Billing and Coding lecture: aka The Most Interesting Topic Ever!
Don't clone visit from previous visit, each visit needs new Hx, PE, MDM
CPT Codes:
81:minor problem
82: low to mod ie car accident
83: med or rx given
84: high severity, emergent
85: highest in ed excluding critical care
mri, Dopplers, ct, keg abg, Cx – blood or urine, multiple xrays, multiple nebs = start
at 84 as risk higher threat to patients
who are these patients:
cardiac resp, neuro and abdominal pain workups
3 components: Hx, exam, MDM
MDM decides the level of service of the visit:
3 subcomponents of MDM:
1. Table B: Data – everything you order and is on a point system ie labs, xrays,
ekg/monitor, discussion of test results with radiologist, review and summarize
old record ie “ekg is unchanged from previous”, ie “patient is a freq flyer based on
previous chart”, hx obtained from someone other than patient, ie guardian,
discussion of case with another health care provider (when you admit, transfer,
consult or speak to pcp), individual visualization ie interpretation of 1st read of cxr
4 points or more = high medical decision making!!
2. Table C: Risk: The risk of complications morbidity and mortality associated with
the patients cc, the diagnostic procedure
3. Problem Categories: the number of possible diagnoses – put differentials!!
3 or more ancillaries documented, 1 special study ordered, provider makes apt for the
patient ie ophthalmology
History, physical and ros must come up to meet the MDM for the 84 or 85 to be
coded correctly
History: If patient can’t give good hx have to say why, ie dementia, confusion
HPI: always pick 4 or more always
Location- anatomical
Quality
Severity- scale 1-10
Duration- when it started
Context- circumstance ie what caused the symptoms (after working in yard)
HPI for depression and etoh is difficult
Tips:
ROS: 10 or more: (the number 1 area where we don't document enough)
For 85 level of service: can use “ all other systems neg except as above in HPI” –
you can only do this fore 85 level patients, be careful doing this on all charts as its
considered cloning!
Past, Family, Social:
Need 2 out of 3, if family and social not pertinent then state that
Exam:
For level 5 need findings from >= 8 organ systems
ie if neck: supple = msk, no adenopathy = lymph nodes ie there’s 2 organ systems just
for neck
Exam caveat: need to document areas that cant examine and why, ie: psych patient,
patient refuses due to religious beliefs
Procedures : if resident does it, the attending must review this
Xrays/ekg: same, attending has to agree
The attending has to have contact with the patient. “ I examined the patient and agree
with assessment” – this is ok for now but eventually they are gonna want more
Critical Care: need documentation over 30 min
(Really for the attending)
Beside patient care
Reviewing ancillary
Discussions with family, physicians
Chart completion
Clinical conditions consistent with critical care:
Airway compromise, acute mi or cva with lytics, cardiac dysrhythmia, sepsis aortic
dissection, perforated viscous, coma, resp failure, gi bleed, dka, anaphalaxis
Not found in critical care:
Triple lumens
Intubation
Pacemakers
Pericardiocentesis
Thrombolytics
Procedures:
Document separate exam
ie laceration:
length in cm
location
type of closure and material
nv exam
ie: fracture care
bill for attempts to reduce
Primary Diagnosis:
1st one listed
ie if car accident and have back pain , dx should be Back Injury
FINALLY ITS OVER~!!!
Kevin’s Lecture: Ocular Trauma
Eye Exam:
Visual acuity and light reflex
Palpate
Open globe injuries:
2 types: globe rupture, globe laceration
Risk Factors:
Younger, male
Initial assessment: trauma so CAB 1st!
Exam:
Decreased visual acuity
Tear drop pupil- eye extruding out of iris
Extrusion vitreous
Uvea prolapse (iris/pupil comes out under cornea)
APD
Seidel’s Sign- leaking of flurocein, but don't do this is suspect globe rupture
Red Flags:
Hyphema
360 degree conjunctival hemorrhage – covers up the signs of globe rupture
DON’TS:
Don't manipulate eye
Don't remove fb
MUST DO:
Visual acuity
APD
Ocular Trauma Score – just look it up
Regression Trree Score – visual acuity and apd correlate most with visual outcome
Imaging:
Ct is image choice – 50-100% sensitive for globe rupture
Xray- only shows 50% orbital #
ED TXT:
Eye shield
Anti-emetics- avoid vomiting as increases IOP
Pain control
Tetanus
Ophthalmology
Making an eye shield: Styrofoam cup and tape over eye
Definative txt:
Surgical closure w/I 24 hrs
Antibiotics:
Vancomycine/ceftazidime for endopthalmitis ( give it prophalactically to prevent this)
Intubation:
Ketamine and Succ increase IOP/ICP?
- the data sucks – 1957 study says don't give succinylcholine from one case
study
Then kevin shows a pic of jess cook!!
What about Ketamine??
2 studies show no elevation of iop
Retrobulbar hematoma:
Bleed in back of eye  IOP  orbital ischemia
This is compartment syndrome of the eye!
Indications:
Proptosis
Iop >40
Restriction eye movement
Acute visual loss
Treatment: Lateral Cathotomy
Equipment:
Lido with epi, needle and syringe, saline, suture kit
Cut inferior crus, but if that doesn't work cut superior too
1. inject lido with epi 1 cc in corner of eye
2. crimp with hemostat- helps bleeding
3. lateral incision
4. dissect down
5. cut lateral cathus
Vision should come back in 5 min
Resolution of APD
Vision improved
blood should start coming out if you have released the hematoma
Optic Nerve Sheath hematoma- needs definitive OR management
Hyphema
Blood in anterior chamber
- blocks blood flow  increase iop
- graded 1-4
Initial Management
Eye shield
Elevate head of bed
Cycloplegics
Steroids
Beta blockers /Actz
Analgesia
Antifibrinolytics – aim is to prevent re-bleeding
TXA, AMA
Cochrane reviews:
These only found to decrease risk of re-bleeding
Re-bleeding:
Occurs day 3-5
Admit them if its bigger
Corneal Blood Staining
Rbc’s deposit hemosiderin in cornea, takes months to resolve
Glaucoma
Criteria for Admission for hyphema:
>3 or 4 grade
IOP >22
Coagulopathy and blood thinners
SCC
Children/compliance
If discharging, need 24 hr optho fu and IOP measured daily
Take home:
Trauma patient 1st
Eye shield
HOB 30 degrees
Zofran
Abx, tetanus
Know criteria for hyphema admission
Rabrich CQI:
Patient was triaged as intox, never intox.
FS never done as patient was a& o x 3 eventually and dc and went to waiting room
Upon ems arrival to bring back to shelter patient couldn't walk
Found to be tachy, rhonchi and with acute sepsis with multilobar pna
Dan Solis CQI Bulletin: RVU’s
Interns 0.6, 2nd year 1.2, 3rd year 1.6 patients per hour
RVU’s: community docs will need to know about this
Level 1 patient: $21
Level 5: $173
For every ekg interpret = 0.2 RVU = $7
1 RVU is $35
If get 10 RVU’S per hour = increase salary by 10%