Anesthesia Coding Alert

2 scenarios help hone your E/M coding skills E/M visits are an important part of pain management services because your physician determines each patient's best course of treatment. Before you report any E/M procedures, look for documentation details on the patient's presenting illness because this information can make or break your patient's complete history -- plus affect your coding and your specialist's bottom line.

Check out the following two questions to determine your review-of-systems (ROS) savvy. Then check your answers against our experts' opinions.  Don't Let Language Barrier Keep You From Full HPI  Question 1: A new patient who cannot speak English and explain her medical problems presents to your pain management practice. The patient's inability to communicate prevents your physician from obtaining a complete history of present illness (HPI) and ROS from her. Your physician treats the patient's migraine but cannot develop a definite plan for her treatment. 

Your pain management specialist calls the patient's previous two physicians to discuss her medical problems and discovers that the patient also has a history of hypertension. Your physician spends a total of 90 minutes on this patient on the same day, including face-to-face patient time and telephone calls to the other providers.

How should you charge for this scenario? Which E/M codes and modifiers should you use to justify the extra time your physician spent on the phone with other physicians on this patient's behalf?

Answer 1: You should select the appropriate E/M service level from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) based on the information your pain management specialist obtained from the patient and her previous physicians.

Be careful of time: If you want to bill based on time, your physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time. Instead, justify the E/M level of service with documentation of the patient's history, examination and medical decision-making.

Watch out: In most cases, you cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Normally, communication barriers do not meet the criteria for counseling/coordinating care.

The pain specialist may document the extra effort in trying to obtain an appropriate history with the reason for the extra effort and a reason why he was unable to get the full history. The physician may receive credit for the "unobtainable" history.

If your pain management specialist documents service time when the patient is not physically present (such as his postexam calls to her other physicians), you will probably be unable to be reimbursed this [...]