Don’t Undervalue Patient Complexity

August 7th, 2016 - Robin Sewell, CCS, CPC, CHTS-PW
Categories:   Audits/Auditing  
0 Votes - Sign in to vote or comment.

Healthcare professionals can readily discern the acuity and severity of a patient's illness based on the presentation of the patient and objective data at their disposal. Although it is the responsibility of the clinician to convey the complexity of the case, it is not always easy for an auditor to infer that complexity while auditing an E&M encounter.

One approach that can be used is referring to a diagnosis coding manual that contains notations for CC and MCC conditions. Not all publishers use these symbols in their coding manuals as they are representative of indicators for inpatient coding purposes. However, these particular codes may be found on the CMS website at https://www.cms.gov/icd10manual/fullcode_cms/P0370.html.

The symbol 'CC' designates a complication or co-morbidity while 'MCC' represents a major complication or co- morbidity. When one of these codes is documented, one can infer that it is a severe to majorly severe condition and aptly apply it to the presenting problem on the table of risk.

An additional approach is to identify what types of management options are considered for a given disease. Consulting a reputable clinical reference can provide valuable insight. These management options can be compared to the table of risk under management options. However, they are only given credit if actually ordered or performed. It becomes a useful tool when combing a record for data.

Below are two examples, that when documented properly and using the approach outlined within this tip, will help capture and credit for patient complexity. In this scenario, even if the patient did not have emergent surgery for perforation or hemorrhage, but did have a colonoscopy, one can infer the overall risk is high in a patient with a perforated and/or bleeding diverticulitis.

While the table of risk provides a few examples of presenting problems and management options that are considered moderate and high risk, why not consult your coding manual and clinical references to help identify patient complexity?

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
July 17th, 2019 - Wyn Staheli, Director of Research
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
Denial Management is Key to Profitability
July 15th, 2019 - Wyn Staheli, Director of Research
A recent article by Modern Medicine cited a report by Becker’s Hospital Review which stated that it costs approximately $118 per claim to resolve a claim denial. Granted, these were hospital claims, but the process is essentially the same for outpatient services. In fact, you could say it is...
Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?
July 15th, 2019 - Wyn Staheli, Director of Research
Question: It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...
The Importance of Medical Necessity
July 9th, 2019 - Marge McQuade, CMSCS, CHCI, CPOM
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
When Can You Bill Orthosis Components Separately?
July 9th, 2019 - Wyn Staheli, Director of Research
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
Q/A: Can I Put the DC’s NPI in Item Number 24J for Massage Services?
July 8th, 2019 - Wyn Staheli, Director of Research
Question: Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services? Answer: While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
July 8th, 2019 - Wyn Staheli, Director of Research
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following: Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...



About Codapedia by InnoviHealth Systems Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™ by InnoviHealth Systems™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association