Coding Tips and Coding Tips and Other Strategies to Other Strategies to Increase Practice Increase Practice

RevenueRevenueCynthia W Denmark, FNP-BC, Cynthia W Denmark, FNP-BC,

Wesley Primary Care-Wesley Primary Care-LeakesvilleLeakesville

Wesley Medical CenterWesley Medical Center

Disclosure of Financial Disclosure of Financial RelationshipsRelationships

Cynthia W Denmark, FNPCynthia W Denmark, FNP

Has no relationships with any Has no relationships with any proprietary entity producing health proprietary entity producing health care goods or services consumed by care goods or services consumed by

or used on patients. or used on patients.

ObjectivesObjectives

The participant will be able to:The participant will be able to:

Evaluate the financial status of the Evaluate the financial status of the clinical practiceclinical practice

Identify common causes of lost Identify common causes of lost revenuerevenue

Identify opportunities for additional Identify opportunities for additional sources of incomesources of income

Know Your Financial Know Your Financial StatusStatus

Know your largest payerKnow your largest payer Request a monthly/quarterly Request a monthly/quarterly

statementstatement Meet with CFO quarterlyMeet with CFO quarterly

Common Causes of Lost Common Causes of Lost RevenueRevenue

Office proceduresOffice procedures Codes not recognized by payersCodes not recognized by payers CollectionsCollections E&M Miscoding E&M Miscoding

Common Causes of Lost Common Causes of Lost Revenue:Revenue:

Office ProceduresOffice Procedures Destruction of Benign Lesions (Cryo)Destruction of Benign Lesions (Cryo)

Keratoses (17000/1; 17003/2-14) Keratoses (17000/1; 17003/2-14) Warts (17110/1-14)Warts (17110/1-14)

Bicillin CR 1,200,000/2mLBicillin CR 1,200,000/2mL $13/unit + injection fee$13/unit + injection fee

Shave BiopsyShave Biopsy Injection feeInjection fee VenipunctureVenipuncture Pap SmearsPap Smears

Common Causes of Lost Common Causes of Lost RevenueRevenue

ICD codes no recognized by PayersICD codes no recognized by Payers Benign LesionsBenign Lesions FatigueFatigue Vitamin DVitamin D

CollectionsCollections E&M miscodingE&M miscoding

Seek Additional RevenueSeek Additional Revenue

Contract with BusinessesContract with Businesses See Pts in LTCFSee Pts in LTCF House CallsHouse Calls Group Visits (SMA)Group Visits (SMA)

Case Study #1Case Study #1

Established ptEstablished pt cc: sore throatcc: sore throat HPI: 23 yo F c/o sore throat “hurts HPI: 23 yo F c/o sore throat “hurts

to swallow”, fever>101. The to swallow”, fever>101. The problem started suddenly yesterday. problem started suddenly yesterday. She took ibuprofen last night & this She took ibuprofen last night & this morning. Nothing relieves the pain. morning. Nothing relieves the pain. Her child is currently taking Her child is currently taking amoxicillin for strep throat.amoxicillin for strep throat.

Case Study #1Case Study #1 SH: quit smoking 2 yrs agoSH: quit smoking 2 yrs ago ROS: no ear pain, no sinus pressure or ROS: no ear pain, no sinus pressure or

drg, no cough or chest tightness/paindrg, no cough or chest tightness/pain Exam: BP 112.68 HR 72 RR 18 T 100.8Exam: BP 112.68 HR 72 RR 18 T 100.8

EyesEyes: non-injected, no drg: non-injected, no drg ENMTENMT: TMs clear, no nasal drg, Tonsils : TMs clear, no nasal drg, Tonsils

enlarged/erythematous with exudatesenlarged/erythematous with exudates NeckNeck:: cervical lymph node tenderness cervical lymph node tenderness LungsLungs: BBS CTA : BBS CTA CVCV: RRR, no murmur: RRR, no murmur GIGI: no splenomegaly; abd soft, non-tender: no splenomegaly; abd soft, non-tender SkinSkin: no rash: no rash

Case Study #1Case Study #1

Labs: rapid strep (positive)Labs: rapid strep (positive) Impression/Plan:Impression/Plan:

Streptococcal Sore ThroatStreptococcal Sore Throat Bicillin CR 12 units IM nowBicillin CR 12 units IM now Alternate Tylenol & Ibuprofen q 3 hrs Alternate Tylenol & Ibuprofen q 3 hrs

prn fever/painprn fever/pain Chloroseptic lozenges for sore throatChloroseptic lozenges for sore throat Discard toothbrushDiscard toothbrush RTC if symptoms persist/worsenRTC if symptoms persist/worsen

Case Study #2Case Study #2

cc: f/u DM, dyslipidemia, HTNcc: f/u DM, dyslipidemia, HTN HPI: 68 yr M presents for refills and HPI: 68 yr M presents for refills and

f/u. FBG was 118 this a.m. His f/u. FBG was 118 this a.m. His previous TG was slightly elevated at previous TG was slightly elevated at 162 and has since been taking 162 and has since been taking 2000mg fish oil daily along with his 2000mg fish oil daily along with his lovastatin. His BP is controlled by lovastatin. His BP is controlled by diet & lisinopril 10mg daily. diet & lisinopril 10mg daily.

Case Study#2Case Study#2

PFSH: reviewed with no changesPFSH: reviewed with no changes ROS: denies SOB, chest painROS: denies SOB, chest pain Exam: BP 130/78 HR 72Exam: BP 130/78 HR 72 RR 20 T 98.8 RR 20 T 98.8

BMI 29BMI 29 Overweight; normal affect; BBS CTA; RRR; Overweight; normal affect; BBS CTA; RRR;

no murmur;no murmur; Impression/PlanImpression/Plan

DM, Dyslipidemia, HTNDM, Dyslipidemia, HTN Continue current medicationsContinue current medications RTC in 30 days for labs (A1c, Lipids, CMP)RTC in 30 days for labs (A1c, Lipids, CMP)

E&M Coding (Est. E&M Coding (Est. Patient)Patient)

CPTCPT 9921299212 9921399213 9921499214 9921599215HPIHPI

ROSROS

PFSHPFSH

11 11

114 4 (3 chronics)(3 chronics)

22

11

4 4 (3 chronics)(3 chronics)

1010

22

ExamExam 11 22 55 88

MDMMDM SFSF LowLow ModMod HighHigh

TimeTime 10 min10 min 15 min15 min 25 min25 min 40 min40 min

E&M Coding (New E&M Coding (New Patient)Patient)

CPTCPT 9920992011

9920992022

9920992033

9920992044

9920992055

HPIHPI

ROSROS

PFSHPFSH

11 11

1144

22

11

44

1010

33

44

1010

33

ExamExam 11 22 55 88 88

MDMMDM SFSF SFSF LowLow ModMod HighHigh

TimeTime 1010 2020 3030 4545 8080

Pearls for DocumentingPearls for Documenting

Have Nurse/MA document history & Have Nurse/MA document history & ROS (You must document that you ROS (You must document that you reviewed)reviewed)

Risk: moderate risk=level 4 visitRisk: moderate risk=level 4 visit Prescription drugsPrescription drugs 1 chronic illness w/ progression or SE of tx1 chronic illness w/ progression or SE of tx 2+ stable illnesses2+ stable illnesses Undiagnosed new problemUndiagnosed new problem

Pearls for DocumentingPearls for Documenting

Document ALL exam elements. There are Document ALL exam elements. There are 7 elements to document PRIOR to the 7 elements to document PRIOR to the “examination”“examination” General appearanceGeneral appearance Eyes: injected, no drgEyes: injected, no drg ENT: hearing intactENT: hearing intact MSK: normal gait/limpMSK: normal gait/limp Psych: normal affect, depressed, agitatedPsych: normal affect, depressed, agitated Skin: no rash on face/armsSkin: no rash on face/arms Immunologic: NKDA (use of PMH or PE)Immunologic: NKDA (use of PMH or PE)

Pearls for DocumentingPearls for Documenting

Avoid “all others negative” for ROS. Avoid “all others negative” for ROS. State the # of systems reviewed. State the # of systems reviewed.

Avoid “non contributory” or “not Avoid “non contributory” or “not significant to current illness” for significant to current illness” for PFSH. Recommend “was reviewed PFSH. Recommend “was reviewed and is negative”and is negative”