Documenting and Coding Procedures in AHLTA 19 December

Documenting and Coding Procedures in AHLTA 19 December 2006 LCDR J. George

Why is it important? l l l Correct documentation of procedures is ESSENTIAL! Procedure RVU’s are added to the E&M code. For example: visit for impaired hearing (E&M 99213 = 0. 67) + ear wax removal (RVU = 0. 61). TOTAL = 1. 28 RVU IMPORTANT: Although the RVU’s are counted and “billed” under the provider, the RVU total is a measure of the healthcare teams work. Procedures need to be documented completely in order to get full credit for completing the work

Sample Procedure RVU l l l Circumcision Ear Wax Removal Excision of Skin Tags I&D Abscess Punch Biopsy IV Fluid, 1 hour 1. 81 RVU 0. 61 RVU 0. 77 RVU 1. 17 RVU 0. 81 RVU 0. 17 RVU

Procedure RVU l l l Nebulizer Treatment EKG Reading Cryotherapy of skin Screening Pap by Physician IM/SC Injection Oxygen Sat Reading 0. 32 RVU 0. 17 RVU 0. 76 RVU 0. 37 RVU 0. 17 RVU 0. 04 RVU

What should be documented l Generally the following items should be documented: – – – – – Procedure name Operator Assistant Informed consent/risks Prepping and draping Describe procedure Complications Pathology Disposition

How to document in AHLTA l l Use AIM form Use Medcin template – Users may modify this to suit their needs. The important point is that they document completely.

AIM Forms l l Easy to use; visually appealing Can’t be easily modified General Family Medicine AIM also includes tabs for colposcopy/laryngoscopy and vasectomy Can be used in combination with Medcin tree

This template has a tab for a minor procedure

Template l l These are the Medcin templates Can be edited by user Layout may not be as appealing as Form User can also choose to combine with Form

Coding a procedure in AHLTA l A/P Tab – – Select appropriate ICD-9 Select appropriate CPT/HCPCS code l l l Select unit of service Select modifier Select additional provider

1) Select procedure tab 2) Highlight code 3) Click on Add to Encounter

Click on Modifiers icon to get this dialog box

Check to make sure E&M code is correct. Should be 99499 if the visit was for the procedure only. Change Service Type to Other Unlisted E&M

Set up in AHLTA l l Provider should receive guidelines from coding on how to code their procedures (what CPT or HCPCS codes to use and when to use units of service and modifiers) Providers should set up encounter templates that include either the AIM form or template plus the appropriate CPT/HCPCS codes. Ask superusers, clinical champions, and template managers if in place at MTF to make the templates.

Backup Slides l The following slides include the top 10 procedures for the clinics: – – – B ENT Clinic B Family Practice B Gen Surgery B Gynecology B Orthopedics B Pediatrics

ENT BBFA B ENT CLINIC ------------- 92511 NASOPHARYNGOSCOPY 99071 PATIENT EDUCATION MATERIALS 31575 DIAGNOSTIC LARYNGOSCOPY 92504 EAR MICROSCOPY EXAMINATION 31231 NASAL ENDOSCOPY, DX 69210 REMOVE IMPACTED EAR WAX 69200 CLEAR OUTER EAR CANAL 15850 REMOVAL OF SUTURES 99024 POSTOPERAT VIS, E/M PERFORM

Family Medicine BGAA B FAMILY PRACT Totals -------------- Q 0091 OBTAINING SCREEN PAP SMEAR 17000 DETROY BENIGN/PREMAL LESION 94760 MEASURE BLOOD OXYGEN LEVEL 93000 ELECTROCARDIOGRAM, COMPLETE 57454 CLPSPY CRVX UP/AJCT VAG W/BIPY 94200 LUNG FUNCTION TEST (MBC/MVV) 76817 ULTRASOUND, TRANSVAGINAL 17003 DESTROY LESIONS, 2 -14 82270 TEST FOR BLOOD, FECES – if done in clinic (G 0107 discontinued as of 1/1/07) Q 0111 WET MOUNTS, INCL VAGINAL, CERVIX OR SKIN SPECIMENS

General Surgery BBAA B GEN SURGERY Totals ------------- 99070 SPECIAL SUPPLIES 11400 EXC B 9+MARG ARM DIAM 0. 5 < CM 11100 BX, SKN, TISS/MUCOUS MEMBR; 1 LES 99024 POSTOPERAT VIS, E/M PERFORM 10040 ACNE SURGERY OF SKIN ABSCESS 10060 DRAINAGE OF SKIN ABSCESS 12021 CLOSURE OF SPLIT WOUND 46600 DIAGNOSTIC ANOSCOPY 19100 BX OF BRST; PERCUTAN, NEEDL CORE 19000 DRAINAGE OF BREAST LESION

Obstetrics & Gynecology BCBA B GYNECOLOGY Totals ------------- Q 0091 OBTAINING SCREEN PAP SMEAR 57452 COLPSPY CRVX UP/AJCNT VAGINA 57454 CLPSPY CRVX UP/AJCT VAG W/BIPY 76817 ULTRASOUND, TRANSVAGINAL 58100 BIOPSY OF UTERUS LINING Q 0111 WET MOUNTS, INCL VAGINAL, CERVIX OR SKIN SPECIMENS 57455 COLPOSCOPY, CERVIX W/BX(S) 76830 US EXAM, TRANSVAGINAL

Orthopedics BEAA B ORTHOPEDICS Totals ------------- 99024 POSTOPERAT VIS, E/M PERFORM 20610 DRAIN/INJECT, JOINT/BURSA 29075 APPLICATION OF FOREARM CAST 25600 TREAT FRACTURE RADIUS/ULNA 26600 TREAT METACARPAL FRACTURE 20605 ART, ASP &/ INJ; INTE JNT /BURSA 20600 ART, ASP &/ INJ; SML JNT /BURSA 26720 TREAT FINGER FRACTURE, EACH 29065 APPLICATION OF LONG ARM CAST 29405 APPLY SHORT LEG CAST

Pediatrics BDAA B PEDIATRICS Totals ------------- 94760 MEASURE BLOOD OXYGEN LEVEL 36416 CAPILLARY BLOOD DRAW 99173 VISUAL SCREENING TEST A 4627 SPACER BAG/RESERVOIR 69210 REMOVE IMPACTED EAR WAX 92551 PURE TONE HEARING TEST, AIR 36400 VP, <AGE 3; FEM/JUGULAR VEIN 94200 LUNG FUNCTION TEST (MBC/MVV) 17000 DETROY BENIGN/PREMAL LESION C 9003 PALIVIZUMAB-RSV-IGM, PER 50 MG