Gastroenterology Coding Alert

Learn how to justify those level-4 and -5 E/Ms your physician is performing.

You already know that insurers scrutinize your practice's evaluation and management levels to see if you're coding more high-level E/Ms than the average gastroenterologist. Don't undercode out of fear of the auditor --" instead, get in the habit of good documentation to back up your practice's good patient service.

Undercoding E/Ms is a long-standing problem. Back in 2003, the American Gastroenterological Association's GI Practice Management newsletter stated: "In our experience undercoding, billing a level of service lower than performed, is as prevalent in GI as overcoding. Often minor adjustments of the documentation will result in a higher level of service than what was billed."

Evaluation and management of gastroenterology patients is complicated business. A thorough review of systems is an everyday thing for a gastroenterologist, so make sure good documentation of ROS is routine, too.

Level-four and -five E/Ms are not that uncommon for a gastroenterologist's practice, so mastery of the doctor's review of systems is critical to backing up codes like 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, medical decision-making of moderate complexity ...).

When your physician performs an E/M service, he conducts a review of systems (ROS) to check on the condition of the patient's body systems. For coding purposes, the level of ROS helps determine the level of patient history, which helps determine the level of E/M. If you do not know the level of ROS the physician performs, you will be unable to decide which level of E/M code you should use on the claim.

To claim a level four or five E/M, documentation must indicate a comprehensive history. That requires an extended history of present illness; a complete past, family, and social history (PFSH); and a complete ROS.

The basics: The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the HPI.

The ROS is an interview in which the physician or nurse asks the patient about a specific system and records the patient's answers. Some physicians also get ROS information from patients through a questionnaire.

CMS defines 14 systems for documentation:

• Constitutional symptoms (such as weight loss)

• Eyes (blurred vision)

• Ears, nose, mouth, throat (trouble swallowing)

• Cardiovascular (hypertension)

• Respiratory (shortness of breath)

• Gastrointestinal (nausea)

• Genitourinary (urine incontinence)

• Musculoskeletal (joint pain)

• Integumentary (discolored skin)

• Neurological (numbness)

• Psychiatric (depression)

• Endocrine (taking synthetic hormones)

• Hematologic/lymphatic (anemia)

• Allergic/immunologic (asthma/immunodeficiency).

Tip: The physician can hand off the ROS work. "Your ancillary staff can document your review of systems and personal, family, social history," says Kim Garner-Huey, CPC, CCS-P, CHCC, an independent coding and reimbursement consultant.

There are three levels of ROS: problem-pertinent, extended and complete. If you want to code a level-four or -five E/M, the ROS must be at the highest level: complete.

Confirm 10+ Systems for Complete ROS

For a level-four or -five visit, the ROS requirement is steep: The physician must document that he checked at least 10 systems.

Consider this example:

A new patient reports to the gastroenterologist with heartburn, stomach ache, and nausea (gastrointestinal). She also reports a chronic cough (respiratory) and trouble swallowing (ear, nose, mouth, throat.)

The notes indicate that the patient has negative responses for fever (constitutional), eye discharge (eyes), dysuria (genitourinary), headache (neurological), and rash (integumentary). The physician also notes that the patient reports anxiety (psychiatric), some pain in her right shoulder (musculoskeletal), and has urinary frequency (genitourinary).

During this encounter, the physician checked a total of 10 systems (noted in parentheses). Remember, you may count a single system once only; though the example mentions gastrointestinal and genitourinary systems more than once, they only count once each.

On the claim, if documentation meets all other factors (history and exam), this level of ROS would support 99204 (... a comprehensive history; a comprehensive examina-tion; medical decision making of moderate complexity ...) or even 99205 (... medical decision making of high complexity ...) for the E/M.

Templates for success: One easy way to ensure providers document the E/M visit components is to create templates they can follow. Have your provider reference an ROS in the dictation, and initial and date the form.

What to include: "I think that a good template should really prompt the physician to put in the information specific to his practice," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. It should remind him to put in "a complete review of systems (or remind him to refer to 'that patient questionnaire' that they have every patient fill out). It should remind the physician to ask about social history and family history and should lead him away from words like 'non-contributory' or 'unremarkable,' which are not good indicators of the service provided."

Standard operating procedure: "An excellent template should also remind the doctor to document exam elements that are routinely performed but not always documented," Bucknam says. And "it should remind him to list the patient's co-morbid conditions."

Payers and auditors who smell cloned documentation may hit your practice with fines and refund requests. Patient-completed ROS templates may be OK, but ask physicians to make their documentation specific to each patient. Also, be sure your gastroenterologist documents that the ROS was reviewed with the patient by noting any pertinent information. For established patients, a statement of "ROS unchanged" or "same as last visit" is not acceptable.

Negativity: Physicians may use a shortcut by stating "all other systems are negative," Huey says. However, this is not a substitute for performing the ROS, just a way to ease the documentation burden on the physician. "They have to list at least one system specifically," she adds.

Some local carriers may not accept the notation of "all other systems are negative." CMS is reviewing the acceptability of this statement but has yet to release further information.