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picture1_Ed Documentation Presentation Gottlieb


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File: Ed Documentation Presentation Gottlieb
emergency medicine documentation review 2020 documentation provides proof of the delivery of quality patient care better protection medico legally ability to ensure accurate billing and reimbursement through practices that comply ...

icon picture PDF Filetype PDF | Posted on 04 Oct 2022 | 3 years ago
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    Emergency Medicine 
   Documentation Review
       2020
      Documentation Provides
      • Proof of the delivery of quality patient care
      • Better protection medico-legally
      • Ability to ensure accurate billing and reimbursement
       through practices that comply will all laws, rules and
       regulatory guidelines
      • Communication with colleagues.
                                                      2
       EM DOCUMENTATION GUIDELINES -CPT & CMS
   E & M Nature of                                  CPT                              CMS                          RVU
                  Presenting                   Nomenclature                     Quantification                    2020
                  Problem
     99281        Minor;              Problemfocused Hx                 1 HPI- 0 ROS- O PFS Hx                    0.64
                  self limited        Problem focused Exam              1 Organ system exam
                                      Straightforward MDM               Straightforward MDM
     99282        Low                 Expanded problem focused Hx       1HPI-1 ROS-0 PFS Hx                       1.23
                                      Expanded problem focused Ex       2 Organ system exam
                                      Low Complexity MDM                Low Complexity MDM
     99283        Moderate            Expanded problemfocused Hx        1HPI-1 ROS-0 PFS Hx                       1.84
                                      Expanded problem focused Ex       2 Organ system exam
                                      Moderate Complexity MDM           Moderate Complexity MDM
     99284        High                Detailed Hx                       4 HPI- 2 ROS- 1 PFS Hx                    3.38
                                      Detailed Exam                     2+ Organ System Exam
                                      Moderate Complexity MDM           Moderate Complexity MDM
     99285        High                Comprehensive Hx                  4 HPI- 10 ROS- 2 PFS Hx                   4.91
                                      ComprehensiveExam                 8 organ systemexam
                                      High Complexity MDM               High Complexity MDM        3
     Determine the Extent of H & P
     •Medical Necessity of a service is the
      overarching criteria for payment in addition to
      the individual requirements of a CPT Code
     “Medical necessity is defined as accepted health care services and 
     supplies provided by health care entities, appropriate to the evaluation 
     and treatment of a disease, condition, illness or injury and consistent 
     with the applicable standard of care.”
     “Medicare Claims Processing Manual Chapter 12, Section 30.6.1”
                                              4
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...Emergency medicine documentation review provides proof of the delivery quality patient care better protection medico legally ability to ensure accurate billing and reimbursement through practices that comply will all laws rules regulatory guidelines communication with colleagues em cpt cms e m nature rvu presenting nomenclature quantification problem minor problemfocused hx hpi ros o pfs self limited focused exam organ system straightforward mdm low expanded ex complexity moderate high detailed comprehensive comprehensiveexam systemexam determine extent h p medical necessity a service is overarching criteria for payment in addition individual requirements code defined as accepted health services supplies provided by entities appropriate evaluation treatment disease condition illness or injury consistent applicable standard medicare claims processing manual chapter section...

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