Gastroenterology Coding Alert

Nugget: The four levels of history problem-focused, expanded problem-focused, detailed and comprehensive are key to determining the level of reimbursement for E/M visits.

The history component of an evaluation and management (E/M) service is particularly important during a new patient visit when all three components of the service history, examination and medical decision-making must be considered to determine the level of service provided. Complicating matters are the numerous bullet points that Medicares 1997 guidelines say must be met to bill a particular level of service. Many coding experts feel, however, that gastroenterologists are taking a high-level, comprehensive history from patients, but they need to concentrate on properly documenting that portion of the visit in the patients medical record.

As specialists, gastroenterologists are going to do a lot of level-four E/M visits. Gastroenterologists frequently take a detailed history; it takes about 10 minutes, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a member of the American Medical Associations (AMA) CPT advisory committee. The problem is learning to write everything down.

Four Levels of History

Medicare and CPT agree that there are four levels of history for an E/M service: problem-focused, expanded problem-focused, detailed and comprehensive.

A problem-focused history contains:

Chief complaint;

Brief history of present illness (one to three elements); and

No review of systems or past, family or social history is required.

It is a component of the following E/M codes frequently used by gastroenterologists: 99201 (new patient office visit), 99212 (established patient office visit), 99231 (subsequent hospital care), 99241 (office consultation), 99251 (initial inpatient consultation), 99261 (follow-up inpatient consultation, established patient), 99271 (confirmatory consultation) and 99281 (emergency department visit).

An expanded problem-focused history contains the following:

Chief complaint;

Brief history of present illness (one to three elements);

Problem-pertinent review of systems (one system); and

No past, family, social history is required.

It is a component of the following E/M codes frequently used by gastroenterologists: 99202 (new patient office visit), 99213 (established patient office visit), 99232 (subsequent hospital care), 99242 (office consultation, new or established patient), 99252 (initial inpatient consultation), 99262 (follow-up inpatient consultation, established patient), 99272 (confirmatory consultation) and 99282/99283 (emergency department visit).

A detailed history contains the following:

Chief complaint;

Extended history of present illness (four or more elements, or three or more chronic or inactive conditions if 1997 Medicare E/M guidelines are being followed);

Problem-pertinent system review extended to include a review of a limited number of additional systems (two to nine systems); and

Pertinent past, family, and/or social history directly related to the patients problems (one or two areas of history).

It is a component of the following E/M codes frequently used by gastroenterologists: 99203 (new patient office visit), 99214 (established patient office visit), 99218 (initial observation care), 99221 (initial hospital care), 99233 (subsequent hospital care), 99234 (observation or inpatient hospital care), 99243 (office consultation), 99253 (initial inpatient consultation), 99263 (follow-up inpatient consultation, established patient), 99273(confirmatory consultation) and 99284 (emergency department visit).

A comprehensive history contains the following:

Chief complaint;

Extended history of present illness (four or more elements, or three or more chronic or inactive conditions if 1997 Medicare E/M guidelines are being followed);

Review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems (more than 10 systems); and

Complete past, family and social history (two or three history areas).

It is a component of the following E/M codes frequently used by gastroenterologists: 99204/99205 (new patient office visit), 99215 (established patient office visit), 99219/99220 (initial observation care), 99222/99223 (initial hospital care), 99235/99236 (observation or inpatient hospital care), 99244/99245 (office consultation), 99254/99255 (initial inpatient consultation), 99274/99275 (confirmatory consultation) and 99285 (emergency department visit).

Extended HPI Is Common

The chief complaint and related history of present illness (HPI) tend to be the areas where gastroenterologists have to do the most documentation because the review of systems (ROS) and past, family and social history (PFSH) usually are covered by the patient intake form, which also is referred to as the patient information or history form, and is completed by the patient, often with the help of a nurse. The chief complaint is a concise statement explaining why the patient is in the physicians office, according to Stephanie Jones, CPC, a multispecialty coding consultant in Boca Raton, Fla. All E/M services need a reason for the visit, which will be found in the chief complaint.

The HPI is a more thorough description of the development of the patients chief complaint, says Jones. It includes the following eight elements: location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms.

A very brief sentence can convey several of these elements at once. A patient who complains of sharp pain (quality) below the breastbone (location), which occurs after eating (context) and has been happening for the past six weeks (duration), already has given an extended history of presenting illness because it includes four elements, says Jones.

Most gastrointestinal complaints are easily going to have a least four elements, Weinstein claims. The patient will generally be describing the location of their symptoms and the duration and be able to qualify and quantify those symptoms to some extent.

Although Jones says that gastroenterologists should be taking an HPI every time a patient walks in the door because there always has to be a reason for a visit, she notes that the 1997 Medicare E/M guidelines allow an exception to the HPI requirements. If a gastroenterologist goes by these more detailed guidelines instead of the ones from 1995, an extended HPI also can consist of three or more chronic or inactive conditions instead of four or more of the HPI elements. So under the 1997 guidelines, a patient who has chronic hepatitis, diabetes and hypertension automatically would have an extended HPI.

ROS and PFSH Carry Forward

The ROS consists of the positive and negative responses the patient gives to a series of questions designed to inventory the systems of the body. Most of the time, it is part of the patient intake form, Jones says.

The review of systems is designed to provide more information on the presenting complaint, says Susan L. Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Marshfield, Wis., and member of the AMA CPT advisory committee. It also helps the gastroenterologist determine if something other than the presenting complaint is going on with the patient.

The elements of a system review have been identified by Medicare and CPT as the following: constitutional (general appearance, weight loss, etc.); eyes; ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic and allergic/immunologic.

Because the patient intake form is an effective guide for performing the ROS, gastroenterologists often will be able to quickly review the 10 systems needed for the comprehensive ROS. To indicate the gastroenterologist did an ROS, however, the gastroenterologist should note he or she reviewed the form in the patients medical record, and initial and date the patient information form. In a subsequent visit, if the patient has no significant changes, Medicare will allow the ROS to carry forward from the initial visit. The gastroenterologist should write no change on the patient information form, sign and date it, and make a similar notation in the patients medical record, says Jones.

The final aspect of the history is the PFSH, which is a review of the patients experience with illnesses, injuries and treatments as well as age-appropriate questions about past and current activities (marital status, occupation, sexual history, use of drugs, alcohol and tobacco). Many of these questions also will be on the patient information form, Jones explains. Again, the gastroenterologist needs to document the review of the PFSH by indicating in both the patients record and the patient information form that this area was discussed during the visit.

In subsequent visits, the PFSH from the initial visit can be carried forward if there are no significant changes. The phrase no change should be written on the patient information and signed and dated by the gastroenterologist, who also should make a similar note in the patients medical record.

Three Tips to Better E/M Histories

Gastroenterologists can improve the history portion of the E/M service by following these tips:

1. Use the overall severity of the problem to determine the level of history, instead of focusing on the individual elements. Gastroenterologists should not be focusing on the number of elements needed to meet a particular level of E/M coding, Turney suggests. Instead, they should concentrate on determining the complexity of the patients problem and making sure that they have a level of history that is reflective of that complexity.

The gastroenterologist should first ask himself or herself whether the patients problem was a simple one or a really hard one, advises Turney. If the problem was a simple one, then the gastroenterologist should determine whether the history was a problem-focused or expanded problem-focused history. If the problem was difficult, then was it a detailed or comprehensive history?

If the gastroenterologist spends 80 minutes with the patient, then this sounds like it should be a level-five visit, she continues. If the gastroenterologist happens to leave out one element in the HPI or ROS, then I hope that an auditor will be reasonable and wont discount the visit.

On the other hand, just because you have an extended HPI and a complete ROS and PFSH doesnt mean you have a comprehensive history, Turney points out. There has to be some medical necessity for taking a comprehensive history, she explains. You cant bill for updating a patients record.

2. Document everything that goes on during the E/M visit and dont neglect the ROS and PFSH. I have yet to met a gastroenterologist that didnt do a review of systems, says Jones. But they often fail to document that they went over the patient history form. All they have to do is initial and date the form and also make a note of the review in the patients medical record.

Gastroenterologists dont always write down the no-brainer questions that they asked about drug allergies or use of tobacco, alcohol or drugs, especially when the answers are negative, she adds. But they need to document that they reviewed during the visit.

Documentation becomes much easier when checklists and templates are used. If you wrote down everything that takes place during the E/M visit, you would spend more time on the documentation than you did with the patient, says Weinstein. I use forms for the history and examination of the patient, and almost everything is contained on those.

3. History ceases to be a component in the E/M service when the patient is unable to communicate. If the patient cannot give a history for reasons such as he or she doesnt speak English, is suffering from dementia or is unconscious, Jones says, then it no longer is a portion of the code selection.

In that situation, the gastroenterologist needs to note the inability to take a history from the patient. Examination and medical decision-making then become the only two components for E/M code selection.