I know what you're thinking. Another boring lecture on E&M coding! Well, this is a little different. This is from the Clinical auditor's perspective.
As an auditor, sometimes the most difficult choices are to try and interpret what the provider actually was saying vs. what he/she thought they were saying!! We have all seen the case where the provider "assumed" all the previous information, never cited references or brought forward any other supportive documentation and yet, he/ she thought this visit deserved a level 4 new patient 99204. In reality, after reviewing all the records available, you determined that the visit lasted about 28 minutes, the actual ROS only contained information on 7 systems, and the PFSH only discussed 2 pertinent facts, and the History ended up being only detailed.
The physical examination was not comprehensive because only 6 body systems were documented with the G-I system being more detailed. And finally, the MDM warranted only low complexity. Therefore this was a 99203 documented visit.
With Medicare telling us to focus on the nature of the presenting problem or illness, the provider is sometimes at a loss of how much documentation to record. I tell all providers the same thing: don't change your style of history taking or physical examination. Learn how to incorporate based on CPT and E&M guidelines, how much information must be brought forward into the Impression and the Medical Decision Making. This is where the provider's downfall is; they don't carry important information into Medical Decision Making which I know they thought of in their course of discovery.
Remind them that if they are thinking about "ruling in or out" something, discuss it and bring it into the Impression with a status statement as to why this is relevant. That shows their MDM more clearly. The ordering of labs, radiology, etc., needs to be justified as well.
In Appendix C of the current CPT Professional Edition book, many excellent examples are shown for level 3 and 4. The initial office visit for a 76 y/o male with stasis ulcer of lower leg of 3 months duration is probably a level 99203. However, that same man comes in with history of recent bowel habits, weight loss and abdominal pain probably warrants a level 99204. Another example is the initial visit for a 22-year old female with irregular menses vs. the 70 year-old male with recent onset of episodic confusion.
As one can see, no visit "IS" any level, until we review all the current documentation. The decision of what level E&M is appropriate is unfortunately still based upon the 1995 or the 1997 CMS E&M guidelines. Admittedly, these are not ideal, but providers must learn to follow these guidelines to justify appropriate revenue production. The biggest loss of revenue that I see in most practices is the constant lack of necessary and appropriate documentation required for whatever level of E&M service is provided.
Another good example is the subtle yet important differences between established level 3 and 4 visits. The level 99213 requires a CC, 1-3 facts in the HPI, 1 ROS and 1 PFSH each to make an expanded problem focused history.
The physical exam requires on 2-7 body systems be documented and a low complexity MDM. On the other hand, a level 99214 requires CC, 4 or more facts in the HPI, 2-9 systems in the ROS to make a detailed history. The detailed exam requires everything the same as 99213 but one system must be described in detail and the MDM is of moderate complexity.
Once again, this is where most clinicians fail to capture the necessary important facts to adequately provide solid documentation to be reimbursed fairly and appropriately. The art of understanding proper E&M coding lies in incorporating the tenants in these guidelines combined with excellent clinical skills.
John F. Bishop, PA, CPC, CGSC, CPRC is a Senior Consultant, Multi-specialty Coder, Auditor and Educator with DecisionHealth Professional Services. www.decisionhealth.com/consulting/default.aspx
