Coding and Documentation: A Brief Guide

Dipesh Navsaria, MPH, PA-C

September 12, 2001

Introduction

Student: "Dr Smith, I've always wondered about how you know which box to check off on the billing sheet?"

Dr. Smith: "Oh, well, you know... if you did a bit of work, you use a 'Brief', a bit more, a 'Limited', and a lot more, an 'Extended'."

Student: (confused) "Oh... and a 'Comprehensive'? When do you use that?"

Dr. Smith: "Oh, I don't use those... I don't want to get audited! Now, what's the differential diagnosis for eosinophilia... ?"

The fictitious exchange above shows the very real tendency of medical educators to give the financial side of medicine no more than a cursory nod. Most medical students are kept at arm's length from basic concepts of coding and documentation, and many residents often are not taught how to correctly bill either. "Why do I care? I'm going to work for a group which has a billing department that handles all that." The provider has the ultimate responsibility for ensuring that the correct level of service was provided. This duty cannot be passed on to someone else -- you provided the service, you decide what to bill. (Besides, even if you are salaried, don't you want your employers to know exactly how much valuable revenue you bring in?)

The current billing system is a product of the World Health Organization (WHO) and the US federal government. As confusing as this system can be, it's likely that it will remain in place for some time, so it's important to learn some basics on how to navigate it.

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Table 1. The E&M Visit: A Multifactoral Process
History Duration of duration of condition, intensity, provocative and palliative factors, etc [3-day history of 5/10 chest pain, increased with exertion] Past medical history, family history, social history [GERD for 3 years, mother with MI at age 45, patient smokes] Review of systems -- how many systems did you cover?
Physical Exam Number of body systems covered [Examined respiratory, cardiovascular, abdominal systems] Intensity of exam for a few systems [Performed detailed neurological and psychiatric examination]
Medical Decision Making Number of conditions. New or old conditions? Worsening or stable? [Stable asthmatic for routine care but worsening hypertension] Seriousness of condition [A stroke clearly outweighs the common cold] Tests ordered, etc. [Did you order tests? Did you order old records?]

Coding and Documentation: A Brief Guide

Introduction

Tables

Authors and Disclosures

Authors and Disclosures

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