Medical Coding

Medical Coding, Medical Coding Certification Details, Sample charts of Medical Coding, Medical Coding Companies in India, Medical Coding News, Medical Coding Interview Questions, Medical Coding Jobs in India, Medical Coding Sample Questions, Sample/Practice CPT questions, Sample/Practice ICD questions, Sample/Practice Coding Reimbursement Questions, Medical Coding Quiz, Medical Coding Sample Charts, Medical Coding Sample Scenarios, Sample Radiology Coding Reports, Sample Surgery Coding Reports

Saturday, August 18, 2012

Injection/Infusion Guidelines

Injection/Infusion/Hydration CPT Coding - Guidelines

Ø Coding guidelines for IV infusion, IV injection (IV push) are complex

Ø Must follow AMA CPT® coding guidelines

Ø Documentation of start and stop times, mode/route of administration, location of line and line flushes

Primary/Initial Service: hierarchy

§ Chemotherapy infusion

§ Chemotherapy injection (push)

§ Therapeutic/prophylactic/diagnostic infusion

§ Therapeutic/prophylactic/diagnostic injection (push)

§ Hydration

Ø Only one initial code for each IV line for each episode of care

Ø Additional Sequential Service

§ Administered in sequence (one after the other)

§ Line flush may or may not occur between drugs

§ Secondary or subsequent service to the initial service

§ Report once per sequential infusion of same “infusate mix”

Ø Concurrent Infusion

§ Multiple drugs running at the same time through the same line, different bags

§ Billable only once per encounter regardless of the number of drugs infused

Ø SQ/IM Injection/Vaccine

§ Does not affect distinction between primary and secondary

§ Report as many times as ordered and Administered

Ø Hydration

§ Do not report hydration less than 30 minutes

§ Do not report hydration used only to facilitate administration of another drug

§ Do not report KVO, line flush, heplock

§ Must be an order for the solution

§ CPT® defined solutions – normal saline, lactated ringers, D5W, premixed electrolytes

§ Start and stop times are essential

§ Calculation nuances for hydration versus infusion

§ Initial Hydration time must be 31minutes

“31 minutes to 1 hour” = 31 – 90 minutes

§ Initial Infusion must be greater than 15 minutes

“up to 1 hour” = 16 – 90 minutes

§ Each additional hour (hydration or infusion) – may report multiple units

“more than 30 minutes beyond 1 hour increments”

= 91 – 150 (1 additional hour)

= 151 – 210 (2 additional hours) etc.

Ø The History:

ED patient presents to a small community hospital with multiple medical problems, including possible CVA, pneumonia, sepsis and septic shock, skin ulcer, R foot. After stabilization, patient is transferred to regional medical center for further specialty care.

Medication Record:

Additional Nursing Notes:

1430 #18 IV placed L hand

1520 – B/P 71/51 HR 96, reported to PA.

NS 500 ml bolus began, sterile dressing applied to R lower extremity

1630 – SC #20 to L FA

1645 Dopamine 5meq kg/min

1715 Dopamine (down arrow) 2.5 meq kg/min

1558 saline bolus complete. IV @100 ml/hr

1815 NS 500 ml bolus began

2000 EMS here to transfer pt via stretcher. Vancomycin infusing without difficulty.

Ø Good medication form – includes start and stop times, fluids hung, IV rate, IV volume infused, and initials of provider

Ø Medication record does not specify location of IV line

Ø From nurses notes we know IV place in left hand at 1430

Ø From nurses notes we know a second line was started in the left forearm at 1630

Ø Dopamine start time documented at 1645per nursing notes, start time 1700 per medication record – conflicting

Ø We know that clinically, Dopamine drip and antibiotic would not be infused in the same Line

Ø If coder is to accurately assign drug administration codes, must make assumptions or clarify documentation, and coders cannot assume!

Ø Illegibility and wide use of abbreviations

Ø Patient transferred at 2000

(assumes clarification of documentation of multiple lines)

Therapeutic infusions – Line 1:

Rocephin 1625–1715 (50 min) = 96365 (initial service, up to 1 hr)

Zithromax 1715-1830 (75 min) = 96367 (sequential, up to 1 hr)

Vancomycin 1930-2000 (30 min) = 96367 (sequential, up to 1 hr)

Therapeutic infusions – Line 2:

Dopamine drip in D5W 1700-2000 (180 min) = 96365-59; 96366 x2

(initial service, separate line, separate drug)

Hydration infusions:

NS bolus then 100ml/hr 1525-1558; NS 100 ml/hr 1558-2000

Must carve out 1625-1830 and 1930-2000 for drug delivery

Leaving 1525-1625 (60 minutes) and 1830-1930 (60 minutes) = 96361

(secondary/subsequent service, 120 minutes)

AJUBA at Hyderabad

AJUBA to set up healthcare BPO plans to hire 1,500

Healthcare business process outsourcing (BPO) services company Ajuba Solutions, the Indian subsidiary of the US-based over $100-million MirMed Global Services Group, is planning to set up a facility in Hyderabad. It is expected to commence operations in the next 12-18 months, according to chief executive officer Tony Mira.

The company, which offers revenue cycle outsourcing services to over 10,000 physician practice groups, to some 700 hospitals and billing receivables management companies in the US, presently has a BPO centre in Chennai’s Tidel Park with a capacity of 2,700 operational seats across three shifts.

“We right now get close to full utilisation in Chennai. And, with our clientele base growing rapidly in the US, we are looking at Hyderabad as our next premier destination to expand. We are in the process of leasing a 40,000 sq ft office space and the facility will be up and running in the next 12 months,” he told Business Standard.

The company will make an incremental investment of $5 million (approximately Rs 25.5 crore) in the Hyderabad facility which will be funded through internal resources. As part of the two-layer expansion, the centre will have 1,000 professionals initially and it will be scaled up to 1,500 in Phase-II in 18 months from now.

Healthcare, an around $70-billion market which is growing at 20 per cent year-on-year, is a significant piece of the gross domestic product of the US. Besides, Barack Obama’s 2010 healthcare reforms in the US that is triggering growth opportunities is increasing demand for outsourcing because of the complexity in regulatory requirements, including insurance claim submissions and client verifications, Mira said.

“This requires a high-level of expertise and quick deliverables that are available aplenty down south, besides giving us 20-25 per cent cost benefits,” he said, adding that Ajuba was also looking at entering the pharmaceutical and payer insurance space, hopefully in the next 24 months. “Right now, we are evaluating opportunities in the areas of payer verification for insurance and new drug trials for pharmaceuticals. We hope to win at least five clients in the insurance segment and potentially three in pharmaceuticals in the US market, services for which will be offered both from our Hyderabad and Chennai centres,” he said.

E/M Template

Evaluation and Management (E/M) Template

PT TYPE: OFFICE/NEW_____ OFFICE/EST _______

Hosp Obs____ Hosp Obs w/ Adm & DC ______ ER ________ CONSULT OFC/OP _________Consult Initial IP______

Consult FU IP______ Consult Confirm_______

Nursing facility Initial Comprehensive Assessment_____

Nursing facility Subsequent______

CC_____________

HISTORY

HISTORY OF PRESENT ILLNESS:

____Location diffuse/localized, unilateral/bilateral, fixed/migratory

____Duration How long? 20 min, onset 3 yrs ago, since last Friday, for approx 2 months, since yesterday

____Quality sharp, dull, burning, gnawing, fullness, aching, throbbing, stabbing, radiating, color of sputum, non-productive, asymptomatic etc. Laceration jagged/straight. Sore throat scratchy

____Context What was going on at time symptoms occurred, exercise, big meals, dairy products, spicy foods, etc. What were they doing when it occurred, MVA, running down steps, sitting in chair, playing sports.

____Severity Rank of pain on pain scale 0-10, severe, slightly, worst I’ve ever had, mild, moderate, 0 pain, increase, decrease, progressive, well, major, poor, significant, complicated (must be ranked; can’t just say “pain in my leg”

____Modifying Factors What makes better or worse, any meds helping, rest or eating, affected by spicy foods, ice pack or quiet room for MHA, coughing irritates the pain, OTC or prescribed meds have been attempted, etc What were the results?

____Timing Onset, night, day, continuous, occasional, episodic, AM, PM, constant, recurrent, seldom, frequently, off and on, morning, evening, intermittent, transient.

____Signs/Symps Associated with…, Negative Responses will count

Document of at least 3 chronic/inactive conditions_____

REVIEW OF SYSTEMS:

Negative, Normal, WNL can count in any/all systems
_____Constitutional – Activity, appearance, appetite, exercise, fatigue, fevers, mood, sweats, weakness, wt change, chills

_____Eyes - Blurred vision, drainage, dryness, flashing, pain, photophobia, redness, tearing, vision change

_____ENT & Mouth - Airway, balance, bleeding, discharge, hearing, pain, ringing, smell, swallowing, taste, voice

_____CV - Chest pain, diaphoresis, dizziness, exertional pain, irregular beats, leg cramps, orthopnea, palpitations, peripheral edema, radiation, SOB

_____Respiratory - Allergies, cough, dyspnea, hemoptysis, pain, SOB, sputum, wheezing

_____GI - Appetite, Change in bowel habits, constipation, diarrhea, heartburn, hemetemesis, indigestion, nausea, pain, rectal bleed, swallowing, thirst, vomiting

_____GU – Burning, discharge, dribbling, frequency, hematuria, incontinence, menopause, nocturia, odor, pain, pregnancies, starting, stopping, urgency, dyuria

_____All/Imm – Allergies to meds, chemo, hay fever, HIV/AIDS, hives, immune suppression, immunizations, sweating

_____MS - Limitation of activity, pain, redness, stiffness, swelling, weakness

_____Skin – bleeding, color change, cyanosis, dryness, growths, jaundice, rash

_____Neuro – blackout, HA, memory loss, numbness, seizure, syncope, tingling, tremors

_____Psych – Anxiety, delusion, depression, hallucination, insomnia, nervous, panic, personality, phobia, suicidal

_____Endocr – Change hair pattern, heat/cold intolerance, polydiipsia, Polyphagia, polyuria, sweating

_____Hem/Lym – bleeding, bruising, gland swelling, menses, nodes

_____Documentation of adequate ROS & all others negative

PFSH :

_____Past Medical History

Surgeries

Any item labeled as PMH may only be used for that. This is true for even chronic

problems. Don’t try to count them for HPI or ROS elements

Diagnostic tests, even when they appear in the HPI area, can only be used as PMH.

Don’t try to count them as something else

_____Family History

Family History of Neoplasms

Family History of Congenital / Hereditary conditions

_____Social History

Smoking, Alcohol, Marital status

____Unable to do comprehensive history due to patient condition

PHYSICAL EXAM

CONSTITUTIONAL (2)

____BP, Pulse, Respiration, Temp, Ht, Wt Measurement of any 3 of the above VS. (May be measured/recorded by staff person)

____GENERAL APPEARANCE – Development, Nutrition, Body habitus, Deformities, Grooming

EYES (3)

____ Conjunctivae, Lids

____ Pupils and Irises PERRLA

____ SCOPE EXAM, Optic discs, C/D ratio (Cup to Disk Ratio), Size,Appearance
Posterior segments,Vessel changes, Exudates, hemorrhages

EARS, NOSE, MOUTH, THROAT (6)

____External auditory canals, TM’s

____EARS & NOSE – Appearance, Scars, Lesions, Masses

____Hearing, Whispered voice, Finger rub, Tuning Fork

____NOSE - Mucosa, Septum, Turbinates

____MOUTH – Lips, Teeth, Gums

____THROAT/OROPHARYNX – Oral mucosa, Salivary glands, Hard and soft palates, Tongue, Tonsils, Posterior pharynx

NECK (2)

____NECK – Masses, Appearance, Symmetry, Tracheal position, Crepitus

____THYROID – Enlargement, Tenderness, Mass

RESPIRATORY (4)

____Effort, Retractions, Muscles, Movement

____Percussion, Dullness, Flatness, Hyper resonance

____Palpation, Fremitus

____Auscultation, Breath sounds, Rubs

CARDIOVASCULAR (7)

____Palpation, Location, Size, Thrills

____Auscultation, Abnormal sounds, Murmurs

ARTERIES –
____Carotid, Pulse, Bruits

____Abdominal Aorta,Size, Bruits

____Femoral, Pulse, Bruits

____Pedal Pulse

____Extremities, Edema, Varicosities

CHEST/BREASTS (2)

____Breasts, Symmetry, Nipple discharge

____Breasts and axillae, Mass, Lump, Tenderness

GI/ABDOMEN (5)

____Abdomen, Mass, Tenderness

____Liver, Spleen

____Hernia

____Anus, Perineum, Rectum, Sphincter tone, Hemorrhoids, Rectal mass

____Occult blood

GU, FEMALE (6)

____External genitalia, Appearance, Hair distribution, Lesions,

____Vagina, Appearance, Estrogen effect, Discharge, Lesions, Pelvic support, Cystocele, Rectocele

____Urethra, Mass, Tenderness, Scarring

____Bladder, Fullness, Mass, Tenderness

____Cervix, Appearance, Lesions, Discharge

____Uterus, Contour, Position, Mobility, Tenderness, Consistency, Descent or Support

____Adnexa/Parametria, Mass, Tenderness, Organomegaly, Nodules

GU, MALE (3)

____Scrotum, Hydrocele, Spermatocele, Tenderness of cord, Testicular mass

____Penis, phallus

____DRE of prostate for Size, Symmetry, Nodules, Tenderness

LYMPHATIC (4)

____Nodes

____Neck

____Axillae

____Groin

____Other

MS (26)

____Gait, Station, Romberg, Ambulatory??

____Nails/Digits, Clubbing, Cyanosis, Inflammation, Petechiae, Ischemia, Infection, Nodes

HEAD AND NECK

____Misalignment, Asymmetry, Crepitation, Defects, Tenderness, Mass, Effusion, EOMI