Medicare Compliance & Reimbursement

Myth: You can't bill an evaluation and management claim unless the patient has pain or some similar complaint.

Reality: Sometimes it's test results that prompt a patient visit, not pain or even a complaint. A patient may come to a specialist or emergency physician because he or she has abnormal test results.

Challenge: It can be a challenge to obtain four out of eight elements of the history of present illness (HPI) when the patient comes in with severe anemia, for example. The patient may say something like, "My doctor told me to come to the ER because my blood count is low." Often times these patients have no complaints whatsoever. And sometimes patients will simply say, "My doctor sent me here but I don't know why!'"

The patient's medical decision-making is complex, but the doctor can't obtain a level-four visit without full HPI documentation. If the visit doesn't last over half an hour, you can't bill as critical care. And if the patient's history only has three elements, the coder must downcode the case to a level-3 visit.

The solution: To make a solid level-four claim, you should include things in the HPI to clarify why the patient is there -- and why this is a complex case. Make sure that your coders see the appropriate words so they can feel comfortable documenting the level of service based on the medical decision making.

For example, you might see something like: "73-year-old male sent by PMD for low blood count done today. There are no aggravating or relieving factors. Patient denies nausea, vomiting, or any other associated symptoms."

And then the doctor will add: "Location: blood. Onset: today. Modifying factors: there are no aggravating or relieving factors. Associated symptoms: denies nausea, vomiting, etc." That way he'll have a history of the illness, even though it only came up in test results today.

The physician could also write the following: "Patient saw her physician one week ago (timing) for a regular yearly exam and the lab work showed a low blood count (hgb) (context). The patient states that she is not tired/has no symptoms/ complaints (S&S). She has been on no medications that would account for this (modifying)."

And then the physician could add: "ROS -- patient has no current problems with (check 2-9 systems). Past History: no allergies. Family History: no family history of low hgb or blood dyscrasias. Social: does not smoke." And then include the exam and medical decision-making, including any planned work-up.

Most of the time, if a patient has a low blood count, the primary care physician may suspect internal bleeding. Even if the HPI doesn't provide any symptoms, it would be very unlikely that the review of systems (ROS) wouldn't reveal any.

Sometimes patients will have serious signs and symptoms from a clinician's perspective, but the patients won't pay attention to them. The physician is justified to ask pertinent questions and get credit regardless whether the responses are positive or negative.

A patient with a low red blood cell count may feel fatigued, weak, short of breath, and dizzy or lightheaded when he changes positions quickly. He may also feel an increase in his heart rate. These are all things that the physician should inquire about.

Bottom line: If the patient truly has no symptoms, it would be difficult to justify medical necessity for a visit. But you could use an ICD-9 diagnosis code for the lab findings, such as 285.9 (Hematocrit low) until the doctor came up with a more definitive diagnosis.