General Surgery Coding Alert

Question: I have a question regarding E/M coding for our office, a general surgery practice. Our physicians are coding a higher E/M code for a patient with, for example, gallstones when the patient has other factoring problems such as diabetes,

COPD, hyper-tension, etc. Normally I would code a 99243 for gallstones, but if the patient has other problems as stated above, the physicians want me to code a 99244.  Some insurances have requested office notes for these patients, have

reviewed the notes, and are asking us to downcode to 99243. We have been under the impression that we can bill a higher code if we are documenting the other problems. Even though our physician is not treating the patient for diabetes, COPD,

etc. it does affect our physicians- medical decision making. Is our coding correct or should we code 99243 based on the reason the patient is being seen?

Maryland Subscriber

Answer: Despite having a higher level of medical decision making (MDM), the information about the rest of the visit seems to indicate that the history and exam portions of the visit would not be any higher level than a "normal" 99243 visit.

Therefore, even though the MDM might be higher, you still have to choose the lower code.

Why: The documentation requirements for a level-three consultation are a detailed history, detailed exam, and low complexity decision making. The documentation requirements for a level-four consultation are a comprehensive history,

comprehensive exam, and moderate decision making. Although a higher level of decision making is one factor in the level of service, it is certainly not the only factor.

Although you are correct that documenting additional problems has an impact on the level of medical decision making, even though the physician is not treating those problems, this is not enough by itself to support coding 99244.

Bottom line: Just adding a problem list for the patient will not raise the level of medical decision making.

Tip: You should note that, for decision making itself, a patient with a new diagnosis of cholelithiasis and a decision for elective major surgery would qualify for moderate decision making, not low. With additional comorbidities and appropriate

documentation of the impact of those comorbidities, this same situation could be a high complexity visit. Note that elective major surgery with identified risk factors like hypertension, diabetes, and COPD is a "high" risk on the table of risk.

Caution: Without the additional history and exam, however, the service will never support the higher level of service. You should have a good template for documenting the critical components of history and exam to help appropriately boost the

level of outpatient services.