EM Coding Alert

Hone your E/M skills with the answers to the quiz from last month’s issue.

If you aren’t properly reporting your physician’s E/M services, you are costing your practice money. Even veteran coders need to assess their skills and focus on areas for improvement. 

Get out your answers and see how you did on last month’s quiz titled “Test Yourself to Avoid These Critical E/M Errors.” If you get all of these questions correct, you are on your way to having fewer stressful moments when coding E/M.

Answer 1: A. This is an example of a review of systems (ROS) that is problem-pertinent. The physician performs this ROS when he reviews only the system related to the patient’s problem.

Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-two new patient E/M 99202  (Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision making …) or a level-three established patient E/M 99213 (... an expanded problem focused history; an expanded problem-focused examination; medical decision making of low complexity …).

Tip: Many follow-up visits for patients with plans of care in place result in problem-pertinent ROS.

Answer 2: C. You should report a new patient physical and new patient E/M. The patient remains new throughout the initial encounter. So you should code such encounters with 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual …) and 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the new patient E/M 99201-99205 if you have separate documentation that supports both services.

In the October 2006 CPT® Assistant Q&A, the AMA confirmed that if a physician provides a preventive medicine service and an office or other outpatient service during the same patient encounter, you can appropriately report both services as new patient codes if the patient meets CPT®’s definition of a new patient as one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Therefore, you should consider the patients status for the encounter, not for the individual portions of the overall encounter.

Answer 3: True. According to CPT® rules, you need two out of three elements to support an established patient E/M service. In this case you have a detailed history and a detailed exam, which support a level-four office visit code, as long as there is medical necessity for a level-four established visit.

Important: Medical necessity must support the level of your coding. With this patient, due to his severe chronic allergies, the physician is justified in performing a detailed exam and detailed history even though his medical decision making (MDM) is only low level.

If the nature of the presenting problem won’t support a higher-level E/M service, you can’t get paid for the service just because the physician documented a higher-level history and exam. Medical necessity is the overriding factor that should determine the service level.

Remember: MDM does not equate to medical necessity. Just because MDM is low for an established patient, that does not mean there is not medical necessity for the physician to perform (and bill) a level-four visit. Because of the way you must calculate MDM — using the number of diagnostic options the physician considered using the number of tests he ordered, and/or using the table of risk — the MDM does not have a one-to-one equality for medical necessity, in particular for a patient who happens to be exhibiting control for previously uncontrolled chronic disease symptoms.

Answer 4: B. Medicare Claims Processing Manual, 30.6.5 Physicians in Group Practice (Rev. 1, 10-01-03) states that physicians in the same group practice who share the same specialty have to bill and be paid as though they were a single physician.

If a patient receives more than one same-day E/M (face-to-face) service by the same physician — or more than one physician in the same specialty in the same group — you can report only one E/M service. The only exception would be if the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a service level that represents the combined visits and submit the appropriate code for that level.

Tip: Physicians in the same group practice who are in different specialties can bill and be paid even if they’re members in the same group.

Answer 5: C. You should report 99214 (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 detailed history, a detailed examination, and medical decision making of moderate complexity …) Usually, the presenting problem(s) are of moderate to high severity. Then, add prolonged services code 99354 (Prolonged  service in the office or other outpatient setting requiring direct  patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) along with 99214. Note that CPT® deleted modifier 21 (Prolonged evaluation and management services) in 2009.