Medicare Compliance & Reimbursement

How to make your E/M documentation bulletproof -- even with few symptoms.

Myth: You can't bill an evaluation & management (E/M) 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 has abnormal test results, says Kenneth Sable, a physician and director of the Division of Medical Informatics in the Emergency Medicine Dept. at Maimonides Medical Center in Brooklyn.

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, according to Sable. The patient may say something like, "My doctor told me to come to the ER because my blood count is low," Sable says. "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, Sable complains. If the visit doesn't last over half an hour, you can't bill as critical care. And if the patient's history has only three elements, the coder must downcode the case to a level-three visit.

The solution: To make a solid level-four claim, Sable will add things to the HPI to clarify why the patient is there ...quot; and why this is a complex case. "I make sure that our coders see the 'magic' words so they can feel comfortable documenting the level of service based on the medical decision-making," says Sable.

For example, Sable often writes 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 he'll 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, says Lindsay-Anne Jenkins, an AAPC-approved PMCC instructor:

"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, says Jenkins.

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, says David McKenzie, director of reimbursement with the American College of Emergency Physicians.

Sometimes patients will have serious signs and symptoms from a clinician's perspective, but the patients won't pay attention to them, notes Kenny Engel, compliance officer with Martin Gottlieb & Associates in Jacksonville, FL. 

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," Engel points out.

Bottom line: "If the patient truly has no symptoms, it would be difficult to justify medical necessity for an ED visit," says McKenzie. But you could try using 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.