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 time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Here's why: Most payers consider extra time (as in this example) to be part of the pre- and postservice work associated with the E/M service payment.

Ensure Your Physician Signs the Nurse's Notes   

Question 2: Can you use a nurse's notes to satisfy elements of ROS and past, family, social history (PFSH) for a new patient visit, as long as the physician documents his review of the notes?

Answer 2: If your physician makes a notation supplementing or confirming the information recorded (i.e., signing and dating the nurse's notes) and documents that he reviewed the documentation, you can meet the requirements for ROS and PFSH with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator at Beeghly Medical Park in Ohio. "I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes," she says.

You'll use the ROS and PFSH, along with the patient's physician-documented HPI, to decide the level of information the physician gathered about the patient's history and code it correctly. 

The ROS is basically an inventory of the body so your pain specialist knows where to direct the physical examination. The inventory might include evaluations of any of the following systems or parts:
 
• Allergic/immunologic

• Cardiovascular

• Constitutional symptoms

• Ears/nose/mouth/throat

• Endocrine

• Eye

• Gastrointestinal

• Genitourinary

• Hematologic/lymphatic

• Integumentary (skin and/or breast)

• Musculoskeletal

• Neurological

• Psychiatric

• Respiratory.

For a problem-pertinent ROS, your pain specialist needs to review the system directly related to the problem(s) identified in the HPI and will usually follow the guidelines of E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history, a detailed examination, and medical decision-making of low complexity).

Multiple systems: If your physician reviews the system directly related to the problem(s) identified in the HPI and records the patient's positive responses and pertinent negative responses for a total of two to nine systems, you should consider the ROS "extended." This means the visit could translate to 99203.

If he reviews at least 10 systems, the ROS is "complete," which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

Example: Many conditions might shift a pain management-related ROS to one of the higher-level codes. These can include a neoplasm related to pain, multiple fractures due to trauma for a patient with acute pain, or comorbid conditions for an elderly chronic pain patient (such as heart or lung disease or diabetes). 

A "pertinent" PFSH consists of a comment in any one of the histories -- information about the patient's past health history, family history or social history -- and helps you on your way to a 99203.

For a "complete" PFSH, the pain management specialist must have information that involves all three of the histories; if so, you'll report either 99204 or 99205 for the encounter.