Gastroenterology Coding Alert

Find out if a patient's history form counts toward ROS, PSFH

Your gastroenterologist's excessive effort trying to provide the best care for a patient doesn't always translate into higher reimbursement. But chin up--you may be able to use your nurse's notes for new patient documentation.

FAQ 1: Does Extra Time Merit Higher Code?

If your gastroenterologist has to exert excessive effort to obtain an appropriate patient history, you may not be able to choose your E/M code based on time.

Example: A new patient who cannot speak English and explain her medical problems presents to your practice. The patient's inability to communicate prevents your gastroenterologist from obtaining her complete history of present illness (HPI) and review of systems (ROS). After examining the patient, your gastroenterologist orders some diagnostic tests but cannot develop a definite plan for her treatment.

The gastro calls the patient's two previous physicians to discuss her medical problems and discovers that she also has diabetes. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, he spends a total of 90 minutes on this patient on the same day.

What to do: You should select the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient) based on the information your physician was able to obtain from the patient and her physicians.

Note: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Warning: In most cases, you cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Normally, communication barriers do not meet the criteria for counseling/coordinating care.

The physician may document the excessive effort of trying to get an appropriate history and a reason for why he was unable to obtain the full history. The physician may then receive credit for the -unobtainable- history in the area of medical decision-making.

If the physician documents service time when the patient is not physically present (such as postexam calls to other physicians), you will probably be unable to report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Most payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the E/M service payment.

FAQ 2: Can Nurse's Notes Satisfy New Patient ROS, PFSH?

Your gastroenterologist may delegate some tasks to a nurse while he's seeing other patients, but can you use a nurse's notes to satisfy elements of ROS and past, family and social history (PFSH) for a new patient visit, as long as the physician documents that he reviewed the notes?

What to do: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator at Beeghly Medical Park in Ohio. -I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes,- she says.

You-ll use ROS and PFSH, along with the patient's physician-documented history of present illness, to decide the level of information the physician gathered about the patient's history.

Keep in mind: Medicare states that either the patient or nurse can fill out a history form for ROS and PFSH. The physician must note that he reviewed it to use this when selecting an E/M service code.