White Papers - E & M Coder
SOAPware's HCFA Evaluation and Management Coder Module
In August of 1997, Medicare announced revised documentation guidelines developed by HCFA/AMA. The good news is that we now have more specific criteria in order to comfortably code the "level of service" for say a "99214." The bad news is that as of 6/1/98, the Medicare carriers have been directed to randomly audit 3% of all Medicare claims and there is the promise to prosecute all that bill for encounters that do not have adequate documentation. It is expected that most managed care companies and Medicaid will adopt the same guidelines and start reviewing documentation next year. According to a recent HCFA report to congress, there was $2.8 billion Medicare dollars of improper physician payments attributed to insufficient documentation in 1996.
In response to this, all physicians must protect themselves from possible fraud and abuse charges. For the doctors using SOAPware, I have developed an easy to follow guide that to great extent can be incorporated directly into the software. The goal will be to allow for a near automatic determination of the proper billing (E/M) code. We have developed an electronic superbill that pops up on the screen allowing you to quickly select the proper ICD/diagnosis codes and CPT/procedure codes, which can then be directly transferred into a billing system.
The following document illustrates in part how the Evaluation and Management Coder is designed:
HISTORY--(Subjective and Summary Fields in SOAPware)-----------------------------------------
CHIEF COMPLAINT __. (Subjective field in SOAPware) Chief Complaint: Yes/No
HPI:
ONSET/TIMING: __.
DURATION: __.
QUALITY/
LOCATION: __.
INTENSITY/SEVERITY: __.
COURSE: __.
AGGRAVATORS:
RELIEVERS:
TREATMENTS:
RELATED PAST HISTORY: __.
RELATED SYMPTOMS: __. Total HPI Score: _____
REVIEW OF SYMPTOMS: (Subjective field in SOAPware)
GEN:
Associated/Constitutional: __.
Endocrine__.
Hematologic/Lymphatic__.
Allergic/Immunologic__.
ENT: __.
Eyes__.
LUNGS/Respiratory: __.
HEART/Cardiovascular: __.
ABD: __.
GENT/Genitourinary: __.
BJE: __.
SKIN/Integumentary: __.
NEURO: __. PSYCH: __. Total ROS Score: _____
PAST FAMILY AND/OR SOCIAL HISTORY (Summary fields in SOAPware)
Past History:
Active Problems: __.
Inactive Problems: __. Surgeries: __.
Medications: __.
Allergies: __.
Social History: __.
Family History: __. Total PFSH Score: _____
EXAM---(Objective field in SOAPware)---------------------------------------------
GEN: Appear/General-Abn__. VS- __. LYMPH- __.
HEENT: Lips/Teeth/Gums-Abn__. Oropharynx-Abn__. EYES- Conjunctiva/Lids-Abn__. Pupils/Irises-Abn__. Opthalmoscopic-Abn__. EARS- Ear/Appear-Abn__. NOSE- Nose/Appear-Abn__. Nose/Internal-Abn__. Otoscopic-Abn__. Hearing-Abn__.
NECK: Neck-Abn__. Thyroid-Abn__.
LUNGS: Lungs/Percussion-Abn__. Lung/Auscultation-Abn__. Respirations-Abn__.
HEART: Heart/Palpation-Abn__. Heart/Auscultation-Abn__. Pulses/Carotid-Aorta-Femoral-Pedal-Peripheral/Edema-Abn__.
ABD: Abdomen-Mass/Tenderness-Abn__. Liver/Spleen-Abn__. Hernia-Abn__.
GENT: Anus/Perineum/Rectum-Abn__. Guaiac-Positive__. MALE-__. Scrotal-Abn__. Penis-Abn__. Prostate-Abn__. FEMALE-__. Pelvic/External/Urethra/Bladder/Cervix-Abn__. Uterus-Abn__. Adnexa/Parametria-Abn__. Breasts/Inspection-Abn__. Breast/Palpation-Abn__.
BJE: Inspection/Palpation/Motion/Stability/Strength-Abn of __. Digits/Nails-Abn__.
NEURO: Status/Mental-Abn__. Cranial/Nerves-Abn__. Gait/Station-Abn__. Sensation-Abn__. DTR-Abn__. PSYCH- Insight/Judgement-Abn__.
SKIN: Skin/Subcutaneous-Inspection-Abn__. Skin/Subcutaneous-Palpation-Abn__.
STUDIES: Total Exam Score: _____
DECISION MAKING--Has 3 parts - Number, Data, Risk)--(Assessment/Plan fields in SOAPware)
Number of Problems/Diagnoses:
Each diagnosis addressed. 1 point _____
A new diagnosis (not minor/self-limited) 3 points _____
A new Dx with work up in plan. 4 points _____
Data:
Tests-Lab- __. 1 point _____
Xrays-__. 1 point _____
Studies-Medical-__. 1 point _____
Discuss-Physician-__. 1 point _____
Record/History-Acquisition-__. 1 point _____
Second-Interpretation(specimen/image/tracing)-__. 2 points _____
Record/History-Review/Summary-__. 2 points _____
Risk:
Minimal=1 point. Low=2 points. Moderate=3 points. High=4 points. _____
Total Decision Making Score: _____
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99211:
HISTORY:
Chief Complaint: _Yes_
Total HPI Score: _N/A_
Total ROS Score: _N/A_
Total PFSH Score: _N/A_
EXAM:
Total Exam Score: __1__
DECISION MAKING:
Total Decision Making Score: __1__
99212:
HISTORY:
Chief Complaint: _Yes_
Total HPI Score: __1__
Total ROS Score: _N/A_
Total PFSH Score: _N/A_
EXAM:
Total Exam Score: __1__
DECISION MAKING:
Total Decision Making Score: __1__
99213:
HISTORY:
Chief Complaint: _Yes
Total HPI Score: __1__
Total ROS Score: __1__
Total PFSH Score: _N/A_
EXAM:
Total Exam Score: __6__
DECISION MAKING:
Total Decision Making Score: __4__
99214:
HISTORY:
Chief Complaint: _Yes_
Total HPI Score: __4__
Total ROS Score: __2__
Total PFSH Score: __1__
EXAM:
Total Exam Score: __12_
DECISION MAKING:
Total Decision Making Score: __9__
99215:
HISTORY:
Chief Complaint: _Yes_
Total HPI Score: __4__
Total ROS Score: __10_
Total PFSH Score: __3__
EXAM:
Total Exam Score: __18_
DECISION MAKING:
Total Decision Making Score: __12_