Welcome Interns!

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
CPT CODE
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:

• Chief Complaint (CC)
• History of Present Illness (HPI) - has 8 elements (Location, Duration, Quality, Severity, Timing, Context, Modifying Factors, Associated signs and symptoms)
  
• Review of Systems (ROS) - has up to 12 systems
• Past, Family, and Social History (PFSH)

  Exam

• Up to 8 organ systems
• Detailed exam for an organ system involves 3 or more distinct findings

MDM (medical decision making)

• This is a synthesis in the complexity of the patient encounter.
• This involves interpretation of labs, xrays, EKGs, reviewing old records.
• Consultation by specialists

 
Putting it all together (CPT LEVEL CODING)
LEVELS:

1.  1 HPI element, 1 organ system, minimal MDM
   
2.  1 HPI element, 1 ROS element, 2-7 organ systems, low complexity MDM
   
3.  1 HPI element, 1 ROS element, 2-7 organ system, moderate complexity MDM
   
4. 4 HPI elements, 2-9 ROS elements, 1 PFSH element, 2-7 organ systems with one in detail, moderate complexity MDM
   
5. 4 HPI elements, 10+ ROS elements, 2 PFSH elements, 8 organ systems, high complexity MDM

COMMON PITFALLS

• Missing PFSH elements drops level
• Medical and Surgical are considered "PAST" history, only 1 element credit given
• HPI doesn't include 4 distinct billing elements
• Less than 10 ROS elements
• Not documenting lab results/xray results & interpretation

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)!