sourdoughpablo wrote on Tuesday, December 13, 2016:
I usually list two CPT codes for a patient visit: An office visit code and a procedure code (Osteopathic Manual Medicine).
In OpenEMR if I enter four diagnoses for the first CPT (the office visit or E&M code), they are listed first in the diagnosis list within OpenEMR. If I point to all of them (well, the maximum I can point to is 4), they are printed first in the HCFA section 21 as “ABCD”.
Then the diagnoses for the second CPT code (the OMM code) will list farther down on the diagnosis list, and will be printed sequentially in the HCFA section 21 (as “EFGH” etc.) The diagnostic codes that I point to for the CPT code will be listed first, followed by other secondary diagnostic codes.
The above arrangement gives me some control over the sequence of diagnoses in HCFA 21, which “tell a story” to the staff at the insurance company.
However, Medicare only wants me to point to ONE diagnostic code for each line item CPT code in Section 24E. And in OpenEMR, if I point to the fifth diagnostic code in the list to justify my OMM code, the software doesn’t create a reference to “E” in HCFA 24E. Instead, it “promotes” that ICD10 code to slot B in section 21, and then refers to it as “B” in section 24E. This “demotes” the secondary diagnosis codes for the E&M billing to slots C, D, and E, behind the first OMM diagnostic code, scrambling the story I’m telling to the Payor’s coding staff. They no longer have a clear clue as to which secondary Diagnostic codes apply to which Procedure codes.
This is not an ideal situation. Higher level of E&M codes require treating more than four problems, and even though you can only list 4 pointers in 24E, if these are followed by other codes in section 21, BEFORE the first code pointed to on the OMM procedure line, the relationships in the “story” are obvious.
But if the first pointer for the OMM procedure line scrambles this sequence, the story becomes ambiguous. Ambiguity in billing does not help produce timely reimbursements.
Additionally, if I edit the Fee Sheet later, changing or adding a secondary diagnostic code, this addition is put at the bottom of the sequence in the Fee Sheet and in HCFA Section 21, creating similar lack of clarity in the billing sequence. The only way I can see to rearrange the sequence is to delete and re-post the entire Fee Sheet.
Ideally I would be able to list diagnoses in the order of my choosing in within the OpenEMR fee sheet, and re-arrange that order as I edited the list, either by dragging and dropping or by having the power to toggle a specific line up or down. I could put all the diagnoses for the first CPT code line at the front of the list (primary diagnosis first), and follow them with the diagnoses for the second CPT code line (primary diagnosis first), in a WYSIWYG arrangement, controlling and KNOWING how this would sequence in the HCFA 1500 Section 21 listings A-L.
I could fill all 12 diagnostic slots (A-L) in a fixed sequence. And then I could point to any one of those slots to justify a second or third CPT code, without rearranging this (A-L) sequence. If my second CPT code is justified by pointing to the fifth diagnosis, that second line’s 24E will read “E”.
If instead I justify that second CPT code with the sixth diagnosis, then the second line’s 24E will read “F”. I could add a third CPT code line, linking it to the tenth listed diagnostic code, and the third line’s 24E would read “J”. In this case, the Insurer would read the story that in section 24, the first CPT’s primary diagnosis is “A”, with secondary diagnoses “BCDE”, and the second Procedure code line’s primary diagnosis is “F” with secondary diagnoses “GHI”, and the third CPT code line’s primary diagnosis is “J” followed by secondary diagnoses “KL”.
I’ve produced this sequencing for years with rigid DOS software and it works fine at the Payor end. It seems like it should be possible to create the same thing more flexibly with the OpenEMR system. I imagine that if you didn’t want to alter the current functionality for those who are used to it, you could add the ability to re-sequence the Fee Sheet list, and then simply create a separate circumstance where if only one line is pointed to as justification for a CPT code, the program doesn’t shuffle the sequence when printing to the HCFA form.