CODING and RVU’s: CODING and RVU’s: What AHLTA Can Do What AHLTA Can Do For You (and what it For You (and what it

can’t)!can’t)!USAFP ConferenceUSAFP Conference

March 2007March 2007Mark Stackle, MDMark Stackle, MD

Cyborg Coding: Episode One

Coding Basics—The Coding Basics—The Dry StuffDry Stuff Evaluation and Management CodingEvaluation and Management Coding

2/3 areas for Established Patient (History, PE, 2/3 areas for Established Patient (History, PE, MDM), 3/3 for New PatientMDM), 3/3 for New Patient

9921499214 (4-2-1, 12) (4-2-1, 12) HISTORY:HISTORY: 4 4 HPI, HPI, 22 ROS, ROS, 11 PFSH PFSH PHYSICAL:PHYSICAL: 12 12 PE Bullets PE Bullets

9921399213 (1-1-0, 6) (1-1-0, 6) HISTORY: 1 HPI, 1 ROS, 0 PFSH HISTORY: 1 HPI, 1 ROS, 0 PFSH PHYSICAL: 6 PE BulletsPHYSICAL: 6 PE Bullets

What about a 99212? Only for the very What about a 99212? Only for the very straightforward cases.straightforward cases.

9921299212 (1 HPI, 0 ROS, 0 PFSH), 1 PE Bullet (1 HPI, 0 ROS, 0 PFSH), 1 PE Bullet S: Coughing S: Coughing O: Alert O: Alert A: Cough A: Cough P: Drink Water = 99212P: Drink Water = 99212

Most visits should be 99213 or 99214Most visits should be 99213 or 99214

MDM (Choose 2 of 3 MDM (Choose 2 of 3 Components)Components)

MDM MDM ComponentsComponents

99213 99213 (Low)(Low)

99214 (Mod)99214 (Mod)

#/Stability of Dx#/Stability of DxMinor problem (max of 2) = 1 Minor problem (max of 2) = 1

Established problem, stable = 1Established problem, stable = 1

Established problem, worsening = 2Established problem, worsening = 2

New problem, no work up = 3New problem, no work up = 3

New problem, work up planned = 4New problem, work up planned = 4

2 points2 points 3 points3 points

Complexity of DataComplexity of DataReview or Order Lab/Rad/Test = 1 Review or Order Lab/Rad/Test = 1 eacheach

Discuss case with other physician = Discuss case with other physician = 11

Independent Review of image or Independent Review of image or specimen = 2specimen = 2

Review and summary of old records Review and summary of old records = 2= 2

2 points2 points 3 points3 points

Table of Risk (just Table of Risk (just need 1 from this list)need 1 from this list)

*OTC drug*OTC drug

*IV fluid*IV fluid

*2 minor *2 minor problemsproblems

*OT/PT*OT/PT

*Prescription drug*Prescription drug

*IV fluid with *IV fluid with additiveadditive

*Illness with *Illness with systemic symptoms systemic symptoms (flu, pneumonia)(flu, pneumonia)

*2 Chronic problems, *2 Chronic problems, stablestable

Medical Decision Medical Decision MakingMaking

The AHLTA Coding Tool does not currently The AHLTA Coding Tool does not currently fully reflect the MDM coding rules. fully reflect the MDM coding rules. It will weigh certain diagnoses more heavily than It will weigh certain diagnoses more heavily than

others (MI gets more points than URI) and give others (MI gets more points than URI) and give you credit for multiple diagnosesyou credit for multiple diagnoses

It It does notdoes not capture medication orders (remember capture medication orders (remember ordering a prescription RX should give you a ordering a prescription RX should give you a 99214 for Problem Risk)99214 for Problem Risk)

No way to capture medical records reviewed and No way to capture medical records reviewed and summarized which would usually get you points summarized which would usually get you points for Complexity of Datafor Complexity of Data

This is improved in AHLTA build 838 Patch 20This is improved in AHLTA build 838 Patch 20 OPTIONS: OPTIONS:

1) Focus on H&P and take what AHLTA gives you 1) Focus on H&P and take what AHLTA gives you 2) Learn MDM coding rules and manually code 2) Learn MDM coding rules and manually code

that section on the Disposition page.that section on the Disposition page.

Coding BasicsCoding Basics

Time Based Coding (Counseling, Time Based Coding (Counseling, Coordinating Care) Coordinating Care) Greater than 50% of time spent…Greater than 50% of time spent…

99213 – 15 minute appointment time99213 – 15 minute appointment time 99214 – 25 minute appointment time99214 – 25 minute appointment time 99215 – 40 minute appointment time99215 – 40 minute appointment time

Documentation should be driven Documentation should be driven by medical necessity!by medical necessity!

The Disposition The Disposition ModuleModule

Where AHLTA Coding Comes Where AHLTA Coding Comes Together!Together!

The Disposition Page is CrucialTo Accurate Coding

1) Document here if you spent >50% of the total appointment time counseling, educating or coordinating care.

*Important to have statement in note specifying the amount of time and content of information discussed

2) Ensure you document actual patient care time here if you are counseling for more than 50% of that time.

99212 (0.45 RVU): 10-14 min appointment time99213 (0.67 RVU): 15-24 min appointment time99214 (1.10 RVU): 25-39 min appointment time99215 (1.77 RVU): >40 min appointment time

1) There are different E&M codes for new vs existing patient with different RVU’s. (typically you get more RVU’s for a new patient vs. existing patient)

2) New Patient = one who has not had a visit in the MEPRS code within the past 3 years. (e.g. they may have been seen in the Pediatrics Clinic, but not in the Family Practice clinic—this is a new patient to the Family Practice clinic.

3) **Important—AHTLA automatically defaults to Existing Patient—you have to make manual change to New Patient

1) There are different E&M codes for preventive medicine visits (well woman, well child, military physical, etc. . .).

2) These prevention visits usually result in more RVU’s and assume a comprehensive history and physical. These are age based which AHTLA does automatically calculate

3) Again, you have to manually select this, by selecting PREV MED EVAL/MGT from drop down menu.

A 99214 (Outpt visit, existing patient) = 1.1 RVUA 99395 (Prev Med visit, existing patient) = 1.36 RVUA 26% RVU increase!!!

Select Here

More about More about RVU’sRVU’s

Sample RVU ValuesSample RVU Values Proposed target for Family Practice is approximately Proposed target for Family Practice is approximately

16.0 RVU/Provider/Day16.0 RVU/Provider/Day New versus EstablishedNew versus Established

more RVUs for new patients, but greater documentation more RVUs for new patients, but greater documentation requirements)requirements)

E&M CodesE&M Codes New/ESTNew/EST 99202/99212 (Prob Focused)99202/99212 (Prob Focused) 0.45/0.45 RVU0.45/0.45 RVU 99203/99213 (Exp Prob Focused)99203/99213 (Exp Prob Focused) 0.88/0.67 RVU0.88/0.67 RVU 99204/99214 (Mod Complexity)99204/99214 (Mod Complexity) 1.34/1.10 RVU1.34/1.10 RVU 99205/99215 (High Complexity)99205/99215 (High Complexity) 2.67/1.77 RVU2.67/1.77 RVU 99381/91 (Prev Med 0-1 yo)99381/91 (Prev Med 0-1 yo) 1.19/1.02 RVU1.19/1.02 RVU 99382/92 (PM 1-11 yo)99382/92 (PM 1-11 yo) 1.36/1.19 RVU1.36/1.19 RVU 99385/95 (PM 18-39 yo)99385/95 (PM 18-39 yo) 1.53/1.36 RVU1.53/1.36 RVU 99386/96 (PM 40-64)99386/96 (PM 40-64) 1.88/1.53 RVU1.88/1.53 RVU

So What Do RVU’s So What Do RVU’s Mean to Me?Mean to Me?

If considering E&M coding only, a provider If considering E&M coding only, a provider coding only 99212 (0.45 RVU/visit) and NO coding only 99212 (0.45 RVU/visit) and NO procedures would need to see approximately procedures would need to see approximately 36 patients per day36 patients per day to achieve 16.0 to achieve 16.0 RVU/Providers/Day.RVU/Providers/Day.

A provider averaging a 99213 (0.67 RVU/visit) A provider averaging a 99213 (0.67 RVU/visit) and NO procedures would need to see and NO procedures would need to see 24 24 patients per day.patients per day.

A provider seeing A provider seeing 20 patients20 patients (13 patients @ (13 patients @ 99213, 7 patients @ 99214) yields over 16.0 99213, 7 patients @ 99214) yields over 16.0 RVU/day RVU/day withoutwithout including Procedures.including Procedures.

TELCON RVUsTELCON RVUs

Telephone Consults count, tooTelephone Consults count, too This is different from civilian practice This is different from civilian practice

A 99371 (brief phone call) counts as A 99371 (brief phone call) counts as 0.24 RVU0.24 RVU

A 99372 (intermediate phone call—A 99372 (intermediate phone call—i.e. made new diagnosis, made i.e. made new diagnosis, made treatment change, discussed results treatment change, discussed results in detail) is in detail) is 0.60 RVU 0.60 RVU Remember a 99213 visit = 0.67 RVURemember a 99213 visit = 0.67 RVU

I wonder how many RVU’s you get for that?...

PROCEDURESPROCEDURES

PROCEDURESPROCEDURES

Correct documentation of Correct documentation of procedures is ESSENTIAL!procedures is ESSENTIAL!

Procedure RVU’s are Procedure RVU’s are addedadded to the to the E&M code.E&M code.

For example: visit for impaired For example: visit for impaired hearing (E&M 99213 = 0.67) + ear hearing (E&M 99213 = 0.67) + ear wax removal (RVU = 0.61). TOTAL wax removal (RVU = 0.61). TOTAL = 1.28 RVU= 1.28 RVU

IMPORTANT: Providers can receive IMPORTANT: Providers can receive credit for procedures done by credit for procedures done by ancillary staff.ancillary staff.

SAMPLE SAMPLE PROCEDURE RVUsPROCEDURE RVUs

CircumcisionCircumcision 1.81 RVU1.81 RVU Ear Wax RemovalEar Wax Removal 0.61 0.61

RVURVU Excision of Skin TagsExcision of Skin Tags 0.77 RVU0.77 RVU I&D AbscessI&D Abscess 1.17 RVU1.17 RVU Punch BiopsyPunch Biopsy 0.81 0.81

RVURVU IV Fluid, 1 hourIV Fluid, 1 hour 0.17 RVU0.17 RVU

Procedure RVUProcedure RVU

Nebulizer TreatmentNebulizer Treatment 0.32 RVU0.32 RVU EKG InterpretationEKG Interpretation 0.17 RVU0.17 RVU Cryotherapy of skinCryotherapy of skin 0.76 RVU0.76 RVU Screening Pap by PhysicianScreening Pap by Physician 0.37 RVU0.37 RVU IM/SC InjectionIM/SC Injection 0.17 RVU0.17 RVU Prostate CA Screening (DRE)Prostate CA Screening (DRE) 0.17 RVU0.17 RVU

What About What About Procedures?Procedures?

A Properly Coded Well Woman Exam A Properly Coded Well Woman Exam can yield big RVU’s:can yield big RVU’s: E&M Prev Med visit (99395) = 1.36 E&M Prev Med visit (99395) = 1.36

RVU RVU Procedure: Screening Pap Smear Procedure: Screening Pap Smear

(HCPCS Q0091) = 0.37 RUV, (HCPCS Q0091) = 0.37 RUV, 1.73 RVU1.73 RVU for a 30 minute appt. for a 30 minute appt. (You would only need to see (You would only need to see 1010 well well

woman patients to exceed the 16.0 woman patients to exceed the 16.0 RVU/day goal)RVU/day goal)

1) Select Procedure Tab

3) Search by name or number: Peak Flow or (94150)

4) Double click or select ADD TO Encounter

So how do I code procedures in AHLTA? 2) Select Type of Procedure

(Most are CPT codes, but a PAP (0.37 RVU) or Digital Rectal Exam (0.17 RVU) for Prostate Cancer Screening are two important HCPCS codes for FP)

**AHLTA defaults to CPT**

If done correctly, the Procedures will be

listed in the A/P module here.

Recommend putting frequentlyused Procedures into Favorite Listor into an Encounter Template for

easy access

Using the AHLTA Using the AHLTA Coding ToolCoding Tool

Myth: I need to Myth: I need to click on more click on more

bullets to get a bullets to get a higher E&M codehigher E&M code

See Sample Notes on Next See Sample Notes on Next PagePage

HPI = 3

PFSH = 10

ROS = 11 systems

HPI = 4

PFSH = 1ROS = 2 systems

Note #1 = 99213 History

Note #2 = 99214 History

More is not always better…

Using Duration, Onset and Modifier Tool in HPI garners extra HPI bullets over free text

HPI

PFSH

ROS

Using Disposition Tool

The Disposition Tool—clicking on each area will provide more info regarding coding

HPI—this box will tell you what bullets you got credit for—remember 4-2-1 for a 99214

ROS-Remember, 4-2-1 for 99214(remember this is systems)

PFSH- Remember only 1 bullet needed for 99214

Other Quick AHLTA Other Quick AHLTA Coding Nuggets:Coding Nuggets:

Has anyone ever noticed that musculoskeletal Has anyone ever noticed that musculoskeletal based visits seem to get very low codes based visits seem to get very low codes (99212’s)?(99212’s)? Musculoskeletal Exam bullets are only counted if they Musculoskeletal Exam bullets are only counted if they

are localized to a specific sideare localized to a specific side i.e you will get zero physical exam bullets for saying that i.e you will get zero physical exam bullets for saying that

bilateral knee motion is normal, but you will get 2 bullets for bilateral knee motion is normal, but you will get 2 bullets for saying that the R knee motion was normal and the L knee saying that the R knee motion was normal and the L knee motion was normalmotion was normal

System Specific ExamsSystem Specific Exams See next slideSee next slide

You can also change exam type if your exam is focused on a certain system. (The HPI, ROS, PFSH, and Exam coding requirements are the same.

You can now see that you have more exam findings available for a given system. (In this example, you now have 11 Genitourinary exam bullets available instead of only 6 in the General Multi-System exam. (You may choose to use whichever Exam Type gives you the highest code)

KEY POINTSKEY POINTS Knowing how to document accurately and Knowing how to document accurately and

completely results in improved completely results in improved RVUs/Provider/DayRVUs/Provider/Day

Procedures are a critical element of RVU Procedures are a critical element of RVU generationgeneration

Counseling/Education (if >50% of visit)—make Counseling/Education (if >50% of visit)—make sure to provide supporting documentationsure to provide supporting documentation

New vs. Existing Patients (remember if a patient New vs. Existing Patients (remember if a patient hasn’t been seen in that clinic in 3 years, they are hasn’t been seen in that clinic in 3 years, they are a new patient)a new patient)

Outpatient Visit vs. Preventive Medicine VisitsOutpatient Visit vs. Preventive Medicine Visits More bullets doesn’t necessarily mean a higher More bullets doesn’t necessarily mean a higher

codecode

My kids weren’t happy to see this at Christmas…

Questions???Questions???

Back-Up SlidesBack-Up Slides

TELCONSTELCONS 9937199371 Telephone call by a Telephone call by a

physician to patient or for physician to patient or for consultation or medical consultation or medical management or for management or for coordinating medical coordinating medical management with other management with other health care professionals: health care professionals:

simple or briefsimple or brief report on tests/lab resultsreport on tests/lab results clarify or alter previous clarify or alter previous

instructions integrate new instructions integrate new information from other information from other health professionals into health professionals into the medical treatment the medical treatment plan plan

adjust therapyadjust therapy

9937299372 Telephone call by a physician Telephone call by a physician

to patient or for consultation to patient or for consultation or medical management or or medical management or for coordinating medical for coordinating medical management with other management with other health care professionalshealth care professionals

IntermediateIntermediate provide advice to an provide advice to an

established patient on a new established patient on a new problem problem

initiate therapy that can be initiate therapy that can be handled by telephone handled by telephone

discuss test results in detaildiscuss test results in detail coordinate medical coordinate medical

management of a new management of a new problem in an established problem in an established patient patient

discuss and evaluate new discuss and evaluate new information and detailsinformation and details

initiate new plan of careinitiate new plan of care