Download Suture Removal w/E&M

2014
Compliance Training
Billing Compliance Office
Dermatology Staff Meeting
7/10/2014
BWH/BWPO Billing Compliance Office
801 Massachusetts Avenue, 5th Floor
Boston Mass 02118
Phone 617-582-0090 & 617-582-0095 (fax)
Efficiency, Growth, Financial Performance
Efficiency, Growth,
Financial Performance
Physician Billing Compliance
• Modifier 25
when to use and when not to
• Suture Removal Documentation
• Copy and Paste
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Efficiency, Growth, Financial Performance
Modifier 25
• Informs the payers that the E&M service provided
is a significant, separately identifiable service.
• Payment for both the E&M and procedure is made
only if an exception applies:
– An unrelated problem is addressed
– Patient’s condition requires above and beyond
the usual care associated with procedure
– Decision for procedure was made during exam
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Efficiency, Growth, Financial Performance
Procedures
In every procedure there is some element of an
E&M.
• A brief history
• Vital signs may be needed
• Limited exam of the procedure site
These are included in the reimbursement of the
procedure if they are pertaining only to the
procedure that was scheduled and being
performed.
Examples: injection, excision, biopsy, destruction
Efficiency, Growth, Financial Performance
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Injection with E&M
History of Present Illness: Mr. Castro presents today in followup. He was last seen in this clinic in 7/12. He presents for evaluation and treatment of his keloidal scars. He has done well
with these, but over the last 1.5 years, the scars on the chest have slowly enlarged and become increasingly tender, very sensitive to touch. They were flat for a long time,
however.
He does well after the injections but then they start to grow again.
Medications
Acetaminophen Extra Strength 500 MG (500 MG TABLET Take 1) PO Q8H PRN Knee ache, Last Updated: 10/04/2013; No Change
Ecasa (ASPIRIN Enteric Coated) 81 MG PO QD, Last Updated: 10/04/2013; No Change
Ibuprofen 800 MG (800MG TABLET Take 1) PO BID PRN pain - dolor, after eating - despues de comer, Last Updated: 10/04/2013; No Change
Lipitor (ATORVASTATIN) 80 MG TABLET PO QHS, Dose increased from 40 mg to 80 mg today. Thanks, Last Updated: 10/04/2013; No Change
Lisinopril 10 MG (10 MG TABLET Take 1) PO QD, Dose increased from 5 mg to 10 mg today, Last Updated: 10/04/2013; No Change
Miralax (POLYETHYLENE Glycol ) 17 GM (17G/DOSE POWDER DOSE) PO QD, Each 17 GM dose to be dissolved in 8 oz of water, Last Updated: 10/04/2013; No Change
Nifedipine (EXTENDED Release) 60 MG (60MG TABLET Take 1) PO QD, Last Updated: 10/04/2013; No Change
Viagra (SILDENAFIL) 100 MG (100 MG TABLET Take 1) PO as directed PRN , Take 1 hour prior to relation. Maximum one per day., Last Updated: 10/04/2013; No Change
Problems
Hepatitis B : History of Hepatitis B
Hypercholesterolemia
hypertension : EKG: LVH
Alcohol abuse
Keloid scar
Helicobacter-associated disease
Adenomatous polyp of colon : Repeat Colonoscopy 2018
Hyperplasia of prostate : CT scan
Steatosis of liver : CT scan 10/2011
Allergies
NKA
Physical Examination: Focused to the chest, back, arms. Well appearing, in no apparent distress. Mood and affect were normal.
Notable Findings/Assessment/Plan:
1. Several keloidal scars today on the chest, right upper back, left upper arm. These have grown larger since our last visit, although still much smaller than when he initially presented.
Lesion on left upper arm is minimal. Upper chest scar, left, is most severe. The 4 keloidal scars on the chest were wiped with alcohol and then a total of 0.6 mL of 40 mg/mL
Kenalog was injected into the lesions. He tolerated this well.
I will see him back in clinic on an as needed basis.
Efficiency, Growth, Financial Performance
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Injection Only
HISTORY OF PRESENT ILLNESS: Followup visit, a delightful 25-year-old female here
today for followup of keloid ear lobe. Status post excision keloid, left anterior ear
lobe. The area is doing quite well. The patient pleased with results. Continue
intralesional Kenalog 40 mg/mL, 0.3 mL instilled into the keloid and surrounding
tissue. Tolerated well. Follow up 10 weeks/p.r.n.
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Efficiency, Growth, Financial Performance
Medicare’s Global Surgical Package
Services considered part of the global surgical fee include:
• Preoperative visits after the decision is made to operate beginning with the
day before major surgical service and the day of minor surgeries.
• Visits during post op period that are related to the recovery from the
surgery . These services include:
–
–
–
–
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post op pain management
dressing changes
removal of sutures, staples or drains
local incision care
removal of operative packs
– typical postoperative follow-up care
• All medical or surgical services due to complications that do not require
additional trip to the operating room.
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Efficiency, Growth, Financial Performance
Suture Removal w/E&M
CC: Suture removal; f/u eczematous dermatitis
HPI: 55 yo AA male with h/o itchy rash on the abdomen, arms, and hands s/p biopsy revealing pityriasiform and spongiotic dermatitis
with eos and excoriations consistent with eczematous dermatitis. DIF was negative. Was prescribed a taper of prednisone and
has been on 40mg PO q day x 4 days now with marked improvement of the rash on his hands and arms. Using clobetasol 0.05%
oint BID PRN to affected areas.
ROS: negative, no other skin complaints. Feels well, no systemic complaints
FHx: No family h/o melanoma
Physical exam/Assessment/Plan:
Well appearing pt in NAD
mood and affect wnl
A skin examination was performed including scalp, head, eyes, ears, nose, lips, neck, chest, axillae, abdomen, back, bilateral upper
extremities, hands, fingers, fingernails Skin type: VI
1. Eczematous dermatitis -- favoring allergic contact dermatitis
- Resolving patches with residual hyperpigmentation on the arms, hands and abdomen
- Erythematous plaques on the abdomen
- Involvement of the hands favors the radial palmar aspect B, suggestive of exposure to contact allergen
- Pt works in a copy shop -- concern for possible sensitivity to thiuram or PPD in toner
- Referral to patch testing at BIDMC
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- f/u 1 month after course of prednisone is complete
Efficiency, Growth, Financial Performance
Suture Removal Only
Patient presents for suture removal.
Date of Procedure
5/22/14 Location/Pathology
A. SKIN, LEFT ANTERIOR SHOULDER, EXCISION:
BASAL CELL CARCINOMA, nodular type; margins appear negative.
Cicatrix.
There are no signs or symptoms of infection or dehiscence. There is no evidence of bleeding or
hematoma formation. Sutures were removed. Pathology was reviewed with patient and patient was
given wound care instructions.
Patient informed to schedule follow-up appointment for skin check with Dr. Rubenstein
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Efficiency, Growth, Financial Performance
Copy and Paste
• Always document the HPI based on the patient’s
description that day-never copy it from a previous
encounter
• Only use the Review of Systems components that are
relevant to that day’s encounter
• Only use past medical, family and social history from a
previous note if it is reviewed with the patient
• Modify or delete template language when it does not apply
to the visit that day
• The individual performing the copy/paste function is
responsible for the documentation regardless of who
authored the original information
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Efficiency, Growth, Financial Performance
Risks
• Inaccurate or outdated information may adversely affect
patient treatment
• With each copy/paste replication, notes are lengthened and
errors accumulate
• Inability to accurately support medical necessity or defend
services for professional or technical billing
• Inability to identify authors…..who thought what
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Efficiency, Growth, Financial Performance
Payors and Regulatory Agencies
National Government Services (Medicare)
Cloned documentation will be considered a misrepresentation of
the medical necessity requirement for coverage of services due
to lack of specific individual information for each unique
patient. Identification of this type of documentation will lead to
denial of services for lack of medical necessity and the
recoupment of all overpayments made.
OIG
Medicare contractors have noted an increased frequency of
medical records with identical documentation across services.
We will review multiple E/M services for the same providers
and beneficiaries to identify HER documentation practices
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associated with potential improper payments
Efficiency, Growth, Financial Performance
Partners Health Care
Health Information Services EHR Policy PH-140
Copy and pasting information that originated within the Partners
electronic record is not recommended, as it could create redundant
information. It should only be copy and pasted if it is critical that
information be repeated in the current note and had a direct impact
on patient care rendered during that encounter
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Efficiency, Growth, Financial Performance
Questions?
Thank You !
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Efficiency, Growth, Financial Performance