should qualify as high risk.
Determining Which Code to Use
Once the note has been documented, the appropriate E&M code must
be determined. For all notes, a chief complaint or reason for the visit must
be documented. For initial visit notes, all three of the other components
(History, Physical Exam, Medical Decision Making) of the note are
required and therefore the component with the lowest level determines
the code. For subsequent visit notes, only two of the three components are
required and therefore the lowest level component can be dropped and the
code is determined by the lower of the two remaining components.
Tables 2 and 3 summarize the elements required for initial and subsequent visit notes. The data in these tables are generalizations. An institution’s compliance department may have more specific coding tools to
help choose coding levels, in particular with respect to the physical
exam.
146
S. Sigworth, and I. M. Helenius
Table 1 Examples from CMS Risk Table
Low Risk Moderate Risk High Risk
Presenting One stable chronic One or more chronic An acute or chronic
Problem illness or an illnesses with mild illness with severe
uncomplicated exacerbation or an exacerbation or medical
acute illness undiagnosed new severity that may
problem with be life threatening
uncertain prognosis
Diagnostic Non-cardiac Cardiac stress testing Diagnostic endoscopy
Procedure imaging with with risk factors
contrast
Management Over-the-counter Prescription drug Parenteral controlled
Options drugs managements substances
Documenting E&M Codes for Discharge Day Visits
The discharge day note requires four different components.
• Hospital Course
• Final Examination
• Discharge Medication Reconciliation
• Preparation of discharge records
All the components listed above must be described when documenting a
discharge note. If the time required for the physician to complete these
components was 30 minutes or less, then code 99238 should be used. If
the time required was greater than 30 minutes, code 99239 should be used
and the time spent documented in the note.
Documenting E&M Codes for Consultation Visits
Before 2010, an additional set of consult codes (99251–5) was used in the
United States to document new consult visits. However, as of 2010, CMS
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Inpatient Documentation and Coding
Table 2 Inpatient Initial Visit
99221 99222 99223
History
CC cc cc cc
HPI 4 4 4
ROS Problem pertinent + 210 10
PFSH 1 3 3
Physical Exam Detailed exam Comprehensive Comprehensive
exam exam
Medical Decision
Making (need 2 of 3)
Diagnoses 1–2 3 4
Data Points 0–2 3 4
Overall Risk low mod high
no longer recognizes these codes, though the codes are still recognized by
some carriers. For Medicare, all initial hospital codes now require the
accepting physician to attach modifier “AI” to their initial hospital code
(99221–3), and consultant visits for these patients now require a new visit
code without the AI modifier. The rules regarding consultative codes are
detailed by CMS.
2
Conclusion
Do not despair. The process of first determining the code, then documenting only the necessary components to meet the level of that code,
becomes easier and more intuitive with practice and experience. It
remains extremely important to understand the institutional interpretation of the CMS guidelines and be familiar with the institution’s compliance office to better incorporate specific documentation requirements
when needed.
For more information access the official CMS Medical Learning
Network site: http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
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S. Sigworth, and I. M. Helenius
Table 3 Inpatient Established Visit
99231 99232 99233
History
CC cc cc cc
HPI 1–3 1–3 4
ROS 0 1 2+
PFSH 0 0 0
Physical Exam Problem focused Expanded problem Detailed exam
exam Focused exam
Medical Decision Making
(need 2 of 3)
Diagnoses 1–2 3 4
Data Points 0–2 3 4
Overall Risk low mod high
References
1. Center for Medicare and Medicaid Services. Evaluation and manage-
ment services guide 2006 http://www.cms.hhs.gov/mlnproducts/down-
loads/eval_mgmt_serv_guide.pdf (see page 20) Accessed April 3, 2011.
2. Center for Medicare and Medicaid Manual System, Subject:
Revisions to Consultation Services Payment Policy http://www.cms.
gov/manuals/downloads/clm104c12.pdf (see section 30.6.10) Accessed
April 3, 2011.
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Inpatient Documentation and Coding
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Non-Physician Practitioners
in the Hospital Setting
Alan S. Briones*
Key Pearls
• Nurse Practitioners (NPs) and Physician Assistants (PAs) are
autonomous Non Physician Providers (NPPs) that can deliver high
quality patient care in collaboration with physicians.
• Utilization of NPPs is a strategic measure that can increase efficiency
and decrease the escalating cost of healthcare.
• The most common barriers and impediments to a successful NPPs-
Physician collaboration in clinical practice are a physician’s lack of
knowledge of NPPs role and scope of practice, poor physician attitude
towards NPPs, and patient and family reluctance of receiving NPP care.
• There is a growing recognition of the importance of the role played by
NPPs among patients and physicians.
• The three major types of NPPs-Hospitalist Practice model are academic
center model, community hospital model and private physician model.
Definition of Non-Physician Practitioners (NPPs)
The term NPPs is loosely defined as practitioners who render care to patients
but are not physicians, so consist of a broad category of healthcare
practitioners, including Nurse Practitioners (NPs), Physician Assistants
151
*Mount Sinai School of Medicine, New York, NY, USA.
15
Chapter
(PAs), Clinical Psychologists, Clinical Social Workers, Physical and
Occupational Therapists, Nurse Midwives, and Speech Language
Pathologists. The scope of practice, licensure and credentialing requirements for each NPPs are established by the state laws of the jurisdiction in
which the NPPs practice.
1
In many settings, however, the term NPPs is generally used to refer to NPs and PAs, and the collaboration of hospitalists
with these practitioners will be the focus of this chapter.
In the hospital setting, the NPs/PAs practices have expanded due to
regional shortages of physicians, efforts to reduce the cost of healthcare,
and decrease in graduate medical education funding. With the limitation
of work hours of interns and house staff physicians, more NPs and PAs are
expected to assume patient care responsibilities.
Quality and Cost-Effectiveness of NPs and PAs Care
NPs and PAs are autonomous high quality alternative healthcare providers
who practice in all the specialties of Medicine and Surgery, and in the
ambulatory care, acute and subspecialty care, emergency room and longterm care settings. For the hospitalist, the physician-NPP collaboration is
a widely used model of care in the hospital setting and has the potential to
enhance efficiency and reduce costs.
Research has shown that NPs and PAs practices have been shown to
demonstrate patient outcomes that were similar compared to physicians.
2–5
In
a study of five primary care clinics, Mundinger
2
and colleagues showed that in
patients who were randomly assigned to either NPs or physicians, at the end of
six months and one year, no significant differences were found in the patient
health status, health service utilization, hemoglobin A1C for patients with
diabetes, peak flow for patients with asthma, and patient satisfaction scores.
In a comparison of eight quality measures of HIV care provided by
NPs and PAs versus physicians,
4
six of the eight quality measures did not
statistically differ between NPs/ PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative
testing and Pap smears were statistically significantly higher for NPs and
PAs than for physicians. Furthermore, NPs and PAs had statistically
152
A. Briones
significantly higher performance scores than generalist non-HIV experts
on six of the eight quality measures.
Roy
5
demonstrated that among hospitalized medical patients, the
quality and efficiency of patient care on a PAs/Hospitalist service were
comparable to those of the traditional house staff services. No differences
were seen in inpatient mortality, ICU transfers, readmissions, patient satisfaction and length of stay.
In a recent study that compared patient satisfaction with care provided
by NPs, PAs, and physicians in the Veteran’s Health Systems, the satisfaction scores increased when more NPs provided care, but were slightly
higher or remain the same when PAs were involved.
6
The cost of healthcare in the United States of America is one of the
highest in the world, surpassing $2.3 trillion in 2008.
7
The use of NPPs is
a strategic cost cutting measure. Overall, the annual salary and cost of education of NPPs are lower as compared with those for physicians. In surveys
carried out 2009, the estimated annual salary of hospitalists is $215,000
8
;
$90,900 for physician assistants
9
; and $90,200 for nurse practitioners.
10
In a 2004 study of 26 primary care practices with a volume of approximately two million visits annually by 206 providers, the total labor costs
per visit were lower in practices where NPs and PAs were utilized.
11
In a
three-year analysis of the healthcare costs associated with an on-site NP
in a primary care practice, savings were estimated at $1,089,466 per
year.
12
Furthermore, the NPs-Hospitalist team was associated with
decreased length of stay and improved hospital profit as compared with
the “usual care” by a hospitalist.
13
NPPs Roles and Responsibilities
NPs and PAs have expanded their roles and responsibilities over time. PAs
were historically utilized and trained in a military setting, assisting surgeons in the care of wounded and injured soldiers. NPs were born from
highly skilled and clinically experienced nurses who have been mentored
by physicians during the 1950s and early 1960s to augment the need for
primary care services in medically underserved areas.
14
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Non-Physician Practitioners in the Hospital Setting