Gastroenterology Coding Alert

Securing the correct history level is easy with this element-by-element study Warning: Gastroenterologists who take shortcuts when documenting a patient's history during an E/M service may find themselves without the backup materials needed to withstand the scrutiny of a Medicare audit. You and your physician don't have to be overwhelmed by E/M history levels' laundry list of requirements. Take each element one step at a time, and then use our handy history chart to choose the right level for your patient. In a nutshell: You have four levels to choose from: • problem-focused • expanded problem-focused • detailed • comprehensive. When determining the appropriate history level for your E/M codes, consider the following elements.
CC: Clarify Your Medical Necessity Every E/M history level requires a chief complaint (CC). According to CPT, this is a concise statement, usually in the patient's words, explaining the main reason for the appointment. Look for a symptom, problem, condition or diagnosis. Documentation should note specific problems to support medical necessity for the visit. Even if your office asked the patient to return, look for the complaint that prompted the visit. Example: A patient presents for rectal bleeding assessment, and the provider documents rectal bleeding as her chief complaint. Bottom line: Look for a complete CC. Payers won't find "Here for recheck" an acceptable chief complaint. HPI: Look for These Factors in Patient Timeline The second E/M history element, history of present illness (HPI), should be an actual chronological description of the patient's current illness, says Bill Dacey, MHA, MBA, CPC, in his presentation "E/M Auditing: Regulations vs. Reality" at the 2007 national American Academy of Professional Coders conference in Seattle. Check your documentation for location (e.g., rectum), quality (e.g., bright red), severity (large amount with every bowel movement), duration (four days), timing (at least two to three times per day), context (while walking quickly or bending over), modifying factors (better after sleeping), and associated signs and symptoms (break out in a sweat and get lightheaded). If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI. ROS: Count Systems to Determine Proper Level For the third E/M history element, review of systems (ROS), the provider either analyzes a questionnaire filled out by the patient or support staff or directly asks the patient questions (or both). Keep in mind, however, that this section does not involve examining or touching the patient. Red flag: 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 providers to make their documentation specific to each patient. The main purpose of the ROS is to [...]