Gastroenterology Coding Alert

Helping your gastroenterologist become a detail-savvy documenter can lead to higher dividends -- especially when confronted with the history of present illness (HPI) element. Consider these six ways to beef up HPI documentation, and watch your coding become more accurate.

Your appointment scheduler can get some details from patients when they call for an appointment. This can include things as simple as verifying the patient's address, phone number, insurance plan, and plan contact number.

How this helps: Any information you can obtain beforehand and have in the computer system will streamline the process once the patient comes for her visit. That means less aggravation for her and for other patients who don't have to wait as long for your attention.

Enlist help from your nurses or nurse assistants to get more thorough documentation. Some groups have their nurses obtain the patient's vitals and chief complaint when they take the patient to a room.

How this helps: Your nurse is communicating with the patient, which helps her feel more comfortable and gives her the opportunity to voice concerns immediately. When your gastroenterologist comes in, he can summarize the information but spend his time with examination and treatment rather than obtaining general information.

One of the easiest ways to ensure providers don't miss documenting any of the E/M visit components is to create templates they can follow.

"I often see the review of systems (ROS) lacking," says Julee Shiley, CPC, CCS-P, CMC, a coding consultant at Critical Health Systems in Raleigh, N.C. "This should be included in the dictation template, or this information is sometimes included on an 'intake' form."

Have your provider reference an ROS in the dictation and initial and date the form so the details can be included in the HPI.

"The history is a three-of-three area," Shiley says. "Therefore, if you have an excellent HPI and problem-pertinent PFS (past, family and social history) but no ROS, the history component drops to the lowest level."

How this helps: Using templates customized to your specialty can help physicians assign the correct level for visits, remind them to verify information they might have forgotten, and more. "Since we've gone to templates, it's gotten easier because they just have to make a check mark," says Kathy Campbell, CPC, a coder in Bloomington, Ind.

Caution: Some experts warn against relying too much on templates, saying your physician could get in trouble with payers. If your practice uses templates, be sure the documentation is patient-specific.

Some coders say that if you use a good template, the patient can fill out a portion of her own HPI. Your patient-completed portion can include anything related to the body system review, symptoms, and severity or duration of the problem.

How it helps: You give the patient ownership, and boost her confidence. She knows her complaint is written exactly as she wants, without wondering how the nurse or other staff person interpreted her answers. No one knows her symptoms better than the patient, so your gastroenterologist has a better picture of the situation.

"We have to remind our providers that they may use previous dates of service, history form, reason for visit forms and other documentation as part of the HPI," Shiley says. "They sometimes forget that this can be counted and may lower the appropriate E/M level if the reference is made but not documented properly."

Example: An established patient with a chronic condition (such as GERD) visits your practice. If the examination shows that her condition is unchanged, deferred or minimal, your code selection falls to the history and decision-making criteria. "For medication refill visits, we often see circumstances where the history is essential to correct code selection because of the nature of the visit and lack of necessity for extensive examination," Shiley says.

Just getting all the required documentation for the highest HPI level possible can be a challenge. But the extra effort you put into educating providers about documentation can mean a significant change in your group's bottom line -- such as calculating your regional dollar amount by 1.73 RVUs for 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) compared to 3.92 RVUs for the higher-level new patient code 99204. That's $65.57 versus $148.57, a difference of $83.

Example: Mrs. Jones is on controlled substances for pain but also takes other medications to treat fibromyalgia. Mrs. Jones' exam findings are essentially unchanged today, but she is having significant medication side effects causing gastrointestinal symptoms of bloating and constipation. Her combination of medications leads to high-level medical decision-making for the gastroenterologist, but that doesn't constitute the "two of three" criteria needed for a higher-level established visit. If you don't have documentation of the side effects (helping you reach the "two of three" criteria), you must report a lower-level code such as 99213 or 99214 instead of 99215.

Final note: Be sure your provider's documentation meets the medical-necessity test. "In other words, even though the documentation may be substantial, ask 'What is really necessary for the stated condition?' " Shiley says. Match the two sides of the necessity/documentation equation and rest assured you're filing the most accurate claims.