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Twerking Disease: The Definitive Medical Resource For Doctors.

Thanks to the Video Music Awards (VMAs) and Miley Cyrus, the entire world has been exposed to twerking. The internet is filled with detailed commentary discussing the social, political and anthropological ramifications of twerking. Search YouTube for twerking and you'll find hundreds of twerking FAILS. There are the twerking interventions and the twerking cats. There are the twerking parodies and the twerking Vines. There are even videos about twerking at Walmart. The world has gone twerking crazy.

But, what is twerking? Wikipedia describes twerking as a "type of dancing in which the dancer, usually a woman, shakes their hips in an up-and-down bouncing motion, causing the dancer's buttocks to shake, "wobble" and "jiggle." [1] Oxford Dictionary Online, says to twerk is "to dance to popular music in a sexually provocative manner involving thrusting hip movements and a low, squatting stance." [2] The Urban Dictionary describes twerking as "the rhythmic gyrating of the lower fleshy extremities in a lascivious manner with the intent to elicit sexual arousal or laughter in ones intended audience." [3]

These definitions are acceptable for lay folk but not for doctors and nurses. After an exhaustive search on Google, I was unable to find any twerking literature written for the doctor or nurse as the intended audience. So I searched UpToDate instead. I was heartbroken to discover this second most definitive medical source for health care professionals was also woefully silent on the subject. As a physician, I was saddened by the lack of information by physicians, for physicians. Twerking is an epidemic. We owe it to ourselves to get educated about this potentially life threatening condition. So I made this my day's mission. I researched the subject and talked to top medical experts on the subject and created the worlds first white paper resource on twerking. It is my pleasure to present Twerking Disease: The Definitive Medical Resource For Doctors. This publication will hopefully shake the medical community into action. I hope so. I twerk'd my ass off writing it.

DEFINITION

Twerking is estimated to affect like, 69 million Americans, including nine out of ten females with low self esteem and like, nine out of ten females with too much self esteem. Dancing in a gay nightclub will like, increase the risk of contracting twerking by like 100%. In addition, boys who think they look cool twerking to pick up chicks have a 99.99% chance of like, striking out. Further research has shown a 20 and 25 fold increased chance of contracting twerking by like, attending a public or Catholic school respectively. After teenage girls, cougars, demented women with boob jobs and gay men hanging out with straight women are most at risk of contracting twerking disease.

SIGNS AND SYMPTOMS

Patients usually present with a combination of signs and symptoms including back pain, beer goggles and acute exacerbation of looking ridiculous. Parents should be on the look out for locked doors, late night Twitter twerking and, of course, twerxting. Clues to a twerking addiction may include a rapid increase in texting volume during peak music hours. If your kids complain of neck pain, consider closet twerking as a cause of trying to check themselves out in the mirror with ass-inine positions. For Cougars and demented old ladies with boob jobs, sudden spikes in flirting with doctors who are "too young to be my doctor" may be a clue to worsening twerking symptoms.

PHYSICAL EXAM

Ha! Ha! Ha! Ha! Physical exam. That's a good one.

CAUSES

The main cause of twerking is a failure to vaccinate. Decades of research has proven universal vaccination programs can prevent twerking in 99.99999% of the population. That one person out of 100,000 who got twerking disease after being vaccinated is the basis for the anti vaxxers crusade against universal twerxsination. The CDC issued a nationwide alert two weeks before the Miley Cyrus VMA rampage detailing their grave concerns about an imminent twerking epidemic and the failure of a national public health vaccination program to eradicate twerking. Unfortunately, that alert fell flat on its ass. In August, 2013 a rare but humiliating variation of twerking, called Myley Cyritis, swept through America faster than the National Organization for Women (NOW) could boycott something. Anything. When asked for a comment on Miss Cyrus' twerking presentation, the President of NOW said, "Wow! That's a women?"

DIFFERENTIAL DIAGNOSIS

Twerking may be seen as a stand alone disease or as a complication of other disease processes. Always consider the following diagnoses in your differential diagnosis of twerking: frontal lob dementia, encephalopathy, genetic stupidity, lack of parenting, Enbril, wine coolers, typical teenager, Parkinson's (twerking jerking).

RISK FACTORS

If you think twerking is cool, you are at risk.

TWERKING RELATED DISEASE PRESENTATIONS

Twerking can have devastating consequences. Physicians and other healthcare practitioners should be aware of variations in presentation for patients as well as collateral damage twerking can bring to friends and family.

ANKYLOSING TWERKYLOSIS: When your spine permanently fuses in the twerking position.

ATYPICAL TWERKING: When you're just not sure what you're seeing, admit to the hospitalist under observation status.

BOVINE TWERKIFORM ENCEPHALOPATHY: A life threatening variant caused by eating McDonald's before a heavey night of twerking.

JAPANESE TWERKILITIS: When a Japanese teenager tries to twerk.

MILEY CYRITIS VARIANT: Twerking associated with full facial malfunction, uncontrollable tongue spasms. Can induce severe inflammatory eye disease in unsuspecting viewers.

NEUROTWERKOCERCOSIS: A brain disorder manifested by the inability to see how stupid one looks while twerking.

OSTEOTWERKOSIS: A form of osteoperosis caused by excessive twerking.

TWERKAHOLIC-- When you work so much, that the only way your daughter can get your attention is to twerk.

TWERKALARIA: A variant of malaria, Bill Gates has added twerkalaria to his list of diseases he'd like to eradicate with his gobs of money.

TWERKALICIOUS-- A variant of extreme twerking manifested by sucking on a lollipop in a provocative manner while twerking to the beat of the night.

TWERKANGINA-- Chest pain after watching your daughter dance away her dignity.

"If you get chest pain after watching your daughter twerk, go to the ER immediately! You may have terkangina."

TWERKARIASIS: A skin condition caused by constant irritation of one's dignity.

TWERKILIS: An STD, usually contracted by twerking without wearing underwear.

TWERKILITIS: When you feel so dirty after watching it, you have to take a shower to wipe away the inflammation.

TWERKINOSIS-- An STD, usually contracted after a heavy night of twerking and feeling insecure.

TWERKIOLITIS: A breathing disorder manifested by heavy panting while twerking.

TWERKOCELE: Formation of fluid collections in places never seen before the twerking epidemic.

TWERKOPY-- Passing out after watching your daughter twerk.

TWERKULOSIS: Highly resistant to most drug therapy and mostly manifested as large lung lesions, twerkulosis is seen in travelers returning from third world countries and Hawaii.

SYSTEMIC TWERKIS ERYTHEMATOSUS: When it looks like twerking or lupus but it isn't lupus because the answer is never lupus.

YouTwerk®: A life threatening CNS disorder, usually caused by watching twerking videos on YouTube.

WHEN TO GO TO THE ER

Anytime you feel like it. This is America.

"4 years of chronic nausea is not an indication to visit the ER at 2 am. I'm an ER doctor. As in emergency. As in 4 years of anything makes me nauseated."

4 years of chronic nausea ER doctor crude medical ecard

TESTS AND DIAGNOSIS

Twerking and twerking related diseases are often diagnosed based on history and physical. That means most cases will be missed because everyone knows history and physical is generated by computers these days and since a template for twerking and twerking related diseases has not been mandated by any government agency, most EHR systems do not yet offer them. Twerking and twerking related diseases are the most under-diagnosed pathological conditions today. Even Watson, the computer that won Jeopardy, failed to recognize twerking. After presenting Watson with a YouTube video with over 600 million views titled "How To Twerk", Watson promptly quit his job as super computer to become an extreme Twerker and live off his YouTube income for the rest of his life.

Twerking can be diagnosed in less than 0.001% of cases using nonFDA approved TWE-E-G and twerkemetry technology. That means everyone with a suspected diagnosis of twerking will get both tests. Twice. Just to make sure. In addition, flexible twerkoscopy, the act of inserting a flexible scope into the rectum to verify nothing made it in there during a night of heavy twerking, is occasionally performed during a twerking hospitalization, usually as a stat recommendation called in by the Night Nurse RN, MSN, M&M and PRN, because the hospitalist is too busy admitting 14 other twerkers in the ER after a performance from Miley Cyrus at her Hannah Montana: What the Fruck Happened To Me? tour.

TREATMENTS AND DRUGS

The best treatment for twerking and twerking related illness is to just stop. Don't shake your ass. Don't wiggle your thighs. Don't arch your back like a little hoe-bag. Don't slap that booty around like the piece of vagina you're trying to be. Just stop. Seriously. WTF. Just stop. Enough already. However, if you find yourself overcome with twerking emotions, agitation and withdrawal, one nonrandomized, retrospective observational trial of 25 twerkers from The Ethiopian Hospital For Poor People proved daily exercise, vaccination at birth and looking at yourself in the mirror to prove just how stupid you look can send twerking addicts into remission 96% of the time. This study was published in Time magazine so it must be true. In addition, the story was picked up by 95.8 THE BONE and was described by a self proclaimed expert twerker jockey between songs about booty slappin' and G-thangs.

EXERCISE

Studies have shown most folks watching Richard Simmons in "Twerking to the Oldies" have been cured of their twerking addiction.

MIRROR THERAPY

Consider buying a full length wall mirror for full therapeutic effect. Alternatively, take a video of yourself twerking while checking yourself out in a mirror, put it on YouTube and let everyone leave nasty comments in a public display of humiliation. This study has not been performed in Ethiopia because they are too poor to have mirrors, but, in theory, it should work.

DRUGS

There are no known drug treatments for twerking. Big Pharma, however, is working diligently to rebrand an old generic drug as a treatment for twerking so they can start charging your ass off.

PREVENTION

There are only three ways to prevent twerking: vaccines, parenting and not watching Miley Cyrus.

VACCINES

A twerking vaccine has been available every since 1952, the year the polio vaccine was invented. Some reputable celebrities with years of internet based medical training believe twerking is a complication of the polio vaccine and have started a nationwide campaign to stop immunizing our children, pregnant women and nursing home residents. In fact, Jennifer McCarthy was seen Tweeting this twerking comment: Poor Miley: Twerking AND Autism. But no polio. I'm right again.

ANTIVAX FORUM COMMENTS

My husband and I cried for years after vaccinating our triplets with the polio vaccine. We read all about these dangerous side effects on McCarthyExpertAdvice.com only after we mutilated our children. We will have to live with this for the rest of our lives. Go Jenny! We love you!
We will never vaccinate our kids again. Their arm hurt after the shot. F***ing drug companies. They're just trying to make money off my kid.
My chiropractor told me diet could prevent twerking. My pediatrician is a quack. I'm never going back again.
I talked to my neighbor about vaccinating my kids and they said, "Hell no!". But then they had to leave and can another 100 jars of tomatoes in preparation for Doomsday, so I never got to hear why. But I believe them. No shots for my beautiful kids. No sir. No way.

NEWBORNS AND PREGNANCY

The CDC recommends vaccinating against twerking starting in-utero at 10 weeks gestation in the ER. They hope to capture 100% of uninsured females going to the ER for abdominal pain but really just wanting a pregnancy test after heavy twerking the night before and missing their period for less than 24 hours. For the stable, family oriented pregnant women who has never been to the ER, the CDC recommends they continue their great parenting skills. No vaccination is necessary.

ELDERLY

The CDC recommends vaccinating all Americans over the age of 65 or in a nursing home. They recommend giving it as a combivalent vaccine to protect against Parkinson's and statin related twerking jerking. It should be given in combination with the Zoster vaccine, the flu vaccine, the pneumonia vaccine and the new for 2013 Hospital Readmission Prevention vaccine in the hopes of preventing this butt-iful display of disinhibition.

HEALTHCARE WORKERS

The CDC recommends vaccinating all healthcare workers to prevent outbreaks of creative hospital YouTube twerking videos set to catchy music and lame dance moves that appear benign but are actually made as clever marketing campaigns intended to infect the unsuspecting public.

PARENTING

Parenting means to be a parent.

STOP WATCHING MILEY CYRUS

Stop watching Miley Cyrus means to stop watching Miley Cyrus.

BREASTFEEDING

The CDC recommends not breastfeeding during twerking, unless you plan to post pictures of your experience on the Hot Twerking Breastfeeding Moms website or unless you are trying to win the cover shot contest for Time Magazine's Twerking Mother of the Year Award.

TWERKING SEASON

Americans are at greatest risk of twerking epidemics during music award shows on television or being within 100 miles of Miley Cyrus.

SIDE EFFECTS OF TREATMENT

Treatment of all twerking disorders will result in return of one's dignity. There are no other known side effects of treatment.

COPING AND SUPPORT

There are no support groups for twerking. Not every disease needs a support group, but every disease does deserve an online forum filled with self proclaimed experts just waiting to make you second guess everything you thought to be true and just in this world. The best forum can be found at proudtotwerk.com. It appears the most knowledgable member goes by the name ChronicTwerkStud, a highly respected never married member since 1995. Despite this evidence, we recommend against searching for these support groups, but if you must, consider instead TwerkDC.com as your trusted source for online twerking related research. TwerkMD.com was unavailable, as it was apparently bought by a bunch of chiropractors with the hopes of gaining respect for their new cash only business venture called the Holistic Twerkupuncture, Twerkulation & Twerkness Institute with franchise rights available in every city with a home and garden show or county fair, the only known venues to advertise their services.

HOSPITAL ISSUES RELATED TO TWERKING

Hospitalists and other medical practitioners who work in the hospital setting should be aware of issues related to twerking. During epidemic and pandemic situations, hospitals should have policies and procedures in place to handle the rapid increase in twerking volume that could put a significant strain on hospital resources, especially on weekends when many doctors and nurses are forced to function under limited twerking conditions.

WHEN TO ADMIT TO ICU

Twerkers should be admitted to the ICU if they show signs or symptoms of fragile emotional lability. Floor nurses just don't have the time to comfort them every five minutes with bedside empathy such as, "Everything is going to twerk out OK". On the other hand, ICU nurses are trained in rapid Versed infusions at the slightest suggestion of forced conversation.

"Forget about all that lame nonsense nursing garbage we learned in school. We're ICU nurses. We've got Versed for anything that moves!"

Forget about all that lame nonsense nursing garbage we learned in school. We're ICU nurses. We've got Versed for anything that moves ecard humor photo.

"I twerked my ass off today and got the best patient satisfaction scores EVER!"

WHEN TO GET A PALLIATIVE CARE CONSULT

All twerkers deserve an opportunity to discuss their palliative care options on admission.

CENTERS FOR MEDICARE & MEDICAID SERVICES(CMS)

Government officials estimate twerking and twerking related illnesses cost Medicare over 6.9 billion dollars a year, mostly from young females on Medicare for disability related to complications of fibromyalgia. After disabled fibro, divorced Cougars and nursing homes residents who look older than their stated age are the second and third most costly twerkers for Medicare. As such, CMS has promised 422 new demonstration projects at a cost of 12.6 billion dollars over the next ten years to try and save 50 million dollars a year by implementing untested and unproven national guideline driven twerking standards. Specific policy issues are detailed below.

READMISSION POLICY

A readmission penalty will be applied for all twerkers readmitted to the hospital with twerking or twerking related illness as the primary diagnosis within 30 years of their sentinel hospitalization. This policy is in line with up and coming readmission policies for other medical conditions. The penalty will be equal to a value greater than a complicated formula that has not yet been determined or 100% of charges, which ever is greater.

DOCUMENTATION

Hospitals should plan on hiring dozens of additional clinical nurse documentation experts to fully comply with new twerking rules and regulations.

COMPLICATING CONDITION/DRG

Twerking is considered a major complicating or comorbid condition (MCC). Despite the etiology of the disease process, CMS decided not to make twerking an O.P.P condition.

OSHA

Twerking shall not be allowed at the nurses station at anytime due to the potential transmission of body fluids. However, OSHA does allow drinking coffee while twerking at the nurses station because they know everyone does it anyway, especially on weekends, holidays and whenever they efin want to.

"If you read the fine print, it says no food or drink at the nursing station, except on nights, holidays and whenever I f***in' feel like it."

If you read the fine print, it says no food or drink at the nursing station, except on nights, holiday and whenever I feel like it nurse ecard humor photo.

JOINT COMMISSION

The Joint Commission (JC) has no specific twerking standards except to comply with OSHA rules and regulations. However, if they catch any staff twerking during an unannounced visit, the staff member will be treated to a night of heavy drinking and smooth talkin' romance by the, "I have to go on another unannounced trip, Honey. I'll be back in week" JC consultant.

TWERKING SEASON

All hospitals should post warnings at public entrances asking families not to bring infected twerkers to the hospital during elderly season. They can, however bring concealed weapons into the hospital to protect themselves against doctors or nurses who tell patients they cannot leave the floor without their permission. According to most state and federal statues, kidnapping is a federal offense. In addition, twerkers are encouraged to smoke 'em up in the ABSOLUTELY NO SMOKING section of the hospital campus because hospital staff would rather have them out of sight and out of mind.

PET THERAPY

Pet therapy volunteers are encouraged not to be afraid of twerkers, although it's understandable if they are. If a twerker does request pet therapy, make sure the animal is spayed and neutered.

AMERICANS WITH TWERKING ABILITIES ACT

All hospitals should comply with all federal laws regarding patients with exceptional twerking abilities. This includes full length mirrors, ample space to shake that tang and an updated surround sound system with booty thumpin' base.

PHYSICIANS

All physicians and non-physician practitioners (NPPs) should be aware of work related twerking issues in the hospital setting.

PROGRESS NOTE EXAMPLE

Documenting a hospital followup progress note (99231-99233) for twerking should follow the S.O.A.P note format most often used during evaluation and management encounters. Here is one example:

S. Patient says her ass is jiggling. It started 3 days ago. It involves the ass. It only jiggles when she shakes it. It goes away when she stops shaking it. It is associated with loss of dignity.
O) 120/80 80 AF
Ass appears symmetric. Normal skin tone and turgor. Ass turns red when slapped. No craters, valleys, lumps or bumps are appreciated. Breast exam normal too.
A) Acute on chronic twerking complicated by lack of self respect.
P) Discharge patient and tell her to go to the ER immediately for a pregnancy test and a pelvic exam.

BILLING AND CODING

Physician should bill twerking encounters like they do any other hospital encounter. Note, twerking is considered high risk disease management on the medical decision making risk table.

ICD CODE

According to ICD standards, twerking and twerking related injuries are considered an external cause of injury by an environmental event and are given an E code. The E code for dancing related injuries is E005.5. Injury, specifically related to twerking is new in the 2013 ICD-9 book of numbers and has been given the code E005.69. ICD-10 however has 42,000 additional subclassifications of twerking related injuries and will have 14 additional decimal data points. For example, ICD-10 differentiates between twerking injuries related to tap-twerking while listening to the Golden Girls sound track and super-fast twerking while smoking pot at a strangers house at 3 am in a neighborhood near a strip club.

PQRS

Starting in 2014, hospitalists will be able to submit PQRS data for twerking admissions. Twerking now occupies quality measure number perfect 10. Hospitalists may report G6968, G6969 or G6970 for their twerking quality improvement data. G6968 should be reported if the twerker received an order for a one hour shower on admission, with special attention to the retrorectoneal region. G6969 should be reported when no order was given but only if the reason documented was because the patient had fibromyalgia and an allergy to water. G6970 should be reported when no shower was ordered and no reason was given because none of this crap matters anyway.

OTHER TWERKING RELATED ISSUES

HANDICAP TWERKING TAGS

Talk to your doctor today about obtaining a special handicap twerking sticker. They are only available by physician authorization. Please do not park in spots designated for those afflicted with twerking and twerking related diseases. These folks are sick and need all the assistance they can get.

TALK TO YOUR KIDS ABOUT TWERXTING

There's just one rule here. If you are caught twerxting, you lose cell phone privileges for life. End of story.

WORDS THAT RHYME WITH TWERKING

If you're trying to think of something clever to say about twerking, you need to know what words rhyme with twerking. Here you are: jerking, lurking, perking, shirking, smirking, working

SLANG

Slang speech is a part of popular American culture. Learning how to speak twerky is important if you want to have influence in your circle of friends, or if you want to get a lot of likes on Facebook. Here are a few examples of twerky slang creeping into pop culture: twerky jerky, do the funky twerky, twerk off, twerk it, twerkin' for a livin', I twerk'd my ass off, live hard twerk hard.

DO YOU HAVE THE GOODS TO TWERK?

[1] Wikipedia
[2] Oxford Dictionary Online
[3] Urban Dictionary

You can find all of these original Happy Hospitalist crude medical ecards on Pinterest.

This post contains humor that may only be understood by those in a healthcare profession or by those who know how to twerk it. Read at your own risk.

99214 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99214 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99211-99215. CPT® 99214 represents the mid-high (level 4) office or other outpatient established office patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). This procedure code lecture for established office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria required to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

Make sure to also review my detailed lectures on CPT® 99213 and CPT® 99215, both part of my complete collection of CPT® lectures organized in one easy-to-find resource on Pinterest. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99214 MEDICAL CODE DESCRIPTION

My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99214 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99214 CPT® procedure code as follows:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.

This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99214 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for an established outpatient clinic note are the:

History
Physical Exam
Medical Decision Making Complexity

For all established office patient billing codes (99211-99215), the highest documented two out of three above components determines the correct level of service code. Compare this with the requirement for the highest documented three out of three above components for new office patient care encounters (99201-99205). Again, only the highest two out of three components are needed to determine the correct level of care for CPT® 99214. The following discussion details the minimum requirements necessary to remain compliant with CPT® 99214. In addition, as with all E/M encounters, a face-to-face encounter is always required. However, in the case of outpatient clinic codes, Medicare does allow incident to billing, where the the service is provided by someone other than the physician. If certain requirements are met, the physician may collect 100% of allowable charges in these situations. Services billed incident to are billed under the physician's provider number.

Detailed history: Requires 4 or more elements of the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. One element from the past medical history or social history or family history is also required. The review of systems should inquire about the system directly related to the HPI and at least 2-9 additional systems.
Detailed examination: 1997 guidelines require documentation of at least 12 elements identified by a bullet in two or more organ systems(s) or body area(s). Alternatively, documentation of six organ systems or body areas with at least 2 bullet elements each is allowed as well. 1995 guidelines require an extended examination of the affected body area(s) and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
Medical decision making of moderate complexity (MDM): This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?

Diagnosis (3 points)
Data (3 points)
Risk (moderate); The risk table can be found on page 37.

The medical decision making point system is highly complex. I have a detailed reference to it on my E/M pocket cards described below. These cards help me understand what type of care my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long. As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

CLINICAL EXAMPLES OF 99214

What are some progress note documentation examples for a CPT® 99214, the level 4 established patient visit in an office or other outpatient setting? Most doctors use the subject, objective, assessment and plan (SOAP) note format. A 99214 note could look like this:

S) Abdominal pain. RLQ. Started yesterday. Constant. 8/10. Associated fever (at least 4 HPI). No nausea, chest pain, dizziness, shortness of breath (at least 2 additional ROS ). Nonsmoker (One element from social history).
O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses, positive bowel tones, RLQ tender with guarding; lungs clear; heart no murmur, RRR; legs no edema; skin no rash, eyes, no icterus, no JVD, alert, mild distress. (at least 12 total bullets in 2 areas )
A) Nothing needed
P) Nothing needed

In this example history (subjective) and physical (objective) meet the requirements to get paid for a 99214. Remember, the highest 2 out of 3 components determine the highest level of service for established patients in the clinic or other outpatient setting. Do note that linking an ICD code to a CPT® medical code is required for all visits submitted to CMS for reimbursement. Therefore, most progress notes should provide at least one ICD code to clearly indicate a purpose for the visit. I suspect this is necessary to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation. Medicare doesn't want to pay for doctors to talk about football with their patients. There must always be an approved ICD code linked with the CPT® medical code when billed to CMS and most other insurance companies.

I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients determines the overall level of CPT® code service. For history, four elements of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS at least 2-9 additional review of systems in addition to inquiry about the HPI related problem PLUS at least one element of past medical, family, or social history is required for this level four progress note. For physical exam, using 1997 E/M guidelines, documentation of 12 bullets from at least two organ systems or body areas is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99214 established patient clinic visit:

S) Cough resolved; No SOB; No CP (2-9 ROS). Stopped taking lisinopril due to cough (one element from past medical history)
O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal (at least 12 total bullets from two or more areas)
A) HTN-stable, no changes planned.
DM-stable, no changes planned.
COPD-stable, no changes planned. (the status of three chronic medical conditions in place of HPI)
P) Start ARB instead due to ACE cough.

As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in at least 2 additional review of systems and one element from past medical family and social history and this is the minimum history documentation required for CPT® 99214. With at least 12 bullets documented in the physical exam, this note is complete and accurate and meets documentation requirements to get paid for a 99214. All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensation of disease. While not necessary to remain compliant, this progress note example meets 3 out of 3 components (history physical AND MDM) for a level 4 established office visit. The medical decision making also meets criteria for a CPT® 99214 because it gets 3 points on diagnosis for describing the at least 3 medical conditions (DM, HTN, COPD) and moderate risk for ordering an ARB. Prescription drug management is considered moderate risk, as you can see on my bedside E/M reference card detailed below. Here is another clinical progress note example of appropriate documentation for a CPT® 99214:

S) Here for routine f/u visit. No CP/SOB/N/V/HA (at least 2 additional ROS). Still a nonsmoker (one element from social history).
O) 120/80 80 Tmax 98.9 (three vital signs = one bullet).
A) 1) HTN, controlled 2) DM II, controlled 3) CAD, controlled (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
P) Nothing needed.

According to the guidelines E/M risk table guidelines linked above, documenting the status of two stable chronic medical conditions qualifies as moderate risk in the medical decision making process. I have documented the status of three chronic medical conditions and that meets the minimum CPT® 99214 moderate medical decision making criteria using diagnosis (3 points) and risk (moderate). This qualifies for moderate risk in the risk table based on their qualifying description as "two or more stable chronic medical illnesses". I have meet my 99214 note requirements for 2 out of 3 areas from history, physical and MDM by meeting minimum criteria for history and MDM. This note is short and to the point. Some docs may think it's "too short" to be a CPT 99214. But, documentation is about content not quantity. It meets all minimum criteria for a mid-high level outpatient established office patient encounter based on the evaluation and management rules we have been given. Also remember, reasonable and necessary is always part of any evaluation, as is the requirement for the visit to be face-to-face in nature.

The complicated table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37. What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. At least for the hospitalist population (as a consultant on observation status scenarios), most established outpatient coding decisions will not be determined based on low risk medical decision complexity. I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it. I generally only use the table of risk when determining moderate and high risk encounters. In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference (and print it and post it in your office) should you desire a more detailed understanding. Here is another clinical example that meets minimum documentation requirements for a CPT® 99214:

S) HA present 4/10, global pain for 3 days and constant. No ringing in the ears (at least 4 HPI). No nausea/vomiting. No chest pain or SOB (at least 2 additional ROS). No FH brain cancer (one element family history).
O) Nothing
A) Acute HA, stable. (one new problem with more work up planned and of uncertain prognosis 4 points on MDM for diagnosis and moderate risk too)
P) Check CBC/BMP. OTC IBU for now. (consistent with 4 points on diagnosis for more workup planned)

That's all you need folks. Documentation of 2 out of 3 areas at their defined minimum requirements. That means 4 HPI, at least 2 additional ROS and one element from family history. Documentation of one new problem with more workup planned gets 4 points in the diagnosis portion of medical decision making. Note, this is more than the required 3 points for moderate complexity. The data portion is straightforward to low with only lab being drawn. The risk table is moderate risk due to an "undiagnosed new problem with uncertain prognosis". In this situation overall MDM is moderate even though no two MDM components are moderate levels. Remember, overall MDM is determined by the highest two out of three for diagnosis, data and risk. In this example, one of each exists. Therefore, the overall medical decision making is the highest two out of three, or moderate medical decision making. This is progress note is an example of a level four CPT® 99214 established outpatient clinic visit based on history and medical decision making complexity. Notice the volume of documentation matters much less than the quality of what is written to support the E/M charge appropriate for the visit.

In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for a level four established patient clinic visit. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?

USING ESTABLISHED PATIENT CLINIC CODES IN THE HOSPITAL SETTING

The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible admission codes that could be used in the hospital setting. These established patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.

For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the established outpatient clinic code group 99211-99215 as their initial encounter and for all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.

If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty,, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.

The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.

DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES

What is the distribution of CPT® code 99214 relative to other levels of service in this medical code group? The graph below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services. You can find these charts and graphs starting on page 9 of this link provided here. As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher. The proportion of level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three 99213 services billed for payment has decreased by 8% between 2001 and 2010. On an absolute percentage basis, in 2010, CPT® code 99214 was being billed 36% of the time, up from 21% of the time ten years previously.

E/M-Established-Patient-Clinic-Outpatient-Distribution-Curve-Graph

photo efd067cb-81b9-4b36-a65a-61723256119a_zps2d121e07.jpg

Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99214 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99214 was billed 81,310,974 times in 2011 with allowed charges of $8,175,639,964.48 and payments of $5,710,149,881.25.

2011 Medicare Part B National Procedure Summary File 99211-99215 CMS 2011

RVU VALUE

How much money does a CPT® 99214 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99216 is worth 2.21 total RVUs for facility services and 3.02 total RVUs for non-facility. The work RVU for 99214 is valued at 1.50. A complete list of RVU values on common hospitalist E/M codes is provided at the attached URL. What is the Medicare reimbursement for CPT® code 99216? In my state, a CPT® 99214 pays about $74 (facility) and $101 (non-facility) in 2016. The dollar conversion factor for one RVU in 2014 is $35.8043.

My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.

LINK TO E/M CARD POST

Click image for high definition view

SBAR Nursing Communication Foley Follies (Video Explanation).

What is SBAR? SBAR nursing communication is one popular method of transferring patient care information between physicians and other healthcare professionals. Frequently taught to nurses, SBAR stands for Situation, Background, Assessment, Recommendation. SBAR nursing techniques are easy to learn and easy to implement. This communication method is highly respected by doctors, nurses and patients as a way to verify that vital information is being shared between hospital team members. Hour after hour, day after day, month after month, year after year, SBAR has proven itself to be the preferred communication method of choice. SBAR communication techniques help foster a culture of safety in a very dangerous hospital environment. Nurses love it because they use the process to fill vast amounts of free time during their shift. Hospitalists and other physicians love it because it interrupts their busy workflow to divert their complete and undivided attention toward 13 minute patient care presentations. Patients love it because they... Just. Don't. Know. Any. Better.

In an effort to make an already unbelievably awesome nursing documentation and handoff tool even better, I am recommending all hospitals implement my modified SBAR approach immediately. It's called SBARTS and it's fantastic. That's right folks, since SBAR is amazing, SBARTS promises to turn daily communication between nurses and doctors into one giant Happy Hospital. SBARTS stands for:

Situation

Identify the person to whom you are speaking.
Identify yourself, occupation and where you are calling from.
Identify the patient by name, date of birth, age, sex, reason for admission.
Identify what is going on with the patient.

Background

Give the patient's presenting complaint.
Give the patient's relevant past medical history.
Brief summary of background.

Assessment

Vital signs.
List if any vital signs that are outside of parameters; what is your clinical impression.
Severity of patient, additional concern.

Recommendation

Explanation of what you require, how urgent and when action needs to be taken.
Make suggestions of what action is to be taken.
Clarify what action you expect to be taken.

A number right before 11 and right after 9.
As in, the patient has 12/10 pain.

Seconds

1/60 of a minute. In other words. A very short period of time.
As in, this will just take ten seconds.

From here on out, I implore all hospitals to please consider using Happy's modified 10 second SBARTS nursing communication process. Otherwise, you may, as a patient, doctor or nurse, find yourself in the middle of a raging case of SBAR nursing follies. Er, I mean Foleys! Please enjoy this Happy Hospitalist original GoAnimate movie about the unappreciated and unintended consequences and dangers of aggressive SBAR. Happy's SBART could have fixed this. If only I had gotten to them sooner, all this nonsense could have all been avoided. In this video, by the book new nurse graduate SBAR nursing techniques failed to pick up on surrounding patient and doctor distress signals with devastating consequences. And by devastating, I mean bad patient satisfaction scores, also known as: The Only Thing That Matters These Days.

Here is a scene by scene transcript of the video:

Patient: Help me! Help me! I can't Pee! I need a Foley now! Nurse! Nurse! Please help me!
Nurse: NOBODY makes it through my shift without peeing!
Nurse: Must. Call. Doctor. Stat!
Doctor: I think I hear my phone ringing.
Doctor: What could they possibly want at 2:00 in the morning?
Doctor: This is Dr. Just Say What You Need Now.
Nurse: Thank you doctor Just Say What You Need Now. Is this Dr. Just Say What You Need Now?
Doctor: *standing*
Doctor: *golfing*
Nurse: Hello? Is this Dr Just Say What You Need Now? Please answer. I cannot move forward with my SBAR script without a response.
Patient: Please hurry! The pain is unbearable!
Doctor: Just Say What You Need Now.
Nurse: Great then. This is nurse Page It. I'm calling from the low pain threshold floor. I have Mr. SBAR Tragedy. He has 22 grandkids and he likes gladiator movies. Do you remember?
Patient: Nurse! Nurse! It's hurting bad! Hurry! Hurry! I need a catheter now!
Doctor: *weeping*
Nurse: Doctor? Just Say What You Need Now? Are you listening to me? Hello? Hello?
Doctor: *baffled*
Nurse: I'm calling about Mr SBAR Tragedy. You remember him? He's the white haired man with the large belly in room 12. He also had that skin cancer removed from his ear in 1958.
Doctor: *losing it*
Nurse: He also had bunion surgery 14 years ago and he uses a walker. CBS is his favorite television station. Does not any of this help you remember him?
Doctor: *put a fork in him*
Nurse: He's the one with the problems peeing. Does none of this ring a bell doctor? Doctor? Doctor? Are you still there?
Doctor: *he's done*
Nurse: I am worried, doctor. Very worried. Mr SBAR Tragedy is having severe pain and I need a Foley catheter stat!
Doctor: Why! Didn't! You! Just! Ask! Stick a foley in it. We're done here!
Patient: What! Friggin! Took! So! Long!
Administrator: I got a complaint in the mail today from Mr SBAR tragedy. The ONLY explanation I can come up with is a failure to AIDET. His. Ass.

If urine for some more good humor, check out these Happy Hospitalist original crude medical ecards:

"If I don't make it to your room before you pee all over the floor, it's because I was filling out a form to have the cleaning lady clean the pee off your floor."

If I don't make it to your room before you pee all over the floor, it's because I was filling out a form to have the cleaning lady clean the pee off your floor nurse ecard humor photo.

"Communication is vital in hospital care. And by vital, I mean vital signs. Vital signs are to doctors like lunch breaks are to nurses. Really important."

"Try giving me a verbal order again and I will SBAR your ass into submission."

"We really do tell nurses to page us out of your room when you think you have a right to more than five minutes of our time."

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. If you are offended, learn my SBARTS method instead, then come back and I guarantee you'll laugh your ass off.

Clearing Up Confusion About Health Reform’s Out-of-Pocket Protections

Recent media coverage may have sown confusion about health reform’s requirement that health insurance plans cap how much consumers can pay out-of-pocket each year for medical care. The bottom line: for many plans, the protections will take effect as scheduled in 2014. Some plans will be able to wait an extra year to fully comply.

The health reform law requires that, starting next year, private insurance plans limit how much in cost-sharing charges — deductibles, copayments, and coinsurance — that people enrolled in a plan must pay each year for covered benefits provided by the plan’s network of health care providers. (This includes plans offered in the individual market or through employers. The requirement doesn’t apply to “grandfathered” plans.) In 2014, this “maximum out-of-pocket limit” will be $6,350 for an individual and $12,700 for a family.

Back in February, the Obama Administration provided an additional year to fully comply with this requirement but only for certain plans offered by employers.

Here are some clarifications about the February policy:

Health insurance plans in the individual market: In 2014, the maximum out-of-pocket limit will apply, as scheduled, to the individual (non-group) health insurance market. Millions of people are expected to gain coverage in this market in 2014, as health reform’s new improvements and federal subsidies significantly increase access to affordable coverage.

Employer-sponsored health insurance plans: The maximum out-of-pocket limit will also continue to generally apply to non-grandfathered plans offered by employers, including small group, large group, and self-insured plans. Employer plans that have a single insurer or administrator have to fully comply with the limit next year.

Employer plans that have “separately administered” benefits: The Administration provided the exception in February for these plans, in which an employer has one insurer or administrator for its primary package of health benefits and a different insurer or administrator for discrete benefits, such as prescription drugs. Because employers and insurers have claimed it will be difficult to coordinate an overall maximum out-of-pocket limit across separately administered benefits, they sought and received the ability to avoid full compliance for one year.

Even those employer plans with “separately administered” benefits that qualify for the delay still must apply some out-of-pocket limits in 2014. As the February guidance explained, these plans must ensure that their primary package of health benefits has an out-of-pocket limit of no more than $6,350 for individuals and $12,700 for families. A separately administered benefit, such as prescription drugs, that already has an existing limit on out-of-pocket costs must comply with the limits of $6,350 for individuals and $12,700 for families in 2014.

An employer plan wouldn’t have to add a cap to a separate benefit if the separate benefit currently lacks one. But this exception shouldn’t be misunderstood as broadly waiving the important out-of-pocket protection that health reform will bring in 2014.

Sarah Lueck
Center on Budget and Policy Priorities

(This was originally posted here on the Off the Charts Blog)

Billing Critical Care and Discharge On Same Calendar Date?

Can I bill a critical care code and a discharge code on the same day? That's a question a lot of folks finding The Happy Hospitalist are asking themselves. I am a hospitalist with over ten years of clinical experience and years of research in evaluation and management (E/M) medicine. I have a very short answer and one that should lay to rest any question about what code the physician should choose when they provide critical care on the date of discharge. On page 3 of 9 in CMS document MM6740, we are told

In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.

That means, if you provide critical care you should bill for critical care, regardless of whether that service was provided on the day of admission or the day of discharge. Yes, I believe the physician can and should bill for critical care even if they discharged the patient on the same date as the critical care service was provided. But can they also bill a discharge code? I do not believe they can. Even though CMS tells us we should bill the available code that most appropriately describes the level of services provided, I believe their rules disallow both codes on the same calendar date. As such, physicians would be better off billing for their critical care services and not the discharge codes in these situations. My exhaustive research on this issue failed to disway my opinion on this matter. If there are any experts with further insight into this common scenario, I welcome your input to expand and accurately identify any misunderstandings. With that said, I think it's important to understand a few key points. Here are a few scenarios to consider.

CRITICAL CARE WITH ADMISSION AND DISCHARGE SAME DATE

There are two possible scenarios to consider when providing admission and discharge on the same calendar date with critical care: Critical care is provided on admission or critical care is not provided on admission.

SCENARIO 1: The initial admission work does not rise to critical care criteria but then critical care is subsequently provided and discharge is then made after that on the same calendar date. In this situation I would bill for the appropriate admit E/M charge and any related critical care charges and not bill the admit and discharge same day codes. Remember, CMS has told us to "bill the available code that most appropriately describes the level of services provided". That is our mandate.

CMS has previously told us that critical care and an E/M code can be billed on the same calendar date if the critical care was provided after the E/M service was provided. Unfortunately, they do not specifically agree or disagree that an E/M code can be billed after a critical care code. I believe, however, that this failure to provide guidance is a round-about way of saying post critical care E/M charges are not allowed on the same calendar date. If they were allowed, I do not know why would they specifically give guidance to allowing pre critical care E/M codes but not post critical care E/M services? I have written about this previously at the link provided just above.
In my opinion, that means discharge services, which are bundled into 99234-99236 codes cannot be billed in conjunction with critical care codes because the discharge services would presumable occur after the critical care service. We are left with a scenario where a patient is admitted and discharged on the same calendar date where a physician provides critical care, but cannot bill for the discharge services. I would bill an admit E/M code (probably initial inpatient admission codes (99221-99223) or initial hospital observation codes (99218-99220) if the documentation supports those codes) and then bill for critical care 99291. Attach a -25 modifier to the first E/M code. If more than 74 minutes of critical care was provided, bill for 99292 as well. I would not bill for discharge services because no code exists to capture that service. Billing for the admit and discharge same day codes would not allow the practitioner to capture their critical care service and CMS has told us to "bill the available code that most appropriately describes the level of service provided. The bundled admit and discharge codes 99234-99236 would not be appropriate in this situation. In this scenario, the work you do discharging the patient is free, but the RVU value of the critical care is still higher using an admit E/M code and critical care code than using the bundled admit and discharge code alone.
Remember, do not bill for critical care time on the discharge work (unless you are transferring the patient to another institution) as the patient would not presumably be critically ill during your discharge decision. In a previous discussion about billing critical care for family meetings in the ICU the following statement was discussed:

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. In my opinion, billing for discharge work after critical care would have to fall into the "include pre and post service work" category because no other codes apply.

It is my opinion, if a physician is transferring a critically ill patient to another institution, discharge work should be considered part of the critical care time as the provider will be writing orders, making medication decisions, communicating their patient's condition with other healthcare providers and providing a safe transition to a higher level of care, as long as that work is provided in the immediate vicinity of the patient or the patient's unit.

SCENARIO 2: The initial admission work does rise to critical care criteria and discharge is subsequently made on the same calendar date. In this situation I would bill all appropriate critical care charges (99291 and or 99292) and not bill the admit and discharge same day codes. Remember, CMS has told us to "bill the available code that most appropriately describes the level of services provided". That is our mandate. Billing admit and discharge codes in this scenario would not allow the physician to capture critical care resources and would not be appropriate.

As I reviewed above, do not include your discharge work in your critical care time, unless that discharge work involves continued critical care decision making during a transfer to a another institution. Providers would have a hard time justifying to an auditor that routine discharge time was of a critical nature.

In either scenario, a single critical care code provides a higher relative value unit (RVU) compensation than any of the same day admit and discharge codes 99234-99236. Thus, whether the provider bills only critical care or an E/M code in addition to critical care code(s) they have the ability (and the right) to collect a higher payment for work that most appropriately describe the level of service provided. Under neither scenario do I believe the inpatient discharge codes 99238 or 99239 or observation discharge code 99217 be used or considered.

Some readers may be wondering how a patient could be critical and then be discharged on the same calendar date. As hospitalists, we see many patients who present with critical illness, or become critical but because of excellent care or rapid reversal of the critical situation, are able to be discharge on the same calendar date. Some of this has to do with when the clock starts running. Remember, Medicare and most insurances use the midnight-to-midnight calendar date rule when determining same day admit and discharges. If a patient came in at 12:01 am, they have until 11:59 pm that same day to be discharged as a same day admit and discharge. 23 hours and 59 minutes is a long time for some critical conditions to improve.

For example, patients with seizures who need airway support on a ventilator are critically ill on admission. Drug overdose patients with respiratory demise may respond rapidly to reversal agents. Patients with hyperglycemia or hypoglycemia may present with critical illness in the form of DKA, seizures, unresponsiveness, encephalopathy or other critical illness, but may respond rapidly to treatment. Just because a patient is treated appropriately and aggressively and shows rapid improvement does not mean their critical illness should be discounted. If a provider provides critical care, they should bill for critical care, regardless of how quickly they respond to treatment.

CRITICAL CARE WITH ADMISSION AND DISCHARGE DIFFERENT DATE

How should critical care be billed when the admission and discharge occur on different dates and the critical care is provided on the date of discharge. Regardless of whether the patient is inpatient or observation status if critical care is provided on the date of discharge, bill for the critical care service but do not bill for the discharge code. Any work provided on discharge after the critical care charge should not be billed as critical care time, unless, the discharge services involved transfer to another institution. I detailed this reasoning above. Remember, only bill for critical care time when the patient is critically ill. An auditor will ask for your money back if you're billing for a discharge summary on a stable patient going to a nursing home. The discharge work you provide on stable patients will be included in your critical care code(s). From an RVU perspective, critical care 99291 pays more than double the greater than 30 minute discharge code 99239. These scenarios can and do happen that result in critical care that requires immediate stabilization at the bedside that can allow for discharge later in the day. Providers have a right and an obligation to bill the available code that most appropriately describes the level of the services provided.

WHY NOT BILL 99291 AND 99238 OR 99291 AND 99239 ON DATE OF DISCHARGE?

I spent a great deal of time researching why discharge codes could not be billed as separate and identifiable services after critical care was provided on any given calendar date. I was surprised to find very little on this common scenario. Some scattered resources suggested billing the discharge after the critical care and using the -25 modifier. Some resources suggested there was no explicit exclusion by CMS that said both services could not be billed and paid on the same date. CMS says, "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided."

Why would they allow E/M charge before a critical care code but not a discharge code after? CMS specifically states they allow an E/M code before a critical care code. I would presume because they don't specifically address billing an E/M code after a critical care code on the same calendar date, that they do not allow payment for that scenario. I wish they would provide better clarity in their manuals.

Perhaps it has to do with the AMA definition of the discharge codes. The CPT® manual states that discharge codes 99238 and 99239 are to be used by physicians to report all services provided to a patient on the date of discharge. CMS and the AMA do not always agree on their definitions, but I believe if physicians billed the discharge code, then the critical care service would be bundled into the discharge code and the critical care service would be denied. The critical care codes pay much more than the discharge codes. Getting paid for critical care and providing uncompensated discharge work is a better business decision. Alternatively, the physician can always submit a 99291 in combination with a 99238 or 99239 or 99217 using a -25 modifier and see what happens. The worst that can happen is that it can get denied. For a scenario that happens with relative frequency, I'm surprised of so few resources available on the internet for review.

I provide a detailed database of free E/M and CPT® lectures for physicians and other non-physician practitioners. I am a hospitalist with over ten years of clinical experience. My hospitalist resource center also has important information for all clinicians to review.

LINK TO E/M REFERENCE CARD POST