2023 CPT Guideline Changes

[thegenius]

Errrr optum aka United healthcare. What a freaking joke health care has become. Yeah it’s what I tell my colleagues. Chart well. Do all the things. Will take time to figure it out.

Total f'ing joke. Complete conflict of interest for an insurer to also be the one to code and bill. Our hospital is spineless and won't dump optum despite about 100 doctors appeals.

---

Members don't see this ad.

 

[thegenius]

So many questions about the coding changes.

Anybody notice that prescribing OTC medications is not part of the "moderate" risk category? That is what Optum is telling us. So prescribing tylenol and motrin won't count.

 

[southerndoc]

So many questions about the coding changes.

Anybody notice that prescribing OTC medications is not part of the "moderate" risk category? That is what Optum is telling us. So prescribing tylenol and motrin won't count.

Voltaren (pills, not gel) and Robaxin? I try not to prescribe something a patient can get OTC anyway. Better patient satisfaction because they feel their trip to the ER was fruitful if you give them something they can't buy OTC.

 

[thegenius]

Voltaren (pills, not gel) and Robaxin? I try not to prescribe something a patient can get OTC anyway. Better patient satisfaction because they feel their trip to the ER was fruitful if you give them something they can't buy OTC.

our pt population loves to get tylenol/motrin Rxs because it's free for them. We serve a sizable community of folks with limited to no resources.

 

[BoardingDoc]

Voltaren (pills, not gel) and Robaxin? I try not to prescribe something a patient can get OTC anyway. Better patient satisfaction because they feel their trip to the ER was fruitful if you give them something they can't buy OTC.

I've been giving an Rx for "prescription strength ibuprofen" in some of my charts.

 

[WorkNoteEmergency]

There used to be an NSAID Dolobid, don’t think it’s made any more, and we’d pronounce it “duh-LA-bid”. Big winner on the d/c scrip.

 

[Janders]

So many questions about the coding changes.

Anybody notice that prescribing OTC medications is not part of the "moderate" risk category? That is what Optum is telling us. So prescribing tylenol and motrin won't count.

This is straight from the ACEP FAQ supposedly vetted by AMA and the like-->
25. What qualifies as prescription drug management in moderate risk?
"Prescription drug management is based on documentation that the provider has administered, prescribed, or evaluated current medications during the ED visit. This may be any administration of prescription strength medication while the patient is in the ED, a prescription written to be filled at the pharmacy, discontinuation or modifications to the patient’s existing medication dosages, or after consideration of the current medications, the decision to maintain the current medication regimen."

So my read is if you note "rx strength" 600mg Ibuprofen (my fave) either in department OR Rx home, it counts. As well, a SPECIFIC review of the medications would count (i.e. not just a check mark that says med list reviewed per RN staff, but something like "patient on CIPRO for UTI, I did review the culture from two days ago, good sensitivity CONTINUED CIPRO without change" would give you the point for Rx management)

 

[thegenius]

This is straight from the ACEP FAQ supposedly vetted by AMA and the like-->
25. What qualifies as prescription drug management in moderate risk?
"Prescription drug management is based on documentation that the provider has administered, prescribed, or evaluated current medications during the ED visit. This may be any administration of prescription strength medication while the patient is in the ED, a prescription written to be filled at the pharmacy, discontinuation or modifications to the patient’s existing medication dosages, or after consideration of the current medications, the decision to maintain the current medication regimen."

So my read is if you note "rx strength" 600mg Ibuprofen (my fave) either in department OR Rx home, it counts. As well, a SPECIFIC review of the medications would count (i.e. not just a check mark that says med list reviewed per RN staff, but something like "patient on CIPRO for UTI, I did review the culture from two days ago, good sensitivity CONTINUED CIPRO without change" would give you the point for Rx management)

Yea this is good stuff. We are working with Optum and they are basically just disregarding many of the aspects of this prescription drug mgmt part.

 

[southerndoc]

What constitutes "drug therapy requiring intensive monitoring for toxicity"? Does droperidol qualify since we have to have someone on a monitor (to monitor for VT)? Does Dilantin qualify? Warfarin?

 

[BoardingDoc]

What constitutes "drug therapy requiring intensive monitoring for toxicity"? Does droperidol qualify since we have to have someone on a monitor (to monitor for VT)? Does Dilantin qualify? Warfarin?

All 3 of those definitely count. ACEP specifically lists all of them under their example meds.

Source: 2023 Emergency Department Evaluation and Management Guidelines
Item number 33

The below list is not all-inclusive but provides examples of ED-relevant medications that could cause serious morbidity or death and may be monitored for adverse effects:

· Adenosine	· Ketamine
· Amiodarone IV	· Labetalol IV
· Amrinone	· Lidocaine IV
· Atropine	· Magnesium IV
· Bicarbonate IV	· Metoprolol IV
· Coumadin	· Milrinone
· D50/Glucagon	· Nicardipine IV
· Dexmedetomidine	· Nitroglycerin IV
· Digoxin IV	· Nitroprusside
· Dilantin (phenytoin) IV	· Nitrous oxide
· Diltiazem IV	· Norepinephrine
· Dobutamine	· Phenylephrine
· Dopamine	· Potassium IV
· Droperidol	· Precedex (dexmedetodine)
· Enalapril IV	· Procainamide
· Ephedrine	· Rocuronium
· Epinephrine IV, IM, SQ	· Propofol
· Esmolol	· Sodium Nitroprusside
· Etomidate	· Succinylcholine
· Haldol IV	· Thrombolytics
· Heparin	· Vasopressin
· Hydralazine IV	· Versed
· Insulin IV drip	· Verapamil IV
· Isoproterenol	· 3% Normal Saline

 

[TrailRun]

How about Naproxen? I tell patients it’s like ibuprofen but stronger (not sure if that’s true), but it’s prescription only at least

 

[thegenius]

How about Naproxen? I tell patients it’s like ibuprofen but stronger (not sure if that’s true), but it’s prescription only at least

isn't naproxen the same as naprosyn? except one is in salt form and the other isnt? but it's basically the same active ingredient? naprosyn is OTC.

 

[BoardingDoc]

How about Naproxen? I tell patients it’s like ibuprofen but stronger (not sure if that’s true), but it’s prescription only at least

Naproxen is Aleve. It's OTC. If you want to go that route, prescribe Meloxicam or celecoxib or something.

 

[Janders]

I always believed that people leaving the ER should get SOMETHING. Obviously some people get 3 Rx Meds for their vomiting and pneumonia, or admitted / transferred. But even those fast track cases and worried well… they need something. Occasionally you can get away with a few minutes of your time and a human connection, perhaps a little education, but best case was a physical token.

A little Lagniappe.

It could be a work note for that day, and Rx for Ibuprofen 600mg or Zofran or something minor, a solid plan to f/u with PCP/specialist with the referral info and appointment spelled out in writing. But a physical item to hold breeds good will.

I’m glad that the new coding rules incentivize my penchant for the lagniappe.

 

[RustedFox]

I always believed that people leaving the ER should get SOMETHING. Obviously some people get 3 Rx Meds for their vomiting and pneumonia, or admitted / transferred. But even those fast track cases and worried well… they need something. Occasionally you can get away with a few minutes of your time and a human connection, perhaps a little education, but best case was a physical token.

A little Lagniappe.

It could be a work note for that day, and Rx for Ibuprofen 600mg or Zofran or something minor, a solid plan to f/u with PCP/specialist with the referral info and appointment spelled out in writing. But a physical item to hold breeds good will.

I’m glad that the new coding rules incentivize my penchant for the lagniappe.

They did get something: a medical screening exam at their convenience and the opinion of a board certified emergency physician.

Is "Langniappe" Italian for "coddling" or "enabling"?

Most vertical patients/people that I see are there for distinct secondary gain and need to learn how to behave as an adult.

 

[TooMuchResearch]

So many questions about the coding changes.

Anybody notice that prescribing OTC medications is not part of the "moderate" risk category? That is what Optum is telling us. So prescribing tylenol and motrin won't count.

Prescription strength medicine I think is key. You can't buy 800 mg ibuprofen OTC. Yes?

 

[TooMuchResearch]

Nevermind I see it was covered.

 

[Janders]

They did get something: a medical screening exam at their convenience and the opinion of a board certified emergency physician.

Is "Langniappe" Italian for "coddling" or "enabling"?

Most vertical patients/people that I see are there for distinct secondary gain and need to learn how to behave as an adult.

Its a little freebie thrown in after a purchase for appreciation. So not an Rx for #90 Oxy 10’s, but something.

Its a New Orleans term, corrupted through a few languages. Think of a bakery that always throws a 13th Donut in if you order a dozen…

 

[BoardingDoc]

Think of a bakery that always throws a 13th Donut in if you order a dozen…

NB: the etymology for a baker's dozen being 13 units relates to the assize panis (law regulating the sale or bread) dating back to the 12th or 13th century. In short, if you were a baker and sold bread which weighed less than a stipulated amount, you could be held liable for shortchanging your customers and were subject to a flogging. Bakers started throwing in an extra loaf for each dozen as a way to ensure they avoided this.

Relevant: https://www.engr.psu.edu/mtah/articles/pdf/bread_assizes.pdf

 

[Janders]

NB: the etymology for a baker's dozen being 13 units relates to the assize panis (law regulating the sale or bread) dating back to the 12th or 13th century. In short, if you were a baker and sold bread which weighed less than a stipulated amount, you could be held liable for shortchanging your customers and were subject to a flogging. Bakers started throwing in an extra loaf for each dozen as a way to ensure they avoided this.

Relevant: https://www.engr.psu.edu/mtah/articles/pdf/bread_assizes.pdf

Brilliant. The New Orleans lagniappe comes from an Incan mountain tradition of adding a trinket (or a little extra) with purchases in their markets, the Quechua word and tradition making its way into Spanish colonist vernacular as La ñapa. During the 40 years Spain controlled New Orleans they brought the word and concept with them, but it was further modified into a French-creole word as Spanish language really never supplanted French in the area.

I recall as a small child always getting a 13th donut there, and if you bought a couple things at a farmers market or vegetable stall they always threw in a free bundle of herbs or couple small hot peppers.

Proud to carry in the the tradition, one ibuprofen 600mg tid PRN #30 Rx at a time.

 

[TooMuchResearch]

NB: the etymology for a baker's dozen being 13 units relates to the assize panis (law regulating the sale or bread) dating back to the 12th or 13th century. In short, if you were a baker and sold bread which weighed less than a stipulated amount, you could be held liable for shortchanging your customers and were subject to a flogging. Bakers started throwing in an extra loaf for each dozen as a way to ensure they avoided this.

Relevant: https://www.engr.psu.edu/mtah/articles/pdf/bread_assizes.pdf

So we get an extra donut because of an old law about "a*s size pannus?" Funniest thing I've read in a while.

 

[pkwraith]

All 3 of those definitely count. ACEP specifically lists all of them under their example meds.

Source: 2023 Emergency Department Evaluation and Management Guidelines
Item number 33

The below list is not all-inclusive but provides examples of ED-relevant medications that could cause serious morbidity or death and may be monitored for adverse effects:

· Adenosine	· Ketamine
· Amiodarone IV	· Labetalol IV
· Amrinone	· Lidocaine IV
· Atropine	· Magnesium IV
· Bicarbonate IV	· Metoprolol IV
· Coumadin	· Milrinone
· D50/Glucagon	· Nicardipine IV
· Dexmedetomidine	· Nitroglycerin IV
· Digoxin IV	· Nitroprusside
· Dilantin (phenytoin) IV	· Nitrous oxide
· Diltiazem IV	· Norepinephrine
· Dobutamine	· Phenylephrine
· Dopamine	· Potassium IV
· Droperidol	· Precedex (dexmedetodine)
· Enalapril IV	· Procainamide
· Ephedrine	· Rocuronium
· Epinephrine IV, IM, SQ	· Propofol
· Esmolol	· Sodium Nitroprusside
· Etomidate	· Succinylcholine
· Haldol IV	· Thrombolytics
· Heparin	· Vasopressin
· Hydralazine IV	· Versed
· Insulin IV drip	· Verapamil IV
· Isoproterenol	· 3% Normal Saline

Oh boy that dangerous warfarin, better keep that patient in the ED for their INR monitoring in 2 days.

 

[RustedFox]

Its a little freebie thrown in after a purchase for appreciation. So not an Rx for #90 Oxy 10’s, but something.

Its a New Orleans term, corrupted through a few languages. Think of a bakery that always throws a 13th Donut in if you order a dozen…

Yeah, for this to work, there has to be a purchase made in good faith, not: "I'm here at the ER, so give me my free stuff that I deserve because free stuff is what you get when you come here."

Over the past 2 nights, I had people come "for me to change their band-aid" (yes, not a surgical dressing, a band-aid) and "does this look infected to you? This paper cut is less than an hour old"."

And I'm expected to see them within the metrics, while I am single coverage with actively dying people.

Remember: the sign says: "Emergency".

 

[Janders]

Yeah, for this to work, there has to be a purchase made in good faith, not: "I'm here at the ER, so give me my free stuff that I deserve because free stuff is what you get when you come here."

Over the past 2 nights, I had people come "for me to change their band-aid" (yes, not a surgical dressing, a band-aid) and "does this look infected to you? This paper cut is less than an hour old"."

And I'm expected to see them within the metrics, while I am single coverage with actively dying people.

Remember: the sign says: "Emergency".

I feel your pain.
Hourly or eat-what-you-kill? Changing bandaids is silly regardless, but stings less…

 

[BoardingDoc]

I feel your pain.
Hourly or eat-what-you-kill? Changing bandaids is silly regardless, but stings less…

I believe that Rusted is hourly. I had the same reaction. This sort of thing would drive me insane on hourly comp. As it is, I don't get too mad when someone wants to give me 40 bucks via Medicaid to change a bandaid over 2 minutes.

 

[RustedFox]

I believe that Rusted is hourly. I had the same reaction. This sort of thing would drive me insane on hourly comp. As it is, I don't get too mad when someone wants to give me 40 bucks via Medicaid to change a bandaid over 2 minutes.

Hourly + RVU.

Still, I'd rather have a functioning society and not be the band-aid changer because of the expectation it sets that we are responsible for every little thing that any non-ostrich can do for themselves, and they get a free piece of bread when they come.

 

[BoardingDoc]

Hourly + RVU.

Still, I'd rather have a functioning society and not be the band-aid changer because of the expectation it sets that we are responsible for every little thing that any non-ostrich can do for themselves, and they get a free piece of bread when they come.

Yeah, agree completely. I can't begin to imagine how much better this job would be if the average idiot weren't, well, an idiot. Within the confines of our reality, I choose to focus on the personal benefit I can derive from the absurdity that we are forced to endure in this job.

Some may argue that this is an unpleasant mercenary approach. When the alternative is to focus on the sheer inadequacies of humanity at large (pun intended), I'd prefer the former.

 

[KGflyboy]

I sure hope our billers and coders have enough brain cells between them to figure this out. Given the kind of charts I get sent back for completion, which already has the documented information they're asking for, I'm not so sure.

Well, it turns out our coders do not. We had an initial review of charts this year. They apparently need everything spelled out word for word.

 

[thegenius]

@wareagle726 turned me onto a coding tool at Home - ERNotes - ER Charting Made Simple. Click on "Coding level tool". Looks like there is a copy / paste function (or it automatically copies a script to your clipboard) so one can put a LOS in their chart. Looks promising and so far it appears to work.

 

[alphaholic06]

I always believed that people leaving the ER should get SOMETHING. Obviously some people get 3 Rx Meds for their vomiting and pneumonia, or admitted / transferred. But even those fast track cases and worried well… they need something. Occasionally you can get away with a few minutes of your time and a human connection, perhaps a little education, but best case was a physical token.

A little Lagniappe.

It could be a work note for that day, and Rx for Ibuprofen 600mg or Zofran or something minor, a solid plan to f/u with PCP/specialist with the referral info and appointment spelled out in writing. But a physical item to hold breeds good will.

I’m glad that the new coding rules incentivize my penchant for the lagniappe.

You from New Orleans bro?

 

[Janders]

You from New Orleans bro?

Lafayette as a young un. Don’t remember tons of things but remember always getting a 13th donut/cookie at a bakery and peppers/herbs at any vegetable stand with purchases…

 

[Asadullah]

Anyone have any macros to help create a template for the new guidelines?

 

[thegenius]

Home - ERNotes - ER Charting Made Simple

Charting and coding content for ER providers. Freetext procedure notes, MDM notes, Physical Exam notes, etc... Updated for the new 2023 CMS guidelines

ernotes.net

Go to "Coding Level Tool"
appears to be great. can copy/paste a level of service suggesting into your chart. has lots of features.
best one I've found on the internet.

 

[EMCoding2023]

Hi. I'm here to advertise a tool I wrote for all ER docs. For the new 2023 coding changes. It looks like it was already found and mentioned on SDN. Great!

It's a free, web-based tool that makes a script that you can copy and paste and put in your chart. This suggests to the billing and coding company your site employs what you think is the appropriate billing level. 99283, 99284, 99285. I designed it to make it very easy to use. Click on a few radio buttons and checkboxes, click on "Generate Script" and it pops up a screen of the summary of your choices. Then you can "Copy To Clipboard" which is the same as CTRL-C, and you can paste into your note. My site uses Cerner and it works good. It also works on Epic and just about anything that can accept text.

The site also has help topics that pop up if you want to read them. I slowly continue to add functionality to the tool and every 1-2 weeks I publish a new version. Thanks to Wareagle (a member here) for allowing me to host this on his website.

2023 EM Level Of Service Chart Builder

Home - ERNotes - ER Charting Made Simple is where it is hosted.

I think overall charting in 2023 and going forward should be easier. Still kind of annoying but I'm no longer putting in ROS, PMH, things like physical exams are much simplier. We have about 20 docs at our site and we get weekly reports from the coding company about concordance between our suggestions and what they actually code, and it's > 90% agreement. Probably more like 95%.

Love to hear anyways to improve it, suggestions, feature requests, or anything else. Thank you for your time.

 

[Asadullah]

Hi. I'm here to advertise a tool I wrote for all ER docs. For the new 2023 coding changes. It looks like it was already found and mentioned on SDN. Great!

It's a free, web-based tool that makes a script that you can copy and paste and put in your chart. This suggests to the billing and coding company your site employs what you think is the appropriate billing level. 99283, 99284, 99285. I designed it to make it very easy to use. Click on a few radio buttons and checkboxes, click on "Generate Script" and it pops up a screen of the summary of your choices. Then you can "Copy To Clipboard" which is the same as CTRL-C, and you can paste into your note. My site uses Cerner and it works good. It also works on Epic and just about anything that can accept text.

The site also has help topics that pop up if you want to read them. I slowly continue to add functionality to the tool and every 1-2 weeks I publish a new version. Thanks to Wareagle (a member here) for allowing me to host this on his website.

2023 EM Level Of Service Chart Builder

Home - ERNotes - ER Charting Made Simple is where it is hosted.

I think overall charting in 2023 and going forward should be easier. Still kind of annoying but I'm no longer putting in ROS, PMH, things like physical exams are much simplier. We have about 20 docs at our site and we get weekly reports from the coding company about concordance between our suggestions and what they actually code, and it's > 90% agreement. Probably more like 95%.

Love to hear anyways to improve it, suggestions, feature requests, or anything else. Thank you for your time.

You're awesome; I'm actually interested in finishing coding so I can do this sort of thing (make docs lives easier).

Thanks!!

 

[wareagle726]

Hi. I'm here to advertise a tool I wrote for all ER docs. For the new 2023 coding changes. It looks like it was already found and mentioned on SDN. Great!

It's a free, web-based tool that makes a script that you can copy and paste and put in your chart. This suggests to the billing and coding company your site employs what you think is the appropriate billing level. 99283, 99284, 99285. I designed it to make it very easy to use. Click on a few radio buttons and checkboxes, click on "Generate Script" and it pops up a screen of the summary of your choices. Then you can "Copy To Clipboard" which is the same as CTRL-C, and you can paste into your note. My site uses Cerner and it works good. It also works on Epic and just about anything that can accept text.

The site also has help topics that pop up if you want to read them. I slowly continue to add functionality to the tool and every 1-2 weeks I publish a new version. Thanks to Wareagle (a member here) for allowing me to host this on his website.

2023 EM Level Of Service Chart Builder

Home - ERNotes - ER Charting Made Simple is where it is hosted.

I think overall charting in 2023 and going forward should be easier. Still kind of annoying but I'm no longer putting in ROS, PMH, things like physical exams are much simplier. We have about 20 docs at our site and we get weekly reports from the coding company about concordance between our suggestions and what they actually code, and it's > 90% agreement. Probably more like 95%.

Love to hear anyways to improve it, suggestions, feature requests, or anything else. Thank you for your time.

Thanks for the mention and for all the work you have put in!

Guys this tool is an awesome resource.

 

[thegenius]

So how are people's reactions/opinions of the new coding changes. I've noticed a few things:

1) our billing/coder Optum likes to code several lac repairs as low risk and not moderate risk, despite ACEP clearly outlining that the vast majority (or all) lac repairs should be moderate

2) about 6% of all our coding from Jan - Feb are 99282!! daft as that has been explicitly outlined that it should basically never be used unless it's a dressing change or suture removal

3) still getting inconsistent info on how "prescription strength medicine" in the risk column is being applied. I've seen credit given for giving a single norco as "moderate risk", apparently OTC drugs (all of them) cannot be coded as "moderate risk", it just seems inconsistent.

4) lots of downcoding on the complexity of problems addressed. For instance, one of our docs had a F with RLQ pain and vomiting and report of being pregnant. First on ddx was ectopic pregnancy. That suggests highest complexity of problems - yet Optums said it was "moderate complexity."

BTW our biller/coder is Optum and they are simply terrible. what a terrible experience.

 

[wareagle726]

So how are people's reactions/opinions of the new coding changes. I've noticed a few things:

1) our billing/coder Optum likes to code several lac repairs as low risk and not moderate risk, despite ACEP clearly outlining that the vast majority or it not all lac repairs should be moderate

2) about 6% of all our coding from Jan - Feb are 99282!! daft as that has been explicitly outlined that it should basically never be used unless it's a dressing change or suture removal

3) still getting inconsistent info on how "prescription strength medicine" in the risk column is being applied. I've seen credit given for giving a single norco as "moderate risk", apparently OTC drugs (all of them) cannot be coded as "moderate risk", it just seems inconsistent.

4) lots of downcoding on the complexity of problems addressed. For instance, one of our docs had a F with RLQ pain and vomiting and report of being pregnant. First on ddx was ectopic pregnancy. That suggests highest complexity of problems - yet Optums said it was "moderate complexity."

BTW our biller/coder is Optum and they are simply terrible. what a terrible experience.

Still waiting to get some report from our coders on actual numbers. I will say that I have had multiple comments from coders saying it was helpful to have a statement of what I thought was the correct level of service AND why. That's why I started using that tool listed above.

 

[thegenius]

Still waiting to get some report from our coders on actual numbers. I will say that I have had multiple comments from coders saying it was helpful to have a statement of what I thought was the correct level of service AND why. That's why I started using that tool listed above.

Yea good times. Our guys use that tool above too. We get a random sample of QA'ed charts which compare the level we suggest and the level Optum ends up giving. I'd say right now there is about 80% consistency, and out of the remaining 20% about 85% of our charts are downcoded and 15% are upcoded.

Kind of irritating because I feel like Optum just likes playing doctor and asserts that a chart is COPA moderate or RISK low despite the fact we are telling them it's not. I'm aware that there is probably a tendency for docs to overchart, but at the same time we are the ones that have to defend our charts under audit.

If we see a woman with RLQ pain, vomiting, and she says she's pregnant, that is COPA high 100% of the time. Always, on any planet, in any universe.

My back of the hand calculation is that 85% of all ER charts should be 99284, 5, and 99291/2. Only about 15% should be 99283, and there should be ZERO 99282.

 

[wareagle726]

Yea good times. Our guys use that tool above too. We get a random sample of QA'ed charts which compare the level we suggest and the level Optum ends up giving. I'd say right now there is about 80% consistency, and out of the remaining 20% about 85% of our charts are downcoded and 5% are upcoded.

Kind of irritating because I feel like Optum just likes playing doctor and asserts that a chart is COPA moderate or RISK low despite the fact we are telling them it's not. I'm aware that there is probably a tendency for docs to overchart, but at the same time we are the ones that have to defend our charts under audit.

If we see a woman with RLQ pain, vomiting, and she says she's pregnant, that is COPA high 100% of the time. Always, on any planet, in any universe.

My back of the hand calculation is that 85% of all ER charts should be 99284, 5, and 99291/2. Only about 15% should be 99283, and there should be ZERO 99282.

I think you're spot on with those numbers. I don't know of a situation that, outside of a single coverage no NP situation billing for suture removal, that we would ever get a lvl 2. Even so with suture removals I do an in-depth exam and describe wound margins/healing etc... that is way beyond the simple NP triage and MSE stuff.

I agree the CoPA is underrated by coders. A good example is that I had a guy come in for an earplug stuck in his ear for 2 days. Simple removal but still had the risk of infection and trauma to the ear which I think would be moderate. I mean he is at risk of losing his hearing if he developed necrosis of a portion of his tm or had a bad perf or something. Overkill? maybe. Have I seen less likely situations occur? Absolutely.

Our reimbursement shouldn't be based on us treating the horses. It should be based on our highly specific skills of deduction to make sure they aren't zebras painted a solid color. More pointedly, painted zebras that could possibly die or lose function if we don't scratch off the paint.

 

[EctopicFetus]

Optum = United healthcare. Time to get someone else. We have 0 level 2s.

 

[BoardingDoc]

Optum = United healthcare. Time to get someone else. We have 0 level 2s.

Yeah, I don't understand how it isn't an obvious massive conflict of interest to have the coding company, who decides the amount to bill for, be owned by the insurance company, who is the one getting the bill.

 

[TooMuchResearch]

Yeah, I don't understand how it isn't an obvious massive conflict of interest to have the coding company, who decides the amount to bill for, be owned by the insurance company, who is the one getting the bill.

Just wait until they start staffing the ED with Optum "providers," unless that's already happening.

 

[CajunMedic]

Lafayette as a young un. Don’t remember tons of things but remember always getting a 13th donut/cookie at a bakery and peppers/herbs at any vegetable stand with purchases…

Baton Rouge here. I went to then-USL my first attempt at college

 

[gutonc]

Just wait until they start staffing the ED with Optum "providers," unless that's already happening.

They already have UC and primary care so....

 

[EctopicFetus]

Just wait until they start staffing the ED with Optum "providers," unless that's already happening.

Sound physicians.

United is the single largest employer of physicians in America. 1 in 16 docs works for them all specialties. All docs. 1 in 16.

 

[southerndoc]

How do you guys document life-threatening conditions? Do you put down every chest pain as potentially life-threatening (most of them are -- we rule out PTX, MI, PE, TAD, etc. either clinically or via imaging/labs/EKG)? Curious what you guys are considering life-threatening.

 

[wareagle726]

How do you guys document life-threatening conditions? Do you put down every chest pain as potentially life-threatening (most of them are -- we rule out PTX, MI, PE, TAD, etc. either clinically or via imaging/labs/EKG)? Curious what you guys are considering life-threatening.

I'm approaching it as what is my real gut feeling. If its a 20yo talking on their phone with normal VS who PERCs out and has obvious gerd after eating 20 hot wings then I don't. If there are risk factors and it's in the realm of reasonable possibility then I do. I think that's where these new changes benefit us. Hard to argue with a doc who thinks a 55yo with HTN and DM p/w chest pain and has a not completely normal EKG. Don't know how anyone could say that isn't potentially life-threatening. Especially in the populations most of us work with.

 

[Mount Asclepius]

How do you guys document life-threatening conditions? Do you put down every chest pain as potentially life-threatening (most of them are -- we rule out PTX, MI, PE, TAD, etc. either clinically or via imaging/labs/EKG)? Curious what you guys are considering life-threatening.

Time to play the new game.

ROS requiring use of macros and slights of truth was stupid, but almost easier.

Now it’s every chief complaint is initially a risk for deterioration of that organ and life threatening, but upon further evaluation no serious condition identified.

Everyone’s prior records get briefly reviewed and quickly summarized.

Of course I talked to an alternative historian! Their family member/friend/significant other/friend with benefits also speculates that the patient’s belly pain is due to the jalapeños as they munch down the remaining French fries from their fast food themselves.

Everyone tries to come for physicians’ money instead of appropriately paying them for their hard work and expertise. We’ll beat them at this new game. Yet we’ll spend a little more time documenting temporarily until we get all the new macros created furthering demoralization. Thank goodness for wellness seminars…

 

[BoardingDoc]

Time to play the new game.

ROS requiring use of macros and slights of truth was stupid, but almost easier.

Now it’s every chief complaint is initially a risk for deterioration of that organ and life threatening, but upon further evaluation no serious condition identified.

Everyone’s prior records get briefly reviewed and quickly summarized.

Of course I talked to an alternative historian! Their family member/friend/significant other/friend with benefits also speculates that the patient’s belly pain is due to the jalapeños as they munch down the remaining French fries from their fast food themselves.

Everyone tries to come for physicians’ money instead of appropriately paying them for their hard work and expertise. We’ll beat them at this new game. Yet we’ll spend a little more time documenting temporarily until we get all the new macros created furthering demoralization. Thank goodness for wellness seminars…

Agreed.
Chest pain gets a "High risk possible diagnoses include ACS" in my chart (assuming I'm getting an EKG and a trop, even if it's a 30 yr old and the trop was ordered in triage).
Abd pain getting imaging gets: High risk possible diagnoses include perforated hollow viscous, appendicitis, blah blah blah that you would see on a CT scan so writing it down shouldn't open up much medmal risk

Did I order a cbc and a chem only? You bet I'm either documenting one thing family said, or checking their med fill history or whatever to get that 2nd column up to 3 points of data and thus at least a lvl 4.

Everyone who isn't getting admitted either gets a Rx or gets documentation regarding why I considered, but did not provide an Rx. That gets you a lvl 4 at least in the Risk column.

It's all a stupid game. The only part I don't have solidly down (because our coders have been mum on it) is whether my "high risk" comments above are actually checking the box for a lvl 5 chart in the COPA column as that's ultimately at their discretion. The other two columns are pretty checkbox in nature.