Know When to Report High-Level Established Patient Visits

Let history, medical necessity determine your code selection

Make sure your physician’s documentation shows medical necessity when she performs a comprehensive history and examination before you report 99214 and 99215--otherwise, you could be opening yourself up to allegations of unethical coding.
Medical Necessity Should Drive History
When determining a visit’s history, the type of history--problem-focused, expanded problem-focused, detailed or comprehensive--that the allergist claims must be medically necessary based on the encounter. “The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s),” states CPT’s E/M guidelines section, “Instructions for Selecting a Level of E/M Service” (page 3--Ingenix 2005 Expert).

Even though a nurse may take the information necessary to support a comprehensive history, the physician’s clinical judgment and the patient’s problem should determine the amount necessary. “Coding too many 99214s and 99215s could trigger an audit, especially if these codes are associated with one minor diagnosis,” says William H. Ward, MD, IAFP, associate director of St. Francis Family Practice Residency Program in Beech Grove, Ind.

Example: An allergist sees an otherwise healthy established patient for exercise-induced bronchospasm. In this scenario, no medical need exists to collect a comprehensive history. You would report 99213 for a routine established patient exam, says Beverly Ramsey, CMA, CPC, CHCC, CHBC, at Doctors Management in Asheville, N.C.
 
In fact, coding a comprehensive history for such a simple problem could prove unethical, even if your staff has gathered more history than necessary. “Payers and auditors may view such conduct as ‘gaming the system’--obtaining a higher-level component than medically necessary just to charge a higher-level E/M service,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.
Exam’s Extent Hinges on Problem
You also have to consider medical necessity when determining the E/M service’s exam type. CPT’s instructions on selecting the exam type echo its history component guidelines. “The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s),” states CPT’s E/M guidelines.

Translation: A physician’s decision to perform a comprehensive exam should stem from the patient’s problem(s). Simple problems don’t warrant this component level or the physician’s time.

Example: Your allergist evaluates an established patient with a common cold (460, Acute nasopharyngitis [common cold]) and no comorbidities. A comprehensive exam isn’t medically necessary in this case.
 
Other examples that may not warrant a comprehensive exam, Ramsey says, include an established patient visit for the following:

• stable chronic asthma requiring regular drug therapy.

• office visit for a patient who experienced a reaction following administration of immunotherapy at a previous encounter and the allergist is adjusting the dosage.

• atopic dermatitis and food sensitivity follow-up. 
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- Published on 2005-11-11