Documentation/Patient Forms Determine E/M Reimbursement
Published on Sat Jul 01, 2000
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: [...]
