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Medical bill book format for Management

if you're studying evaluation and management coding specifically for the updated 2023 guidelines and you just think to yourself oh my gosh I always understand this so much better if I just had someone to walk me through a couple of examples you are in luck because that is exactly what we're going to do today in this video hey there I'm Victoria I'm a medical coder auditor educator and content creator and on my channel I provide tips tricks and tutorials because I want you to be successful in your medical coding career now I just finished some video series kind of breaking down the different sections for evaluation and management coding the different components of medical decision making different components that we look at for time and now I actually want to take you through a couple of case studies I pulled one for the Emergency Department I pulled one for an inpatient Hospital stay and then we're going to go over an office related case at the end and if you want me to do more videos just like this one you have to let me know in the comments and make sure you give this video also a thumbs up and subscribe and hit the notification Bell so that you can get alerts when I post those episodes now I know it can be difficult to do this on the video because it's hard to read all of those notes so in the description of this video you are going to find a link where you can download the text files for the cases as well sometimes that's a little easier to follow versus just seeing everything on the screen and keep in mind evaluation to management is so subjective the cases that I selected are fairly straightforward ones but as you're out there working and have longer cases that are more complicated you're going to see a variance in how coders analyze them I've seen it compared to like the weathermen you know we're all kind of looking at that same outline and scheme we're looking at the same measures but depending on who who is interpreting that which weatherman you might come up with different forecasts of what's going to be happening so there's this little bit of Art and Science especially in evaluation and management coding you may also often find them that even though some coders will abstract things from different areas oftentimes even though we're saying I would take this but maybe not this you may still come up to the same level you might say yeah this is still a 99214 even though maybe you're looking at things and abstracting different things or or analyzing or maybe saying well I wouldn't accept this unless it says this or I want the provider to say you know this this and this you will definitely encounter depending on how conservative some organizations want to be splitting of hairs of like oh well it says it was red it didn't say that I personally read and because this channel tends to Target more people that are preparing for certification exams oftentimes some of the rationale that I will provide for you is more geared towards this is what will generally be accepted in a certification exam scenario but you can understand you may find variances of interpretations some organizations want to be a little bit more lenient with their providers While others they're looking at that from an audit perspective they want everything to be a hundred percent as it says in the guidelines very very strict now because I have such an audience that is preparing for certification exams they're like people that are going for their CPC or they're going for their cpma or a CM EMC which is your e m coders you're going to want to be familiar with the e m audit tool that the aapc provides even though there might be some out there that are a little bit more user friendly or you may prefer chances are good if you're sitting for a certification exam and they want you to score out an e m the tool that they're going to provide for you for the exam is going to be the aapc tool and actually I don't have a ton of experience using this yet myself so we might just be learning a little bit together as we go so this is the case that I have for the Emergency Department pause to read or you can download it from the link below but we're going to go through this particular patient is 32 year old male they fell while painting their house and it looks like they have a wrist fracture we ordered an x-ray we did a splint now I want to keep in mind even though there's a lot of things going on there's an x-ray that could be coated there is diagnosis that could be coded for these examples we're focusing on the E M we're only going to be leveling the e m now in real world situations you're going to code out the diagnoses and all the other services that were provided but for this one we're we're focusing on the E M so don't come at me later on this I go why didn't you call the diagnosis we're focusing on E M right now okay so we have our three components of medical decision making and these are kind of outlined a little bit differently than we see on the medical decision making grid like the AMA has or that name is has the aapc has this outlined a little bit differently so we have our number of complexity of problems address chart over here we have the risk of complications and then down here is kind of like a and it's not too bad it's this little kind of like data calculator almost now data is one of the areas where it gets a little tricky so a lot of coders myself included will score the other two areas first and if it doesn't look like we have enough data to push that level up further we kind of don't worry as much about the data not that it's not important not that we shouldn't review it not that if we're auditing we shouldn't look at that and give provider feedback but if we're just productivity including e M's and we're like yeah this is a level four based off of just the complexity and the risk you know we can look at that and go okay yeah this is a level four they didn't really look at a lot of data so I'm not going to split too many hairs over you know the little data components if it doesn't look like we're going to get any higher levels based off of them not saying that's right wrong or otherwise simply just telling you a lot of the philosophy most people will save data for last so now with this fracture I think our biggest debate is going to be are we looking at a stable acute illness are we looking at a complicated injury so we might have to go back here and think of ourselves you know what is the complicated injury and I think this one actually does maybe have some definitions here let's take a look so here we have this little definition that the aapc provides on their audit tool and I will link that below as well but in order for it to be considered a um injury that's complicated they're saying it would have to be multiple injuries multiple fractures it would have to be extensive and to me this fracture does not seem to be quite extensive it seems to be a pretty straightforward fracture so I would say this is more low more the acute uncomplicated illness or injury and now we're looking at our risk of complications so one of the first things I like to look at is the medications are we doing over-the-counter medication are we doing prescription drugs because that's again a quick easy thing to first kind of Target hone in look at is that prescription drug versus over-the-counter or are we looking more like a high level complex thing this doesn't look like like obviously we're not sending this patient we're not admitting this patient we're not afraid that they're going to lose their hand it looks like a pretty straightforward wrist fracture and here we can see if if we look at the note the patient was given IV pain medication we did a splint on it we're Consulting Ortho now if this was a live record we could probably go in and see exactly what pain medication was administered I have a hunch though that it was probably not Tylenol we'll say though for the purposes of this let's say we look at it we see that it was definitely a prescription of strength medication for pain relief they were giving they were giving you know morphine or something we're going to consider that more a moderate risk especially considering the patient was scheduled for surgery there are no real minor surgeries as far as fracture repair is considered so that is more in the moderate category and again keep in mind that these are not hard and fast like oh if it says this it has to be in this these are examples only so there is a component of evaluation of the the whole picture of what's going on as far as what is the whole risk of complications of that patient management now we're down to the dreaded data section so did we review prior external notes no uh did we review the results of each unique test all right let's see here did we review a unique test so it says x-ray images personally reviewed by me now since he ordered the test though that doesn't really count them as a unique test because they're not from someone else and again this is probably going to be one of those situations where the data is not going to make much of a level difference but we will get credit for the one that we ordered so there's one and then we didn't do an assessment requiring an independent historian no extra history from an external sources independent interpretation of a test now presumably that emergency department physician isn't the person who did the actual x-ray but chances are good that that emergency department x-ray is getting billed in with all that service so it's considered something that they're billing out for right so the emergency department is billing for that x-ray code they can also then double dip and then Bill the higher level E M service because of it so my professional opinion and of course again my professional opinion is in everyone's professional opinion but for the sake of argument we're going to say this one they build out for the X-ray and then in that case we cannot count it for the interpretation of a test because that is being separately reported by that separate CPT code they're getting the reimbursement for it right there and we did not discuss the test with an external physician so let's see here we've got 1.1 the overall one where is where does that take us let's see so it looks like they count this as the T and D category and it says here under their little grid that one t and D is minimal so we have minimal data we have moderate risk and low complexity now if we take a look at our emergency department Grid in our CPT book then we didn't get two in the moderate category in order to get it to a 99284 but we did at least meet a 99283 so if we kind of just go back to the AMA grid we hit the low I believe here for the number in complexity minimal for data but then we got a moderate for our risk so even though we didn't get two in the same category we exceeded it here we met or exceeded in this low because we have a low and then we have one that we exceeded which means we also met at least this we exceeded it so we have 2 in the low which counts us as a low medical complexity so here for our Emergency Department Services low is our 99283 now if that's the first time you've ever scored out an e m case one of the questions you're probably going to have is when I'm working as a coder how many of these am I going to have to do like in an hour it varies by location but I can safely say at least 10. if I had to a wage or a gas it would be somewhere between 10 to 20 again that depends on how fast your system is what other elements you have to look at you know or just whatever benchmarks or standards your organization has set based off of how others are performing now let's take a look at this next case it is a subsequent hospital visit a patient was admitted for acute myocardial infarction which sounds severe but when we actually look through this note we can see this patient pretty well stabilized they're saying hey we're going to discharge them probably in the next day or so but there's still some things going on we still actively have them on some medications we're still just making sure that they are stabilized but this looks like it it's not going to be a high complexity visit and this patient didn't just have a myocardial infarction we can see here they have hypertension they have hyperlipidemia they're a smoker they came through the Ed with chest pain and that's one of these things that you have to pay attention to as well especially with the exam they're going to trip you up with things like oh this patient presented through the emergency department and they're going to maybe try to trick you into picking an emergency department code but this patient was admitted they are on like the multiple day stay I think like the three-day stay of being admitted to the inpatient hospital so we're not coding for that emergency department visit uh they were admitted to the hospital this is not an emergency department visit this is an inpatient Hospital stay and we can see here they're on some prescription drugs uh they're continuing them they're monitoring some cardiac elements you could probably cut this a couple of different ways you could say oh yeah we definitely have two stable chronic illnesses um we could count it that way we could look at this and go you know this is an acute complicated injury because this is a myocardial infarction that's not a straightforward thing like a sprain right so we could cut it a couple of different ways but I think we could all agree that this is more of a moderate type of complexity and while maybe traditionally their primary care physician is taking care of that high hyperlipidemia and their chronic conditions they are now in the hospital and that hospital service that hospitalist usually is the one that's in control of those while they are admitted to the hospital so they are managing them and sometimes they have them on a different type of dosage even while they're in the hospital versus when they are just an outpatient and seeing their family care position that's why it's so important to have those transition of care appointments with patients because there might be you know they might be discharging them in a whole bunch of medications and then they go back to their family care physician and say Hey you know okay you don't need to take these anymore and kind of manage it from the day-to-day life that that patient will be living outside the hospital so now again this is where we're getting more subjective um you know can we count this as moderate because we're still keeping them on prescription drugs yeah is the patient stabilized and some people might make the argument no I think this is you know low risk because the patient says they're stable and you know it doesn't look like anything's going on uh I think we still have enough data here since they're saying to continue these current medications and they're on prescription drugs that we could still count that for prescription drug management it's clear that this provider did assess and go like yes do we still need these patients on these prescription drugs oh and now we get down to our data point did we review external notes it doesn't look like it I'm not seeing here that there was like a statement from Cardiology or report from them that was reviewed um review of each unique test you know it says that his laboratory values have improved what laboratory values is that because the provider reviewed them is that because the nurse told him that his laboratory values um this personally I wouldn't credit it because it's not saying I reviewed lab values I don't see what lab values it is here he's saying to continue monitoring the cardiac enzymes and EKG but he's not actually saying that he did review them uh I'm not seeing any orders of any tests I'm not seeing any independent interpretations nothing saying you know I personally reviewed this test um you know there's some mentions of their involvement with the Cardiology department and that they're you know having consultations requested but nothing about a discussion I'm not seeing any summarization of a discussion I'm not seeing any you know external sources independent historians I'm not seeing really anything that I would count for data but again this is a situation where even if we wanted to split hairs and go oh no I would count this and this it would not make a difference for the level selection because we already have a moderate level of risk and a moderate level of complexity so again if we look at our grid here inpatient hospital or observation care that's right they combined them both this year um we see our moderate moderate will put us at that moderate category which is the 99232 subsequent code now I will probably take some heat for this and I have certainly in the past so people are like but they're stable and really it should be a level one when I'm looking at this and I see this patient has multiple chronic conditions they're still managing them it still meets that criteria for that level too now of course medical necessity overarching criteria if you think you have a valid argument for medical necessity being an overarching criteria and that it should be a level one totally understand that but if I was someone who was sitting for a CBC exam and I was presented this note and I saw that this patient had prescription drug management and I saw multiple chronic conditions I saw where they're still monitoring that myocardial infarction that's that history of that my MI I would probably weigh in on scoring it more the moderate level if I'm looking at this from an auditor perspective and I'm going okay I'm auditing this position chart yes I'm going to scrutinize it more I'm going to say continue which court and current medications um I'm going to say hey you should have listed here all of the different diagnoses that this patient has under the plan in which you know prescriptions are going for I think there's definitely some areas where we could give some provider feedback but again looking at this at the standpoint of how are we scoring this level more so for general purposes for if you're a productivity e m coder or someone preparing for a certification exam now this last note we're going to get a little wild this is a pediatric patient came in because they have a marble shoved up their nose don't shove marbles up for your nose don't you um don't show marbles up your nose but this patient did and they presented it to their I think this may be it might be an urgent care this might be a PCP it doesn't specifically say so when we look at this this is format added like a typical office note we have our HPI we have our physical exam we have our oppression our plan but really look at this for a second there was a foreign body removal right foreign body that marble lodged up that nostril and we removed it successfully we didn't remove require anything else now there is a code for removal of foreign bodies from the nostril check out the index under removal and then foreign body and then nose and it directs us to 30330 and you can see here 30330 is removal foreign body intranasal office type procedure we also have one for general anesthesia but this was that this was this office type procedure why do I bring this up though because this is the kind of thing that they might try to trip you up on on these exams they're going to give you some options where they may say was it this type of office visit was it that 30300 code or do you Bill both when we when we draw out everything that's in here like if I were to take this note and get my highlighter and go I'm going to highlight everything in here that has nothing to do with that removal of the foreign body is there anything left over that would be a billable e m service this was all related to foreign body in the left nostril the plan was all related I mean there's there is literally nothing here other than the relation to that procedure everything they evaluated was related to that procedure the history was related to the procedure there was nothing else and if we remember our guidelines for our modifier 25 which is when we Bill a procedure and an office visit on the same day it has to be significant it has to be separately identifiable and there is nothing significant beyond what we did extracting that old marble out of the nostril so in this case we aren't going to Bill an office visit code at all even though we might at first glance look at this and think oh this is an office visit it's a procedure and there is no office visit outside of what was related to that procedure every procedure has a little e m component of it in them because obviously you're not going to do something invasive on a patient without taking some history examining things that are related to specifically that service that you're about to provide on that patient so that's built-in into that reimbursement again you have to do something significant separately identifiable in order to build that procedure code and the office visit code if they had come in and had something else going on maybe they had a rash or or the mom said you know this kid's not been sleeping well for the past several days or you know they were coughing and that wouldn't necessarily be related to that that obstruction there you know something separate but there wasn't there was no separate diagnosis there were no separate evaluation this patient had no separate conditions so in this one we really are just billing that 30300 code without the office visit and of course you would abstract as well that icd-10-cm code for the marble stuck in the nose I hope this helped clarify some things for you even though maybe we wish this was a little bit easier than it is I certainly respect that but if you would like me to do more case studies like this or for different Services definitely let me know in the comments below specifically if you have certain types of cases you would like me to provide and again if you like this video make sure to give it a thumbs up I will see you guys in the next video and until then just keep on holding on