Communicating problem status in the assessment and plan

Q: I’m a hospitalist and have a question about documenting my assessment and plan. For the primary presenting problem, I see the billing modifiers for "worsening," "stable," and "improving." However, I'm not sure where "unstable but not getting worse and not yet getting better" fits in? I mean if the patient will be better by the time they leave, they clearly aren't currently "stable.”

 A: This sounds like you are describing some menu options your EHR gives you to “characterize” problems in the A/P. This perspective is uniquely yours as the provider creating the note. Coders don’t see this from your perspective as the notes are reviewed after they are done. So it sounds like they've only given you three “flavors” to pick from... which is not nearly enough.

The CPT book and various other coding resources use lots of words to describe “moderate” level decision-making. Worsening, exacerbated, progressing, unstable, uncontrolled, poorly controlled, inadequate control, minor complication, inadequate response to treatment, side effects of treatment, increased risk of functional impairment, uncertain prognosis....

They all seem to reflect “activity” or “not stable.” So to communicate the patient’s actual status, somewhere in there is your language. Your soundbite.

If your list of variable “descriptors” is editable, give yourself every version of the language above and add your own. It might not hurt to add some that cover a few situations, like “Patients overall condition improved but remains guarded due to multi-system disease.”

Be more specific and describe potential disease interactions. Sit down and think of all the common ones, and their over impact on M/M. If you make a good list, pick from it as needed. And hopefully you can always add more.

Q: I saw a new patient that was recently discharged from rehab. Can I bill for a Transitional Care Management code? Or not because I was not the patient’s physician until today?

 A: The TCM codes are about transitioning back into the community and dealing with problems of at least moderate level complexity. They are not limited to a particular provider type, although they were designed with primary care in mind. You do not have to be the “owner” of the patient, or the problems, for you to assess them.

Two of the requirements that Medicare outlines are:

• The healthcare professional accepts care of the beneficiary post-discharge from the facility setting without a gap; and

• The healthcare professional takes responsibility for the beneficiary’s care.

If you meet these criteria, as well as the other TCM requirements, you are good to go. Do remember though that only one provider can bill the TCM service per hospitalization.

Q:My office manager is telling me that I shouldn’t list the patient’s major problems when I’m treating only one of the patient’s chronic problems. I thought the new “quality” approach required that I report all the diagnoses that the patient had in order to illustrate their “complexity.”

A: You are both right; sometimes. It’s true that the HCC risk-adjustment oriented reimbursement systems need to see all the problems that the patient has to get a proper measure of risk. But you only report those that you evaluate in any one encounter, or those that impact the ones you are managing.

What your office manager is likely saying is that for encounter-level reporting purposes, you have to stick to the problems at hand. From the ICD-10 guidelines:

"Code the Diagnosis, Condition, Problem or Other Reason Chiefly Responsible for the Services Provided

Also Code Any Coexisting Conditions Relevant to the Encounter (i.e., Conditions that Require or Affect Patient Care, Treatment or Management)."