Cardiology Coding Alert
How to Take the Stress Out of Exam Component Coding
Experts offer 4 tips to make sure your systems add up Assigning the right exam level during an E/M visit depends on how well you understand the distinctions between problem-focused, expanded problem-focused, detailed, and comprehensive exam levels in the documentation guidelines - and that's just a start. Exam Audit Turns Up Varied Responses Last month, we featured the results of our cardiology-specific analysis of the E/M documentation guidelines. Our 10 survey participants - all certified cardiology coders from across the country with an average of 12 years of coding experience - differed significantly in the way they coded the history portion of the sample visit note. (See "E/M Audit Results, Part 1: Are You Puzzled by the E/M Guidelines?" in the October 2003 Cardiology Coding Alert.) Look Over the Sample Exam Details Our volunteers' coding varied the most for a follow-up office visit for a patient with coronary artery disease (CAD) and diabetes. Only half of the coders agreed on the documented level of exam for this encounter. The report's actual exam details follow: So, how would you assign the exam level for this note? Here's what your peers said: Given the mixed responses of our study participants, you may be wondering what method to use for assigning the exam component. Use the following four tips to resolve that challenge: "We discovered that whether we code the encounter based on this system or according to CPT (EPF: two to seven systems 'limited'; Detailed: two to seven 'extended'), we will end up with the same level exam in the end," Spaulding says. (See the E/M guidelines section in CPT for a complete list of body areas and systems.)
The key to getting exams right is tallying body areas and organ systems correctly, coding experts say.
Our exam component analysis reveals similar disparities in the levels of exam assigned to each of the five sample notes.
On average, the coders in our study agreed with the most frequently selected exam level only 55 percent of the time. Moreover, of the five encounter notes, there was not a single one in which they all agreed on the level of exam.
This wide variance might not have been the case if the documentation guidelines were clearer, coding experts say.
Weight: 187; Blood pressure: 140/68; Pulse: 64; Respirations: 18
Neck: No jugular venous distention (JVD). No carotid bruits.
Lungs: Clear
Cardiac: Regular rate and rhythm (RRR). No murmur/gallop.
Abdomen: He has a ventral rectus hernia. No mass/bruit.
Extremities: No clubbing/cyanosis (CC). Just a trace of pretibial edema.
Review Our Coders' Answers
Of the eight coders who supplied their audit sheets, one assigned a "problem-focused" exam for this note, three assigned an "expanded problem-focused" exam, and four assigned a "detailed" exam.
We took a close look at the audit sheets of the four coders who disagreed with the most common level of exam (detailed) and found that two participants applied the 1997 guidelines (which include specific exam elements) rather than the 1995 guidelines (which include broadly defined body areas), and awarded an expanded problem-focused level of service.
The remaining two coders used an audit sheet that differed from the others in distinctions between a problem-focused, an expanded problem-focused and a detailed level of exam
Overall, half of the coders indicated that the documentation supports a detailed exam.
Therefore, because this was an established patient encounter, the note supports a level-four service (99214), assuming it meets other requirements (history or medical decision-making).
The note included the appropriate cardio information and other exam details to support a detailed exam, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
Learn 4 Exam Component Best Practices
1. Rely on the 1995 guidelines but use the 1997 rules if necessary. Choosing between the two guidelines can be difficult, but until a better system is in place, coders should use the set that is most beneficial for each visit note, coding experts say.
"Our physicians have tried using both the 1995 and the 1997 guidelines and determined that the 1995 guidelines were more suitable and not as cumbersome as the 1997 rules," says Patricia Gajewski, CPC, with Consultants in Cardiovascular Disease Inc. in Erie, Pa.
For the sample note above, the 1995 set is preferable because the two coders who used the 1997 guidelines came up with a lower-level "expanded problem-focused" exam, which brings less reimbursement than the higher- level "detailed" exam. Even so, keep in mind that you can't mix the two guidelines for the same intervention to get a better result.
2. Distinguish between "expanded problem-focused" and "detailed" exams in the 1995 guidelines. The 1995 guidelines define an expanded problem- focused (EPF) exam as "a limited examination of the affected body area or organ system and other symptomatic or related organ system(s)," according to CPT (page 2). The detailed exam is "an extended examination of the affected body area(s) and other symptomatic or related organ system(s)."
But the guidelines do not clearly define limited and extended examinations, so you have to determine what this means when deciding between an EPF and a detailed exam.
"Typically, we break the exam down according to the following method," says Charol Spaulding, CCS-P, CPC, CPC-H, vice president of Coding Continuum Inc. in Tucson, Ariz.
The documented information on a particular organ system is the key to selecting either EPF or detailed, Spaulding and Callaway say. "If I see that the physician has documented more than just a few lines about one organ system, then I will raise the level to 'detailed,'" Spaulding says.
Additional problem system data is crucial for "detailed" exam status, Callaway says. Look for more extensive information than "within normal limits." For a detailed cardiovascular exam, you should find at least three or four specific exam pieces, such as specific sounds, pulses and edema, she says.
Remember that the physician only needs to document one finding per system to be able to count the system, Spaulding adds.
In the example above, the cardiologist documents five systems, including specifics on the constitutional, cardiac, respiratory, abdomen and extremities, which would support a detailed exam under the 1995 guidelines.
3. Give credit for body areas and organ systems when counting documented exam elements under the 1995 guidelines for the first three exam levels (problem- focused, expanded problem-focused, and detailed). Exams of body areas, such as the head or neck, can generate more than one system exam, so watch for these details in the notes, Spaulding says.
For instance, if the cardiologist examines the neck (a designated body area), he may document JVD as in the sample chart, which indicates an examination of the body area "neck." He may also detect and document enlarged lymph nodes, which would indicate a lymphatic/ immunologic system exam. In this case, the neck exam could produce two exam elements (that is, neck and hematologic/lymphatic/immunologic system), which would raise the exam level.
4. Count systems but not body areas for the comprehensive exam. The 1995 guidelines state, "The medical record for a general multisystem examination should include findings about eight or more of the 12 organ systems." So you should look for at least eight system exams in the notes to assign a comprehensive exam under this guideline set. You would not count body areas under these guidelines because the definition specifies organ systems only, coding experts say.
Moreover, the 1995 guidelines reference a "complete examination of a single organ system" without further defining this standard. Frustration over this vague description triggered development of the 1997 guidelines, coding sources say.
"For a comprehensive exam, I look for several systems, with detail in more than one, and as much information as possible in the system of focus," Callaway says. "I find that in cardiology, the comprehensive exam for most physicians is actually the eight-system multi-system exam."
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