You are no longer medical students. Congratulations!! That being said, your chart actually matters (from a billing perspective). This is a great time to start habits to chart effectively/efficiently.
Basic Documenting Concepts
There are 5 levels of ER chart coding based on your documentation; these are called CPT codes.
Level 1 being the most basic, Level 5 being the most complex. (Billing follows closely, 1 pays the least, 5 pays the most).
RVU - "Relative Value Unit"
Your reimbursement is based on the number RVU's you generate. You generate RVU's by your ER documentation, performing and documenting procedures, and performing and documenting critical care.
Each CPT code correlates with a fixed amount of RVU's.
Level 1 chart = 0.59 RVU
Level 2 chart = 1.16 RVU
Level 3 chart = 1.75 RVU
Level 4 chart = 3.33 RVU
Level 5 chart = 4.93 RVU
Critical Care 1st hour = 6.33 RVU
Critical Care each additional 30 minutes = 3.16 RVU
Missing key documenting elements can easily drop a chart from a Level 5 to a Level 3. As you can see, this is over 3 RVUs!
Components of the Document
History - There are 4 subcomponents:
MDM (medical decision making)
Putting it all together (CPT LEVEL CODING)
This is a brief introduction into mastering charting. Your charts should be a thoughtful representation of the work you performed. Be mindful when using Dragon Dictation that you've included the elements needed to support the work that you are already doing.
Stay tuned for more tips (and feel free to review my previous blog posts)!
For Past Medical/Surgical, Social, Family History:
"Negative," "noncontributory," "not significant," "unknown," or "reviewed in chart" are not considered sufficient to support these history components.
** For "unknown" you must clearly indicate a high acuity caveat or document if the patient is adopted.
*** Our coders do not reference nursing notes for "reviewed in chart." These must be imported into your power note for the coder to see it.
**** It is ok to say "No past medical history"
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.