Gastroenterology Coding Alert

Question: Since history and exam will no longer be key components for determining the level of E/M codes 99202-99215 next year, does that mean our GI physicians will no longer need to perform a history and exam? One of our physicians is convinced this is the case, but we are not so sure.

Michigan Subscriber

Answer: The history and exam will still be important, and they are still needed elements — they just won’t be counted toward the E/M level of service. When you look at the revised CPT^® code descriptors for 99202-99215, the code descriptor includes the phrase “which requires a medically appropriate history and/or examination.” So, from a clinical perspective, the history and exam play a critical role in understanding what’s going on with the patient. You just won’t need to count history and exam elements to determine the appropriate E/M code to report. The gastroenterologist will perform and document whatever they feel is necessary to adequately treat that patient for what the presenting problem is or the reason for that encounter.

You can find a lot of the information in the history and exam is the basis for and must support the medical decision making (MDM). Examples of this include the severity of the condition, which would reflect aspects of history, exam, and patient data such as laboratory test and imaging results. Also, the status of a condition. Is it a chronic illness? It is stable? Is it exacerbated? Is it not improving? In most instances, you (or a chart auditor) are going to be able to glean that information from the history and exam.

As a coder, you are going to be looking at the entire record to get a total picture. You won’t simply skip the history and exam elements in the medical record and move straight into MDM because that information is still important.

Therefore, keep recording the history and physical as part of good recordkeeping and documentation strategies, and no matter what coding rules come up, you’ll still be able to select the right code every time.