1. Never write "benign" positional vertigo, its "paroxysmal" positional vertigo unless you want to be downcoded.
2. Discharge day codes 99238 for less than 30 minutes, 99239 for more than 30 minutes, document time including spent at nursing station doing prescriptions, need not be continuous.
3. Critical care codes 99291, 99292 for first hour (minutes 31-74) and each additional 30 minutes, respectively. Must MANAGE some critical aspect of care and not just consult. Use different ICD9 code than the attending if you are not primary on case. Time need not be continuous, and time spent off unit eg. looking at X rays with radiologist counts, unlike floor patients. Aggregate time with partners if applicable. This is appropriate for er tpa administration.
4. Prolonged care codes 99356, 99357 for INPATIENTS for first hour (minutes 31-74 and each additional half hour respectively. Document reason for prolonged service, submit note to carrier, list start and end clock time required. Time spent off unit eg radiology does not count, but time spent on unit coordinating care counts.
5. Prolonged care codes 99354, 99355 are analagous to (4) above except they are for outpatients and Face to face time (start and end clock time) must be documented along with reason.
6. Modifier 25 for procedure same day as an E/M service usually EEG and EMG are exempt.
7. Documentation for high level visit: Indicate chronic illness with severe exacerbation and/or side effects such as MS exacerbation, seizure, Dilantin toxicity (if you are still using Dilantin), risk of Morbidity and mortality (INR high in stroke patient), Abrupt neuro change (TIA, seizure, AMS).
Must include in note 1) 1 new problem needing additional assessment or 2) 2 old problems inadequately controlled . Document at least a three way differential (Alzheimer's v. frontotemporal v. LBD?; or MS v. CIS v. ON due to sarcoid). Document at least 3 management options (Copaxone, Rebif, Betaseron; steroids; gabapentin: Detrol or Aggrenox v. Plavix v Asa, lipitor v. simvastatin; SQ heparin to prevent DVT's). or iv (parenteral) controlled substances.
New consults need CC, 4 facts for HPI, 1 fact each for PSF (past, family, social history), 10 point ROS (see below), 23 point Neuro SSE (see below).
8. Office followup high level requires CC, 4 facts HPI, med list, social fact, 10 point ROS (may sign and date patient form containing some of these), PLANS (labs, meds, to address problem). midlevel office visit requires CC, 4 point HPI, mention some PMH or current meds, 2 system ROS, palns to address problem (1-2 chronic problems of moderate degree, or uncertainty re risk or prognosis). Level 3, low level requires a self limited stable problem eg chronic pain needing E/M, CC, pertinent positives and negatives, and PLANS to address problem. Most documentation falls out on 3 way differential and plans.
9. ROS items to be covered in your office intake sheet come from the list: constitutional, eyes, ENZT, CV, Respiratory, GI, GU, musculoskeletal, skin and or breast, neurologic, endocrine, hematologic/lymphartic, allergic/immunologic, psychiatric. May be on a separate sheet patient fills out and checks off if MD signs and dates AND refers to it in office note. Comprehensive ROS has 10 (TEN) items out of 14.
10. Neuro single system exam requires 25 bulleted items, need to include 23. These include one of three CV elements (more may be needed for care but not for documentation). The other 22 that must be included are regular parts of neuro exam. Mandatory-- any 3 vitals (BP, HR, RR, temp, height, weight, orthostatics), general appearance, Fundoscopic exam, one of 3 cardiovascular elements (carotids, heart auscultation, peripheral vascular system), Memory (orientation, attention, recent and remote memory, language, and fund of information), CN's 2; 3,4,6; 5, 7, 8, 9, 11, 12). CN's one and ten are not required. Motor exam includes strength (4 ext), tone (4 ext with note of atrophy or abnormal movements), DTR's 4 ext's including pathologic reflexes, Coordination, Gait and station. Sensory exam-- need one element of sensation recorded.
Notes-- must document WHY you can't walk a comatose patient eg. . Constitutional signs and vital signs can be recorded by staff. Office needs to have an approved abbreviation list. Note must be legible. Templates OK, macros OK, pocket cards with elements available from AAN.
Example of a comprehensive Neuro SSE: Well developed. 120/80, HR 72, RR 16. fundi OK no bruit. MS: awake, alert, oriented x 3, dig 6 F, 3/3 objects at 5 minutes, nl naming and vocabulary. CN. VFF, EOMI, facial sensation and power normal, hears well, palate.tongue midline, SCM normal. Sens: normal PP. Motor-- nl tone/bulk/power 4 ext. FNF, gait nl, DTR's 2+ and symmetric throughout, normal.
11, Couselling and coordination of care may be used instead of documentation. Counselling involves face to face discussion with patient and/or family re tests, treatments, alternatives, prognosis, education. Coordination of care may involve interactions with other MD's or providers. Time is key. Documentation should state number of minutes spent face to face, that more than half time was spent on counselling and coordination of care, with some general idea of what was done. No history or exam is needed for documentation.
12. Be sure to document physician referring name for consults. Be sure to document MDM in detail.
2. Discharge day codes 99238 for less than 30 minutes, 99239 for more than 30 minutes, document time including spent at nursing station doing prescriptions, need not be continuous.
3. Critical care codes 99291, 99292 for first hour (minutes 31-74) and each additional 30 minutes, respectively. Must MANAGE some critical aspect of care and not just consult. Use different ICD9 code than the attending if you are not primary on case. Time need not be continuous, and time spent off unit eg. looking at X rays with radiologist counts, unlike floor patients. Aggregate time with partners if applicable. This is appropriate for er tpa administration.
4. Prolonged care codes 99356, 99357 for INPATIENTS for first hour (minutes 31-74 and each additional half hour respectively. Document reason for prolonged service, submit note to carrier, list start and end clock time required. Time spent off unit eg radiology does not count, but time spent on unit coordinating care counts.
5. Prolonged care codes 99354, 99355 are analagous to (4) above except they are for outpatients and Face to face time (start and end clock time) must be documented along with reason.
6. Modifier 25 for procedure same day as an E/M service usually EEG and EMG are exempt.
7. Documentation for high level visit: Indicate chronic illness with severe exacerbation and/or side effects such as MS exacerbation, seizure, Dilantin toxicity (if you are still using Dilantin), risk of Morbidity and mortality (INR high in stroke patient), Abrupt neuro change (TIA, seizure, AMS).
Must include in note 1) 1 new problem needing additional assessment or 2) 2 old problems inadequately controlled . Document at least a three way differential (Alzheimer's v. frontotemporal v. LBD?; or MS v. CIS v. ON due to sarcoid). Document at least 3 management options (Copaxone, Rebif, Betaseron; steroids; gabapentin: Detrol or Aggrenox v. Plavix v Asa, lipitor v. simvastatin; SQ heparin to prevent DVT's). or iv (parenteral) controlled substances.
New consults need CC, 4 facts for HPI, 1 fact each for PSF (past, family, social history), 10 point ROS (see below), 23 point Neuro SSE (see below).
8. Office followup high level requires CC, 4 facts HPI, med list, social fact, 10 point ROS (may sign and date patient form containing some of these), PLANS (labs, meds, to address problem). midlevel office visit requires CC, 4 point HPI, mention some PMH or current meds, 2 system ROS, palns to address problem (1-2 chronic problems of moderate degree, or uncertainty re risk or prognosis). Level 3, low level requires a self limited stable problem eg chronic pain needing E/M, CC, pertinent positives and negatives, and PLANS to address problem. Most documentation falls out on 3 way differential and plans.
9. ROS items to be covered in your office intake sheet come from the list: constitutional, eyes, ENZT, CV, Respiratory, GI, GU, musculoskeletal, skin and or breast, neurologic, endocrine, hematologic/lymphartic, allergic/immunologic, psychiatric. May be on a separate sheet patient fills out and checks off if MD signs and dates AND refers to it in office note. Comprehensive ROS has 10 (TEN) items out of 14.
10. Neuro single system exam requires 25 bulleted items, need to include 23. These include one of three CV elements (more may be needed for care but not for documentation). The other 22 that must be included are regular parts of neuro exam. Mandatory-- any 3 vitals (BP, HR, RR, temp, height, weight, orthostatics), general appearance, Fundoscopic exam, one of 3 cardiovascular elements (carotids, heart auscultation, peripheral vascular system), Memory (orientation, attention, recent and remote memory, language, and fund of information), CN's 2; 3,4,6; 5, 7, 8, 9, 11, 12). CN's one and ten are not required. Motor exam includes strength (4 ext), tone (4 ext with note of atrophy or abnormal movements), DTR's 4 ext's including pathologic reflexes, Coordination, Gait and station. Sensory exam-- need one element of sensation recorded.
Notes-- must document WHY you can't walk a comatose patient eg. . Constitutional signs and vital signs can be recorded by staff. Office needs to have an approved abbreviation list. Note must be legible. Templates OK, macros OK, pocket cards with elements available from AAN.
Example of a comprehensive Neuro SSE: Well developed. 120/80, HR 72, RR 16. fundi OK no bruit. MS: awake, alert, oriented x 3, dig 6 F, 3/3 objects at 5 minutes, nl naming and vocabulary. CN. VFF, EOMI, facial sensation and power normal, hears well, palate.tongue midline, SCM normal. Sens: normal PP. Motor-- nl tone/bulk/power 4 ext. FNF, gait nl, DTR's 2+ and symmetric throughout, normal.
11, Couselling and coordination of care may be used instead of documentation. Counselling involves face to face discussion with patient and/or family re tests, treatments, alternatives, prognosis, education. Coordination of care may involve interactions with other MD's or providers. Time is key. Documentation should state number of minutes spent face to face, that more than half time was spent on counselling and coordination of care, with some general idea of what was done. No history or exam is needed for documentation.
12. Be sure to document physician referring name for consults. Be sure to document MDM in detail.
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