coed CENTRAL OKLAHOMA EARLY DETECTION CENTER DR.SUSAN DIMICK, MD TRANSPARENCY AND COST OF SERVICES We are usually asked how much it costs “to see the doctor”. That is an answer that depends on the visit. It would be like asking how much dinner costs at a restaurant. It depends on what you get. Insurance payers require that physicians use diagnosis codes and procedure codes for patient visits and bill services based on a detailed list of qualifiers that require a physician to document: 1) Decision making. 2) History taking. 3) Examination. 4) Time with the patient. The decision making category must then be documented as to whether the above was straightforward, of low, moderate or high complexity. Then your doctor must document whether the history and the physical was problem focused, expanded, detailed or comprehensive. Next: The Visit Code See below for the instructions that must be followed to code (and price) a visit. See that time spent with a patient must also be documented. Hang on to your hat! Initial visit. (“sys” means system, i.e. cardiovascular, musculoskeletal, etc.) AND Established patient visits. OK, so now you understand why we say “that depends”, when asked about the cost of a visit. It depends upon decision making, detail of the physical exam and the history and the number of elements covered, plus the time spent. Pretty crazy, but if we do not do it, you don’t get reimbursed. There is a coding (CPT/ICD-10) book bigger than a Dallas phone book—listing all of the possible diagnosis and procedure codes—all of which require this documentation. So, here it is. These are our charges for each code. As you can now determine, every visit may be different. Rest assured that you will be paying many people for each visit: the doctor, nurse, phlebotomist, receptionist, medical assistant, and of course, the “coder” and person who provides your claim form, which has been meticulously created to include all “proper” documentation codes.
Transcript
coed
CENTRAL OKLAHOMA EARLY DETECTION CENTER DR.SUSAN DIMICK, MD
TRANSPARENCY AND COST OF SERVICES We are usually asked how much it costs “to see the doctor”. That is an answer that depends on the visit. It would be like asking how much dinner costs at a restaurant. It depends on what you get. Insurance payers require that physicians use diagnosis codes and procedure codes for patient visits and bill services based on a detailed list of qualifiers that require a physician to document:
1) Decision making. 2) History taking. 3) Examination. 4) Time with the patient.
The decision making category must then be documented as to whether the above was straightforward, of low, moderate or high complexity. Then your doctor must document whether the history and the physical was problem focused, expanded, detailed or comprehensive. Next: The Visit Code See below for the instructions that must be followed to code (and price) a visit. See that time spent with a patient must also be documented. Hang on to your hat!
Initial visit. (“sys” means system, i.e. cardiovascular, musculoskeletal, etc.) AND Established patient visits. OK, so now you understand why we say “that depends”, when asked about the cost of a visit. It depends upon decision making, detail of the physical exam and the history and the number of elements covered, plus the time spent. Pretty crazy, but if we do not do it, you don’t get reimbursed. There is a coding (CPT/ICD-10) book bigger than a Dallas phone book—listing all of the possible diagnosis and procedure codes—all of which require this documentation. So, here it is. These are our charges for each code. As you can now determine, every visit may be different. Rest assured that you will be paying many people for each visit: the doctor, nurse, phlebotomist, receptionist, medical assistant, and of course, the “coder” and person who provides your claim form, which has been meticulously created to include all “proper” documentation codes.
INITIAL NEW PATIENT VISIT ( Requires 3 out of 3 to be met or exceeded)
ESTABLISHED PATIENT VISITS ( Requires 2 out of 3 to be met or exceeded) If Decision making is History Must Be Exam Must Also Be Time Code As Nurse Visit Nurse Visit Nurse Visit 5 99211 (Level I) Straightforward Problem Focused Problem Focused (1) * 10 99212 (Level II) Low Complexity Expanded Problem Focused Expanded Problem Focused (6)* 15 99213 (Level III) Moderate Complexity Detailed Detailed (12)* 25 99214 (Level IV) High Complexity Comprehensive Comprehensive (2 from 9 sys) * 40 99215 (Level V)
Decision Making To Qualify for a Particular Level ( 2 out of 3 columns must be met or exceeded) Diagnostic / Treatment Options Amount / Complexity Data Risk of Complications, Morbidity,
Mortality Straightforward Minimal- One Self-limited or minor
problem (eg. cold, insect bite, rash) Minimal- Lab Tests via venipuncture, simple x-rays, ultrasounds, EKG’s.
Minimal- Rest, Gargles, Bandages, Dressings, drug maintenance (refill meds)
Limited - Physical therapy, minor surgery with no identified risk factors, over the counter drugs.
Moderate Complexity Multiple- Chronic with mild exacerbations; 2 stable chronic; acute illness with systemic symptoms; complicated injury, new condition with uncertain prognosis (ex: breast lump)
Moderate – Physiologic tests w/stress; deep biopsies, cardiovascular or endoscopic tests with no identified risk factors.
Moderate- Minor surgery with identified risk factors, prescription drug management (add/change/delete meds) Major surgery w/o risk factors; closed treatment fracture.
High Complexity Extensive- Chronic Illness(s) with severe exacerbation, acute or chronic that pose a threat to life or body function, abrupt change in neurological status)
Extensive – Endoscopies and cardiovascular testing with contrast with identified risk factors.
High- Elective surgery w/ identified risk factors; emergency major surgery; drug therapy w/ monitoring; de-escalation of care DNR.
History
Problem Focused Expanded Detailed Comprehensive x Chief Complaint x 1-3 elements about HPI
x Chief Complaint x 1-3 elements about HPI x Review of one system
x Chief Complaint x 4 elements about HPI x Review of two systems x Personal, Family or Social
History
x Chief Complaint x 4 elements about HPI x Review of ten systems x Personal, Family or Social
History
Review of Systems: x Constitutional
x Integumentary x Eyes x Ears, Nose and
Throat
x Cardiovascular x Respiratory x Gastrointestinal x Genitourinary
x Musculoskeletal x Neurologic x Psychiatric
x Hematologic / Lymphatic
x Endocrine x Allergic /
Immunological
Past, Family and Social History
Past Personal x Current Meds x Allergies x Prior Illnesses/Surgeries x Prior Hospitalizations x Immunizations
Family x Health Status/Cause of
Death of parents, siblings, and/or children
x Specific diseases related to chief complaint present illnesses or ROS
Social x Current Employment x Occupational History x Sexual History x Drug, Alcohol, Tobacco
Use x Marital Status x Education
If Decision making is History Must Be Exam Must Also Be Time Code As
Straightforward Problem Focused Problem Focused (1) * 10 99201 (Level I)
Straightforward Expanded Problem Focused Expanded Problem Focused (6)* 20 99202 (Level II)
High Complexity Comprehensive Comprehensive (2 from 9 sys)* 60 99205 (Level V)
History of Present Illness ( or status of 3 chronic or inactive)
x Location x Quality
x Duration x Severity
x Timing x Context (cause)
x Associated Signs/Symptoms
x Modifying Factors
Multi- System Exam
Problem Focused x 1-5 bulets from 1
or more systems
Expanded x 6-11 bullets from 1 or more systems
Detailed x 12-17 bullets
from 2 or more systems/areas
Comprehensive x 2 or more bullets from EACH of 9
systems/areas
SYSTEM / BODY AREA ELEMENTS OF EXAM SYSTEM/BODY AREA ELEMENTS OF EXAM Constitutional x General appearance of patient
x Measurement of any 3 vital signs Genitourinary Males
Males x Exam of scrotal contents ( hydrocele,
mass, etc.) x Exam of the penis x Digital rectal exam of prosate (size,
tenderness) Eyes x Inspection of conjunctiva and lids
x Exam of pupils and irises x Opthalmoscopic exam – optic
disc,etc..
Genitourinary Females
Females Pelvic Exam w/wo collection of pap smear to include:
x Exam of external genitalia and vagina x Exam of urethra x Exam of bladder x Exam of cervix x Exam of uterus x Exam of adnexa/parametria
Ears, Nose and Throat x External inspection of ears and nose x Otoscopic exam of ext auditory
canals/TM x Assessment of hearing x Inspection of nasal mucosa, septum,
turbinates x Inspection of lips, teeth and gums x Exam of oropharynx (tongue, tonsils
and mucosa)
Musculoskeletal x Exam of gait and station x Inspection and/or palpation of digits
and nails Examination of joints, ones and muscles
1. Head and Neck 2. Spine, Ribs & Pelvis 3. Right Arm 4. Left Arm 5. Right Leg 6. Left Leg
The exam should include: x Inspection and/or palpation- note any
misalignment,etc.. x Assessment of range of motion x Assessment of stability x Assessment of muscle strength or
tone Neck x Exam of neck (eg. masses,
symmetry) x Exam of thyroid (eg. enlargement,
mass)
Skin x Inspection of skin and subcutaneous tissues
x Palpation of skin and subcutaneous tissue
Respiratory x Assessment of respiratory effort x Percussion of chest ( dullness,
flatness) x Palpitation of chest (eg. tactile
fremitis) x Auscualation of chest ( eg. breath
sounds, rubs)
Neurologic x Test cranial nerves with notation of ay deficits
x Exam of deep tendon reflexes x Examination of sensation ( by touch,
pin, etc..)
Cardiovascular x Palpitation of heart x Auscultation of heart x Exam of Carotid Arteries x Exam of Abdominal Aorta x Exam of Femoral Arteries x Exam of Pedal Pulses x Exam of extremities for
edema/varicosities
Psychiatric x Orientation to time, place and person x Recent and remote memory x Mood and affect x Description of patients judgement
and insight.
Chest ( Breasts) x Inspection of Breasts ( nipple, discharge)
x Palpation of breasts & axillae (eg. masses)
Gastrointestinal (Abdominal)
x Exam of abdomen & note any masses/tenderness
x Exam of liver and spleen x Exam for presence or absence of
hernia x Exam of anus, perineum & rectum
Lymphatic x Palpation of lymph nodes in two or more areas:
