Multisystem Inflammatory Syndrome in Children Associated with COVID-19

Posted by Samantha Serfass on May 28, 2020 in Blog, News

Multisystem Inflammatory Syndrome in Children Associated with COVID-19

As we have begun to see more and more cases of COVID-19, the majority of the more severe cases have been found to be in the elderly population or people with underlying chronic conditions affecting the ability of the immune system to fight illness.  We have yet to see many cases of confirmed COVID-19 in infants and children.  However, recently there have been reports of children and adolescents with a multisystem inflammatory condition with symptoms similar to those seen in Kawasaki disease and toxic shock syndrome and required admission to intensive care units.  It is thought that this multisystem inflammatory syndrome may be related to COVID-19. [1]

Kawasaki Disease

Kawasaki disease is an acute febrile illness usually occurring in children younger than 5 years of age.  The fever usually lasts at least 5 days and is associated with rash, swelling of the hands and feet, swollen lymph glands in the neck and irritation and inflammation of the mouth and throat.[2]

Toxic Shock Syndrome

Toxic shock syndrome is another condition that typically presents with a high fever.  Associated symptoms include hypotension, diffuse erythematous rash, and organ dysfunction in at least two organ systems that may progress rapidly to severe shock.  Toxic shock syndrome is typically caused by staphylococcal or streptococcal bacteria.[3]

On May 14, 2020, the Centers for Disease Control and Prevention (CDC) released an official health advisory which provided background information on several cases of multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) along with a case definition of the syndrome.  Cases have been reported in U.S. and other countries. [4]

Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C):

  • Age 21 years or younger presenting with fever
  • Laboratory evidence of inflammation
  • Evidence of clinically severe illness requiring hospitalization
  • Multisystem organ involvement (2 or more organ involvement)
  • No other plausible diagnosis
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

The CDC is recommending that healthcare providers who have treated or are currently treating patients meeting the criteria for (MIS-C) should report suspected cases to their local, state, or territorial health department.[4]

Coding Guidance:

As of April 1, 2020, there is no official coding guidance for MIS-C.  MIS-C cannot be indexed in the ICD-10-CM Alphabetic Index therefore coders must follow the guidance in ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.15:  Syndromes.  This instructs the coder to assign codes for the documented manifestations of the syndrome.  Any additional symptoms that are not an integral part of the disease process may be reported when the condition does not have a unique code.

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Sandy Hall, Coding Education Auditor; CCS, COC, CPC






Posted by Samantha Serfass on May 21, 2020 in Blog, News


As states across the US begin the process of reopening, establishing a sense of normalcy becomes a top priority. Healthcare systems are facing a significant challenge as they work to resume normal operations while still focusing efforts on decreasing the virus.

It is estimated the American healthcare system has lost $200 billion dollars resulting in the job loss of over 1.4 million healthcare workers. While healthcare systems begin to resume full services, several key factors are important to consider.

In March, the CMS first recommended limiting the non-essential care in an effort to save critical PPE supplies. As healthcare systems reopen and PPE supplies still remain limited, the CMS has updated its recommendations for facilities in order to allow health systems to safely provide nonemergent non-COVID-19 care. The CMS will continue to publish recommendations and updates to existing guidelines to help carefully phase in normal hospital operations. More information on the guidelines and regulations established by the CMS for phase one can be found here.

Healthcare IT departments have shifted gears to best assist their hospitals during COVID-19. Hospitals across the US have pressed “pause” on many projects unless considered critical – shifting their focus to support COVID-19 initiatives.

Tim Pugsley, CIO for Titus Regional Medical Center in Mount Pleasant, TX, has dispatched analytics, informatics and technical teams to support their clinical leaders across many platforms. They have created new dashboards which track PPE consumption rates, temperature tracking for staff, video visit encounters and record call center statistics for the CV-19 hotline.  In addition, they have updated their EHR to record the latest COVID-19 documentation requirements all while supporting a remote workforce.

TRMC has also expanded their telehealth presence. Prior to COVID-19, TRMC focused on telehealth equipment in the ambulances and extending specialty care to outlying communities. Since the pandemic, they have enabled video visits in TRMC operated and independent ambulatory clinics, inpatient floors and on the COVID unit. Patient’s visitors also have an option to become “virtual visitors” enabling them to interact with loved ones.

                 “We understand the importance of social interaction with family and friends. To address that need, we supply the patient with a tablet and technology to have a video interaction” added Pugsley.

While preparing to reopen, Telehealth initiatives are the front runners for helping to safely allow these healthcare systems to better assist, treat and safely diagnosis their patients while working to decrease the possibility for COVID-19 exposure. Titus Regional Medical Center’s clinical leaders are developing a strategy and tactical plans to safely provide care by partnering with physicians and key stakeholders. Policies and procedures are reviewed constantly to adapt to the changing landscape and processes continue to evolve to support our community, our providers, and our staff.

As elective services begin to slowly reopen, Titus has leveraged their telehealth solution to keep the community informed. Through the use of MyChart, public radio and social media platforms – like Facebook – Titus has been able to communicate with the community about the virus, guidelines, and regulations being implemented.

Telehealth will continue to play a vital role as phase one of reopening begins to occur. CMS will likely start to remove the waivers they once had in place for telehealth solutions (for example, enforcing HIPAA compliance). Ensuring your telehealth solution is effective and compliant is more crucial than ever. Demonstrated by TRMC, telehealth solutions allow healthcare systems to safely and efficiently communicate, treat, and assist patients during this pandemic.

Excite Health Partners offers the knowledge and experience to implement the right fit telehealth solution. We can develop new workflows and data integration, improve the efficiency of care and help recover revenue. As healthcare systems continue to adapt during these unprecedented times, we can help ease the burden of implementing the best telehealth solution to meet your organization’s needs.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

Posted by Samantha Serfass on May 6, 2020 in Blog, News

COVID-19 and Cytokine Storm/Cytokine Release Syndrome (CRS)

During this COVID-19 crisis, coders are beginning to see the providers document cytokine storm as a secondary diagnosis in patients who have been diagnosed with a primary diagnosis of COVID-19.

Some of the acutely ill COVID-19 patients are developing a cytokine storm which is a Cytokine Release Syndrome (CRS). The sickest patients are the ones who have CRS that can lead to the patient developing secondary hemophagocytic lymphistiocytosis (sHLH) which then causes the patient to develop acute respiratory distress syndrome (ARDS).1

CRS “is caused by a large, rapid release of cytokines into the blood from immune cells” “Cytokines are immune substances that have many different actions in the body.” In some patients, excessive or uncontrolled levels of cytokines are released which then activate more immune cells, resulting in hyperinflammation. It is the overreaction of the immune system.

Coders and CDI Specialists should be very careful when querying the provider for clarification of cause of the signs/symptoms and/or clinical indicators for appropriate code assignment. 1,2 The symptoms of CRS can mimic other conditions.

Cytokine storms can be seen in the below conditions which have similar pathophysiology but have very different treatment options. Therefore, it is imperative to capture the conditions correctly through coding.

  • Sepsis
  • Non-infectious SIRS
  • Macrophage activation syndrome (MAS)
  • Secondary hemophagocytic lymphohistiocytosis

Possible Signs/Symptoms of CRS:

  • Trouble breathing
  • Low blood pressure
  • Rapid heart rate
  • Fever
  • Headache
  • Nausea
  • Rash
  • Multi-organ dysfunction – in severe cases

Possible Laboratory Clinical Indicators of CRS:

  • Elevated serum ferritin2
  • Markedly increased interleukin-6 (IL-6)2
  • High levels of C-reactive protein2
  • Elevated blood nitrogen levels5
  • Elevated D-dimer5

Coding Guidance:

Currently, as of April 1, 2020, neither CRS nor cytokine storm can be indexed in the ICD-10-CM code book.

Per the AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37, with there not being a specific code for CRS and it cannot be indexed in the code book, coders must follow the ICD-10-CM Official Guidelines for Coding and Reporting Section I.B.15 Syndromes where there are instructions to code the manifestations of the syndrome based on physician documentation. Any additional manifestations that are not typically integral to the condition may also be assigned if the condition does not have its own unique code. 4

NOTE: Changes to the official coding guidelines and rules beyond April 1, 2020 will render the Coding Guidance educational content invalid for future educational purposes.

Lorrie Strait, RHIT, CCS

Manager HIM Services, Excite Health Partners


  2., April 8, 2020
  4. AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter 2019 Pages 24-25, and First Quarter 2020 Page 37
  5. Merck Manual,


Posted by Samantha Serfass on April 24, 2020 in Blog, News

CMS has broadened access to coverage and payment of all telehealth services due to the COVID-19 Health Emergency.  On March 30, 2020 CMS published the 1135 IFR (Interim Final Rule) Waiver stating Medicare will reimburse for office, hospital, and other visits furnished by telehealth across the country.  The IFR is retroactive to date of service 3/1/2020 on a temporary and emergency basis for the duration of the public health emergency. 

Prior to this waiver, Medicare would only pay for telehealth on a limited basis.  The most notable exception put into place is that patients no longer must travel to a designated facility in order to initiate telehealth services; these services can now be provided from a patient’s home.  Various common communication technologies can be used in good faith, such as FaceTime or Skype for the duration of the emergency.  The HHS Office for Civil Rights (OCR) will waive penalties for HIPAA violations against health care providers serving patients I good faith through these technologies.  However, communication platforms that are not private (i.e., Facebook Live, TikTok, Twitch) are still considered to be HIPAA violations.

Telemedicine visits are defined as real-time, interactive audio, and video communication between the patient and the provider.  Previously, telemedicine visits were only approved for established patients but that requirement has been relaxed and can now include Evaluation and Management services (common office visits) for new patients also. Evaluation and Management levels may be selected based on Total Time spent or MDM.  They can also perform mental health counseling and preventative screenings.  A complete list of services that qualify for telemedicine is located here.

Virtual check-ins are allowable.  These are defined as brief communication technology-based services and can be conducted with a broader range of communication methods including synchronous discussion over a telephone or exchange of information through video or image.  Virtual check-ins can be provided to both new and established patients, and the appropriate HCPCS codes are G2010 or G2012.

E-Visits are generally done through an online patient portal and is considered a non-face to face encounter that is initiated by the patient and may span over a 7-day period. Total time spent must be accurately documented. Codes for these services are 99421-99423 for physician or mid-level provider and HCPCS G2061-G2063 for Qualified Non-physician Healthcare Professional (Clinical Psychologists, Physical, Occupational, and Speech Therapists).

Telephone Visits must be initiated by the patient and cannot be related to an E/M service provided in the previous 7 days nor leading to an E/M service or procedure within the next 24 hours.  Documentation should reflect total time spent.  Report CPT codes 99441-99443.

As time progresses, there may be additional advice given or changes made to the guidelines.  Because they were initiated fairly quickly, it should be viewed as a “work in progress”.  Therefore, everyone should continue to monitor for subsequent changes as they are published.

Robyn McCoart, RHIT

Managing Auditor, Excite Health Partners


Posted by Samantha Serfass on April 20, 2020 in Blog, News


As telehealth continues to make significant strides during today’s pandemic, Excite Health Partners has the resources and experience to help healthcare organizations identify their telehealth needs. 

Our telehealth solution, SnapMD, was developed by an ER physician and endorsed by the American Academy of Pediatrics. SnapMD is a secure HIPAA compliant enterprise wide telehealth solution with a rich feature set, ready to be fully integrated with your health system’s EHR.

CMS has implemented new rules and guidelines which impact the use of telehealth for hospital systems to better respond to the COVID-19 pandemic. Below are the are three major acts approved by congress.

  • CMS-1744-IFC (Applicability date of March 1, 2020)
    • CMS 1135 Blanket Waiver for Providers (Effective Date March 1, 2020)
    • Blanket Waiver of Section 1877(g) of the Soc. Sec. Act.  (Effective Date March 1, 2020)

Although variance can occur state-by-state, these new telehealth rules and guidelines, set forth by CMS, provide flexibility within the overall health systems and specialty practices. This allows a broad range to provide services using remote communication and permits licensed practitioners to order home health services outside of the hospital.   

CMS has defined interactive telecommunication systems as equipment that can, at minimum, transmit both audio and visual displays to allow for a real time two-way interactive discussion. The HHS has waved penalties for HIPAA violations during this time to encourage telehealth communication. Platforms such as FaceTime and Skype are now accepted as appropriate applications.  

The recent CARES (Coronavirus Aid, Relief and Economic Security) Act, includes funding for the support of telehealth solutions, like Snap MD.  The Office of Inspector General (OIG) is also waiving any costs sharing obligations that federal health care program beneficiaries may owe for telehealth.  This also allows for hospitals to cover the cost of telehealth systems for affiliated physicians and to include remote patient monitoring.

Telehealth systems are now being permitted to communicate and treat both new and established patients while also allowing various types of practitioners to bill for services (social workers, psychologists, physical/occupational therapists, language pathologists, etc.) 

SnapMD’ s platform allows for up to 6 different individuals to join in a virtual meeting space. From patient and family members to supervising physicians, through SnapMD multiple participants can weigh in on the visit to help provide the best service from home.  

As healthcare systems continue to adapt during these unprecedented times, Excite Health Partners can help ease the burden of implementing the best telehealth solutions to meet your organization’s needs while driving revenue.

Todd Klein, CIO, VP of EHR Services & Digital Solutions


Posted by Samantha Serfass on April 8, 2020 in Blog, News


With the growing number of COVID-19 cases arise across the nation, analytics can prove to be a vital element in helping to track the pandemic.

By leveraging data, we can monitor the COVID-19 virus using Early Detection and Rapid Response Outreach programs.  These programs operate to:

  1. Decrease costs while still generating revenue 
  2. Oversee and manage patient flow
  3. Track and manage hospital resources

Data analytics also allow us to identify potential at-risk patients and target demographics. According to the CDC, at-risk patients include:

  1. Older adults, particularly those over 65
  2. People with asthma or other chronic lung diseases
  3. Groups who are at higher risk for severe illness, such as people who are diabetic or immunocompromised
  4. People with HIV

Effective as March 1st, 2020, the CMS has created guidelines for health systems to use Telehealth solutions to assist, track and monitor these at-risk patients and receive reimbursement later. These services typically provided in-person are allowed to use Telehealth –many are still using codes that describe “face to face” services. This helps health systems in various ways. First, by using Telehealth solutions, providers are able to quickly and efficiently provide care. Second, it helps to expand care to new services which helps the population respond better to the virus. Lastly, it helps generate revenue.

An Emergency Response Plan starts by identifying the correct patient populations for specific services to be offered to. To meet the immediate needs, Data warehouses and marts can also be established rapidly. Utilizing an agile approach and integrations tools – such as FHIR – databases can be set up in days/weeks rather than months.

Call center staff can leverage patient data to identify patients who need medication refills but are in the at-risk populations, allowing for medication to be delivered to homes.

Different services lines or specialties can respond to the pandemic in different ways.   Mental and Behavioral Health can reach out to patients to schedule their (now) virtual Telehealth session, or the call center can identify patients that weren’t using the service before.

Diabetes is one of the underlining conditions that increase a patient’s risk for the virus. CMS 1744 allows the Medicare Diabetes Prevention Program (MDPP) to extend allowing beneficiaries to obtain MDPP services more than once per lifetime. This provides patients with virtual educational sessions.  It’s also important for the call center to look for diabetes patients who aren’t performing well and see if they need medication, would like to schedule a virtual visit with their endocrinologists (or psychiatrist) and/or offer them additional virtual educational sessions.  

Every hospital needs to make changes rapidly across the organization, such as expanding beds, increase supplies, setup new triage workflows, etc.  However, each specialty should have a strategy to continue to provide patient care while maintaining revenue and decreasing the impact of COVID-19. 

Excite Health Partners can help. We can help health organizations identify proper COVID-19 pandemic preparation and address additional operational support needed to help patient populations during emergencies. For more information on implementing an Emergency Response Plan, check out our webinar on Emergency Response Management Planning.

Todd Klein, CIO, VP of EHR Services & Digital Solutions

Utilizing the Latest Best Practices for Better Patient Outcomes

Posted by Samantha Serfass on March 18, 2020 in Blog, News

Utilizing the Latest Best Practices for Better Patient Outcomes

The amount of time it takes to perform research and clinical trials to putting new best medicines and best practices into use is considered to be called the time from “bench to bedside”. The average time from bench to bedside is 17 years.  

During these years, two major phases occur.  The first phases consist of the conversion of knowledge from basic science research into a potential clinical product/process for testing, while the second phases consist of clinical trials (testing new products and process with patients) and putting new practices and products within a health system.  

There are, however, many delays along the way which contribute to the 17 years average. 

  • Grant awards
  • Ethical approval
  • Clinical trial execution
  • Drug approvals
  • Publication of test results and absorption

Although clinical trials are a lengthy endeavor, you can see from the latest efforts to fight the coronavirus steps can be taken to dramatically shorten the delay.  The first phase of the coronavirus took only a few short months, as it was declared an Emergency. However, there are more than 20,000 clinical trials registered every year at 16 national & regional registries. 

Historically less than half of all the trial results are published, and there is concern about the quality of the trail and the effectiveness of drugs. Companies like Good Pharma Scorecard ranks new drugs on a range of criteria. This includes the quality of the testing during clinical trials.  However, once test results are published, the new best practices are not always put into use.

There are approximately 49 different major specialties in North America (with hundreds of sub-specialties).  If a physician were to just read the publications within their specialty, they would need to on average read 4 publications each week in order to keep up. To effectively put the publication results into practice would require physicians to remember the symptoms, comorbidities and the test group for each of the studies published. They then would need to recall and act on the recommended best practice.  This provides to be a challenging course of action. 

A number of different initiatives could be implemented in order to help the physician’s stay informed.

  1. Governance focused on clinical quality outcomes
  2. Evidence-Based Medicine (EBM)Tools
  3. Effectively Leveraging the EHR

Governance should be focused on the health system’s specific performance and their patient population.  By effectively leveraging evidence-based medicine (EBM) tools and utilizing the EHR system, health systems will be able to reach and accomplish their goals. Companies like Elsevier and ProVation can be integrated with EHRs to bring best practices (based on EBM) to the healthcare providers. Coordinating Governance goals and optimizing and configuring the EHR to leverage the latest tools is key.

Earlier in 2020, Epic implemented updates to help screen and identify patients with the coronavirus. While this is an important step in better identifying the patients, workflows must be able to support initiatives and new updates to an EHR.  

Knowing the latest feature and functionality of your EHR, coordinating workflows changes, identifying governance goals, and leveraging EBM are all important factors that need to be addressed.   By leveraging the latest EBM and EHR functionality, our team has the experience and expertise to help configure your system to meet the organizational goals.

Todd Klein, CIO, VP of EHR Services & Digital Solutions


Posted by Samantha Serfass on February 25, 2020 in Blog, News


Is your coding quality maintenance program well-rounded?

While the depth and detail of coding quality maintenance programs vary depending on an organization’s specific needs, frequent audits using a mixture of chart selection methodologies will result in the most complete, well-rounded coding quality maintenance program. Performing one annual coding audit of 30 randomly selected records per coder is too limited and does not support a well-rounded plan. 

The benefits of coding audits

Organizations should strive for a complete and accurate clinical database.  While accurate coding is vital to reimbursement, accurate and complete coding is also imperative for:

  • Accurate case mix index (CMI)
  • Accurate reflection of the severity of illness (SOI)/risk of mortality (ROM)
  • Support of medical necessity for services rendered
  • Support of decision to admit/medical necessity for inpatient status; correct place of service status
  • Ward off government and payor scrutiny in the form of RAC, OIG, ZPIC, MIC, MAC, etc.
  • Improved comparison studies and profiling/scorecards
    • e.g., HealthGrades, Leapfrog, state comparison studies, PEPPER reports, PQRS
  • Support of resource consumption and length of stay
  • Support of contract negotiations (payors for managed health care)
  • Decreased number of rejections and denials, including
  • Hospital Acquired Condition/Present on Admission concerns and discharge disposition issues
  • Assistance with research, outcomes analysis, quality of care, critical pathway development and wellness initiatives
  • Reduced penalties related to 30-day readmissions; the excess readmission ratio includes adjustments for factors that are clinically relevant, including comorbidities
  • Accurate planning for population management and accountable care data analytics

One way to assure a complete and accurate database is to perform periodic coding and documentation audits through a well-rounded coding quality maintenance program.

Developing a coding quality maintenance program

Detailed planning is needed in the creation of a well-rounded coding quality maintenance plan.  Various details that should be considered include:

  • The frequency of audits: daily pre-bill, monthly, quarterly, semi-annual, annual
  • The scope of what will be reviewed: 
    • Inpatient DRG validation only or full coding quality review,
    • MS and/or APR DRG    
    • Which outpatient service types to include and if the review will include injection and infusion services and facility E/M
    • Professional fee specialties to include
  • The volumes to review
  • The chart selection methodology
    • Concurrent/pre-bill or retrospective
    • Dates of service of the encounters to review
    • Which payers to include 
    • Random versus targeted

How the audit sampling is selected is one of the most important considerations.  Various methodologies, each with their benefits and limitations, can yield differing returns.  To maintain a well-rounded approach, a coding quality maintenance plan should include a variety of audit sampling approaches. 

Approaches to sampling for coding audits should include:

  • Random selection of encounters across all coders and payers
  • Random selection of inpatients from the top MS-DRGs by volume and random selection of outpatient or professional fee encounters from the most frequently reported APCs or CPTs or diagnoses
  • Targeted sampling based on high-risk DRGs as identified from prior review results, PEPPER reports, OIG and RAC targets

By alternating random and targeted chart selection for each review, organizations can achieve the benefits that are offered by the separate audit sampling approaches.   

All health care organizations should maintain a robust coding quality compliance plan with ongoing monitoring and evaluation, strong coder feedback and education to promote consistency in complete and accurate reporting of a facility’s patient population.

Choosing a coding audit vendor:

A trusted business partner can be invaluable in helping your organization develop and maintain a robust coding quality maintenance program. When choosing a vendor to perform coding audits, consider the following:

  • Range of services – Choose a partner with the ability to perform a wide variety of audit types including inpatient, outpatient, and professional fee.
  • Reporting capabilities – Make sure the vendor will offer statistical findings that will help identify patterns and trends in coding and documentation.
  • Education –  The vendor should have the ability to identify specific areas of educational needs with the ability to offer the education needed.
  • Audit process – Review the audit and communication process with the vendor to ensure it includes a strong coder involvement in the audit process, allowing for coder comments with a dispute resolution process.
  • Auditors– Request information about the vendor’s audit staff in terms of their experience, credentials, education, tenure and training.
  • References – Ask for and check references.

Lisa Marks, VP of HIM Services

Leveraging Technology: Increasing the Quality of Care

Posted by Samantha Serfass on February 14, 2020 in Blog, News


Technology continues to help healthcare professionals make significant strides, but is it all for the better? An article titled “Why Doctors Hate Their Computers” published by the New Yorker describes the high percentage of dissatisfied physicians and the burn out rates related to their use of EHRs. Many healthcare providers finish their documentation after hours due to extensive work schedules. This overload of attention required by the EHR has negatively impacted many physician’s work/life balance.

A scribe could help eliminate several negative factors affecting a physician’s workload. A key advantage to utilizing a scribe is decreasing the overall time the physician spends collecting information and documentation. However, there are well-known downsides to using a human scribe. With the advances technology continues to make, a future scribe could be an Artificial Intelligence (AI) component of the EHR.

The system will integrate with motion detection to identify a physician is checking a heartbeat and provide an overall physical assessment.  While documenting the exam, the physician can tell the EHR system to re-order meds and/or create a referral consult to a specialist. The system will then verify back to the provider the medicine to reorder and which doctor they would prefer to refer the patient to.

The future EHR will automatically collect information and document the EHR based on actions and verbal communication.  The physician will then review and correct each documentation. By leveraging AI, the system will be able to identify each correction and remember the documentation for future documentation.

As Telehealth increases in use, physicians’ and patients’ satisfaction will also improve. The future Telehealth systems will be able to easily transition the patient between providers, ensuring provider is utilizing the highest-level practice within their licensure.  The future Telehealth system will create the documentation and billing claims based on the verbal communication between the provider and patient allowing the provider to again review the automated documentation.  

Until the future is here, there are still several factors we can implement now to improve physician satisfaction as well as increase the quality of care. The overall effort to address satisfaction while leveraging the system requires revisiting workflows, rethinking how we use technology, and how we support the system.  Addressing and streamlining documentation and creating better policies around messages to providers so they can be effective at the documentation and are not overwhelmed are also ways to improve satisfaction.

When Implementing technology to increase physician & patient satisfaction, the system should be dedicated to:

  • Evaluating add on apps geared to improve satisfaction
  • Providing voice recognitions and templates for specific specialties
  • Offering personal physician labs and continuing education

Current EHR’s are able to measure how effective specific physicians are at using the system.  Leveraging these reports and physician support team can continually look to utilize new features and functions. This will also provide support for physicians to become more efficient at documenting.  

Excite Health Partners has the experience and expertise to help increase physician satisfaction. Through these strategies and approaches, we will work with your team to improve physician work/life balance while still providing quality care to the patients.

Todd Klein, CIO, VP of EHR Services & Digital Solutions


Posted by Samantha Serfass on January 31, 2020 in Blog, General, News

Breaking It Down: EGD with Endoscopic Ultrasound

Esophagogastroduodenoscopies with endoscopic ultrasound examination can appear rather confusing, especially when additional procedures such as fine needle aspirations or injections of adjacent structures are also performed in tandem with the original procedure.

The first thing to remember is that all of the Upper EUS codes are subsets of the parent code, 43235 Esophagogastroduodenoscopy.  If you look at the code book, all of the codes under 43235 start with “with”.  Keeping this in mind, you will realize it is always assumed that an entire EGD has been performed (esophagus, stomach, 2nd portion of duodenum) prior to the insertion of the echoendoscope.  Also note that there is a separate code for esophagoscopy with EUS, meaning the stomach and/or duodenum is not entered with the scope.

For the purpose of the EGD’s with EUS, the GI system is broken down into three basic regions:

  1. Esophagus
  2. Stomach
  3. Duodenum (or surgically altered stomach where the jejunum is examined distal to the anastomosis)

The next thing to distinguish is the subtle verbiage differences in the code descriptions, namely AND versus OR, which helps identify the best code for the operative scenario.  For these procedures, the word “and” (esophagus, stomach, AND either duodenum or surgically altered stomach…) means that all three regions have to be evaluated using ultrasound.  When “OR” is used, the intent is to reflect that two out of the three regions are evaluated.  Typically, 43237 is used when the EUS probe is inserted through the esophagus and into the stomach, but does not reach the duodenum. 

Of note, it is also assumed that adjacent structures are always visualized during an ultrasound, even though the only codes that specifically state “and adjacent structures” are 43237 and 43238.  Adjacent structures is defined as not only the walls of the GI tract, but other structures such as the liver, biliary tract, pancreas, lymph nodes.

When determining the correct code assignment, remember that the code descriptions for endoscopic ultrasound refer specifically to the ultrasound probe, and the depth to which it is inserted.  A complete esophagogastroduodenoscopy has to be performed prior to the EUS in order to correctly choose a code from this section as evidenced by the code format contained in the CPT book.


43235 Esophagogastroduodenoscopy
43237 with EUS limited to esophagus, stomach or duodenum and adjacent structures
43238 with EUS with fine needle aspiration (Includes EUS limited to esophagus, stomach, or duodenum and adjacent structures)
43242 with EUS with FNA (includes EUs of esophagus, stomach, and either duodenum or surgically altered stomach where the jejunum is examined distal to the anastomosis)
43253 with EUS guided transmural injection of diagnostic or therapeutic substance (includes EUS exam of esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
43259 with EUS including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis

For additional uses for EUS, check out Excellent Endoscopy.

Robyn McCoart, RHIT

Managing Auditor, Excite health Partners