Anesthesia Coding Alert

Thorough documentation of medical history can help your coding cause

Track down all the details you can about a patient's history of present illness (HPI), and watch your coding--and your bottom line--change. 

Concise Is Good--But Detailed Is Better

Every patient record needs a statement describing the patient's condition, symptoms and problem. The physician should keep this statement short and focused, but teaching physicians to dig a little deeper can help justify higher-level codes.
 
Example: The patient complains of back pain that has lasted two weeks. If this is all you know, you-ll have to report a problem-focused code because the statement only includes two criteria for HPI (type of pain and duration), says Julee Shiley, CPC, CCS-P, CMC, an anesthesia coding consultant in Columbia, S.C. Before reporting even a Level 1 code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making), be sure your provider documents some form of examination and/or medical decision-making. Otherwise, you don't have enough information to support your coding.

But asking questions about how and when the patient's pain began can lead you to higher-level--and more accurate and higher paying--codes.

Asking Questions Leads to Higher-level Codes

A thorough look at the patient's condition means understanding the problem from start to finish:  discussing signs and symptoms from their onset through the present visit, or getting details about changes since the previous encounter. Putting together a complete history includes asking questions about:

- The location of the problem
- The quality of the problem (what it looks or feels like--throbbing, sharp, radiating, etc.)
- The severity of the problem, based on a scale of 1-10
- How long the problem has existed
- When the problem occurs (after walking, after sitting for prolonged times, continuous, etc.)
- What the patient was doing when he first noticed the problem (walking, lifting something heavy, no specific onset)
- What makes the problem better or worse (lying down, taking ibuprofen, walking)
- Other signs or symptoms that are present (fatigue, leg pain, urinary problems). Co-morbidities such as diabetes, hypertension or cardiopulmonary problems help support a higher level of exam and medical decision-making.

Documenting four or more of these details shows you-re dealing with an extended illness rather than a one-time acute problem, says Kathy Campbell, CPC, of the anesthesia billing firm Professional Economics Inc. in Bloomington, Ind.

In the example above, you already know the patient's pain has lasted two weeks. Answers to a few questions show that he doesn't remember exactly when the pain began, but a dull ache is always present. Standing for long periods or walking leads to sharper pain the patient ranks as a 7 on a 10-point scale. Taking ibuprofen relieves the pain to some extent.

Now you know much more about his condition to help your coding:

- Location of pain (back)
- Duration of pain (2 weeks)
- Type of pain (dull, but sometimes sharp)
- Severity (7 on a scale of 10)
- Timing (constant)
- Factors affecting the pain (walking, standing, taking over-the-counter medication).

Break it down: Coding from this more thorough description moves you from a basic E/M code (such as 99212) to a more detailed, higher level code. The visit might even qualify for a Level 4 code such as 99214 (- a detailed history; a detailed examination; medical decision making of moderate complexity).

Reporting the higher-level code makes your claim more accurate and also boosts your bottom line. The difference for Medicare non-facility fees for these visits will vary by location, but some sample ranges based on CMS- 2005 fees include:

- $18-36 for 99211
- $34-49 for 99212
- $47-66 for 99213
- $74-137 for 99214
- $110-146 for 99215. 

The code you select depends on the personal family social history (PFSH), review of systems, lab results, the extent of medical decision-making, and other factors. Remember: If the provider doesn't document an ROS or if you can't locate the information in the HPI, you can only report a Level 1 (99212) code.

-The history portion of an office visit is the driving force of the exam and medical decision-making,- adds Jennifer Gero, a coder and billing specialist with TB Consulting and Billing in Myrtle Beach, S.C. -If a patient has a comprehensive history, the physician is justified in performing a detailed or comprehensive exam, especially for a new patient. If the patient has co-morbidities, the physician is substantiated in doing a high-level exam because the patient has other problems or diseases that must be considered throughout the exam and during the medical decision making process.-

Coding options for these higher-level visits include 99213 for an expanded problem-focused history and exam, 99214 for a detailed history and exam, and 99215 for a comprehensive history and exam.
 
Tip: Having your provider (physician, PA or NP) acknowledge and date his review of the patient's HPI form along with notes from the patient's current visit helps document a complete history.
 
As Campbell notes, you should look at the whole chart when determining the correct level of medical decision-making and corresponding E/M code for a procedure. If you-d like a chart outlining some tips for gathering the HPI you need, email editor Leigh DeLozier at leighdelozier@bellsouth.net.