Wiki Looking for "official" guidance only on this: How to determine COPA

[ljones88]

Hi all,
Recently I was told by a department head at my job that COPA is to be determined based on "how the patient presented to the department/office" when determining the level of the COPA....I can't find any documentation anywhere within the AMA CPT, or CMS stating that COPA is to be determined based on how the patient presented to the department. I was always told COPA is simply the complexity of the problems addressed- nothing to do with how the patient presented. I am specifically referring to the E/M Leveling under the 2023 E/M Guidelines wherein COPA (Complexity of Problems Addressed), Risk, and Data are considered in leveling the E/M visit.
This is the example we are being given in order to understand this rationale: Patient presented to the ED with wrist pain. Without the dr knowing what happened to the patient, and knowing additional workup will need to be done, they are telling us we should be considering this wrist pain as a Moderate level COPA falling under either an "acute complicated injury" or "undiagnosed new problem with uncertain prognosis" regardless of the final diagnosis (in this case, just some wrist pain likely from arthritis, no fractures, or vascular issues).
I'm sorry, but what?! Needless to say I asked for evidence as to where this directive is coming from and I get no answers. Further, they are taking into consideration what the ACEP (American College of Emergency Physicians) in their logic/rationale....With all due respect, ACEP is no one on the totem pole of authority. They have zero influence on the CMS and CPT rules so of course, when I questioned why this department is considering ACEP's interpretation of the rules as fact, no one could give me an answer....This is the first time in my 14 years of coding that any organization has used ACEP in their logic/rationale....everywhere I have worked always refers to CMS or AMA's CPT only. SO here I am asking the general public if anyone can provide proof that COPA is to be determined based on how the patient first presented to the department. The math aint mathin in my search efforts and I have lost so much sleep over this cause it will inadvertently lead to overcoding and risk the organization to an OIG audit.

 

[TThivierge]

Hi Ljones,
Why not look in the AMA manual book entitled Risk Adjustment or Medical Record Auditor. Then check again CMS, OIG NCCI websites for data. The CPT manual states info on MDM risk, levels of visit, Etc. Then have IT Dept. reports per department list denials with payer types, dx and CPT codes used. Also you can tactfully direct providers, but they make final call in their documentation and final dx codes in treating the patient. When a patient present it is more than nature of complaint it is also ancillary processes, settings (OP vs IP) is it follow up, vitals, chronic conditions from provider s input to select final outcome of dx or clinical treatments. Also, each medical specify has certain guidelines in processes of treatment , meds, and acronyms used, Etc. I hope COPA is the defines -the Competency Outcomes and Performance Assessment (COPA) model, which included assessment and intervention, communication, critical thinking, caring and interpersonal skills, management, leadership, teaching, and knowledge integration.
The patient encounters are documented then sent to payer ...... may be look at final dollars billed & collected to see if can present that to add to more specific, clear documentation to ensure coded properly.
Well hope helped you somewhat
Have a Good Day
Lady T

 

[jkyles]

Hi there. This sounds like a classic case of WADITW (we've always done it this way).

It's not uncommon for organizations to create and institute a policy internally. Over time people forget it was an internal decision and assume the policy is based on an official rule or guideline. It might also be that someone submitted a question to a MAC or a payer and created a policy based on the response. Or the policy is based on official guidelines/rules that have become obsolete. In any event, can be difficult (or impossible) to track the internal policy to a official guideline or rule when no one remembers where it came from.