EM Coding Alert

Can you come up with all the right answers?

E/M levelling is part science, part art. And no matter how you do it, you always seem to encounter an unusual situation that leaves you second guessing your decision.

That’s why it’s always a good idea to sharpen your E/M coding skills. So, we assembled these three E/M head-scratchers for you to ponder.

Is Two out of Three so Bad?

Question:  To bill a 99215 visit, can I have a comprehensive history, comprehensive exam, and medical decision making of low complexity?

Answer: To meet the CPT^® requirements to bill 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...), you only need to meet the level of any two of the three key components as stated.

“Two comps and a low,” as in the original question, do qualify for 99215. However, most payers have requirements stating that in order to be considered for payment, all services must meet medically necessary criteria. It would be uncommon for a patient’s condition to require your provider to perform a comprehensive history and physical exam when his findings only meet the low complexity criteria.

Also note: The code descriptor clearly states, “which requires,” which is not synonymous with your practitioner performing the extra work in the history and exam section to just meet the criteria for a higher E/M level.

Reminder: The “at least 2 of these 3 key components” criteria is a constraint for follow-up or established patients but not new patient visits or consultations, which require all three key components be met.

Should You Play It Safe?

Question: We recently performed an internal audit and found that one coder was reporting 99213 in several cases when the documentation warranted 99214 or 99215. When we brought it up, she said she thought the doctor documented enough for 99214, but she wasn’t sure, so she reported 99213 to stay on the safe side. What can we do to avoid this in the future?

Answer:  If the coders are assigning the levels of service, they should be using an auditing tool. There are many auditing tools available, including the ones that the payers use and make available on the web.

Coders should never “think” the doctor documented one way or another: they should know. And then if the documentation and the medical appropriateness of the code is there, it should be billed that way.

When you’re assigning E/M levels, you can’t afford to miss any of the elements of history, medical decision making, or exam. The history, especially on an established patient, is usually the portion of the visit that is not always thorough. However, depending on the payers’ interpretation, the exam might not be documented well. There is a difference between an expanded problem-focused exam and a detailed exam.

The payers may have different rules on this. One payer may say that two-to-seven body areas or organ systems with at least one system being more detailed should count as a detailed visit, while another payer says that at least four organ systems should have four descriptors under each one.

Solution: Coders should have in writing the E/M definitions of their top payers so they can identify when a 99213 was accurately documented.

Can This Visit Be Coded at All?

Question: A new patient presented in our office. We obtained a medical, social, and family history, and the provider documented a comprehensive HPI and a complete (10) ROS. The diagnosis was moderately complex and there was data management. However, no physical exam was done other than vitals and the pre-evaluation testing by the tech. The provider did not document face-to-face time spent with the patient. Can I bill more than a 99202?

Answer: For a new patient, the level designation is determined by all three of the key elements: history, examination, and medical decision making (MDM). Therefore, even if you have a comprehensive history and high complexity MDM but only vitals, you can still only report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …). In your case, with only vitals and the tech’s pre-visit testing taken, you can only report 99201 despite the comprehensive history and moderate MDM. Vitals alone is only one bullet per 1997 guidelines and only one system/body area per 1995, so for either one, this is a problem-focused exam, which limits new patient coding to 99201.

To get to 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …), you would need an expanded problem-focused exam, which is 2-7 systems. To get to 99203 (… a detailed history; a detailed examination; medical decision making of low complexity …), you would need a detailed exam.

And if the provider had done a comprehensive exam, you would have 99204 (… a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) based on a comprehensive exam, comprehensive history, and moderate MDM. But unfortunately, you’re stuck at 99201 due to only vitals for the exam portion.

For a new patient with basically no provider exam, it seems that the encounter was likely spent on counseling and/or coordination of care. If that is the case, there isn’t anything you can do about it at this point, but you should educate your provider on when he can (and should) bill based on time spent with the patient, and what he needs to document to be able to do so.