EM Coding Alert

Would you get an A+ on these evaluation and management (E/M) questions?

Don't miss out on valuable revenue for your E/M patient visits. Whether you've been an E/M coder for two months, two years, or 20 years, now is always the right time to sharpen your knowledge.

Assess what you know already and what you should work on with these four questions garnered from this past year's E/M Coding Alerts.

1. Question: What are the two types of history of present illness (HPI) and how are they distinguished?

Answer: The History of Present Illness (HPI) is an element within the history component - one of the three key factors used in selecting the correct level of E/M service. The CPT® 2017 manual defines HPI as "a chronological description of the development of the patient's present illness from the first sign and/or symptom to the present." It provides the details around the chief complaint.

There are two levels of HPI - brief and extended. These HPI levels are distinguished by the amount of detail included in the documentation for the following elements:

• Location: The anatomical place/site of the chief complaint
• Quality: A detailed description of the problem
• Severity: The degree of intensity of the signs/symptoms
• Duration: Length of time of the complaint
• Timing: How often the symptoms occur
• Context: The circumstances/environment in which the symptoms occur
• Modifying factors: Anything that relieves or aggravates the problem
• Associated signsand symptoms: Other related factors/symptoms

With a brief HPI, the documentation would illustrate one to three of the above elements. With an extended HPI, the documentation would include four or more elements.

Important: Medicare considers all of the above HPI elements, but other payers may not count "duration" because CPT^®  does not include it in the list of HPI components. If you are unsure of a payer's HPI element list, call your payer representative.

2. Question: When you report home visits, is medical necessity documentation sufficient?

Answer: No. If you're reporting home visit codes 99341-99345 (for new patients) or 99347-99350 (for established patients), you must document medical reason along with medical necessity.

Documenting the medical necessity (why the patient needs to see a physician) of the encounter is fairly simple. Medical necessity can be any type of problem that the physician would see a patient for in the office.

Documenting the medical reason a patient needs home treatment can be more challenging. Although the patient does not have to be confined to the home, like with home health services, the medical record must document the medical need for your provider to perform a home visit in place of the office visit. For example, if a patient is blind, paraplegic, or meets other criteria that make it harder for him to go to the office, then your physician must include this information in the documentation she writes into the patient's medical record.

Important: Convenience of the patient or provider would not be an appropriate medical reason.

Many times, home visits do deal with people who are "homebound," and various payers define "homebound" in different ways. For home care nursing services, usually the patient cannot be away from home other than for medical issues. For the physician to come to the patient's home, the homebound status includes that the patient cannot leave the home at all, even for medical purposes.

3. Question: Can you code a counseling exception for the E/M service in this scenario?

Scenario: Your physician performs a problem-focused history and straightforward medical decision making (MDM) on an established patient with asthma, which takes 10 minutes. After those services, your physician spends 17 minutes counseling the patient on the need to be consistent with her asthma medications and how to identify an acute episode. This office encounter ultimately lasts 27 minutes in total.

Answer: Yes, you can use the counseling exception in this scenario. You would report 99214 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family) for this encounter since 99214 is for an established office visit in which "25 minutes are spent face-to-face with the patient and/or family."

To code based on time (also known as the counseling exception), you must ensure your provider has three details in his documentation. First, the documentation must show the total length of time of the encounter (face-to-face or floor time your physician spent with the patient). In this case, that would be 27 minutes.

Second, the documentation must also show the amount of the time your physician spent on counseling, indicated by minutes or percentage. That would be 17 minutes, based on our example.

Third, your physician's documentation must also include a synopsis of the content or topic of the counseling or coordination of care.

Bottom line: Since the counseling and/or coordination of care dominated (more than 50 percent) of this encounter (17 minutes), you can consider time the controlling factor, and you have a counseling exception.

4. Question: Dr. Smith, your physician, admits his established patient, Beth Jones, into the hospital under "observation status" on December 5. Ms. Jones remains in observation until Dr. Smith discharges her on December 7. Dr. Smith sees Ms. Jones each day she is in observation. Which observation codes should you use in this case?

Answer: You would report three observation codes based on the documentation within the medical record.

For your first code for December 5, you will choose an initial observation care code from 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...).

For December 6, the second day of observation, pick a subsequent observation care code from 99224-99226 (Subsequent observation care, per day, for the evaluation and management of a patient ...).

For December 7, the day of discharge, choose code 99217 (Observation care dischargeday management ...) for observation day discharge.