Medicare Compliance & Reimbursement

Don't shortchange yourself for 'routine' visits.

Myth: If an established patient comes back for a "routine" visit, you should automatically code that as a level-three evaluation and management (E/M) visit.

Reality: You should always code based on what your physician actually documented and performed. There's no rule that says a routine follow-up must be a level three, notes Peter Jensen, a physician and founder of EMUniversity.com.

Many physicians and coders wrongly believe that a "routine" visit should always fall smack dab in the middle of the bell curve, Jensen complains. "Most doctors don't give it a second thought," he says. They just circle the middle E/M code for what they perceive to be a routine patient.

If you're new to E/M coding, you should score visits carefully, using the Marshfield Clinic score sheet or something similar, says Jensen. In particular, you should look at the complexity of the medical decision-making (MDM) and consider "the number and nature of the problems you're addressing."

Example: A patient's chief complaint may be "something kind of innocuous, like 'follow-up to hypertension,'" says Jensen. The physician didn't make any changes in medications, reach a new diagnosis or make a referral. This looks like a fairly uneventful visit, but "sometimes the smartest thing to do is nothing." The physician is continuing to monitor the patient, reviewing test results and checking the patient's medications.

A level four E/M, after all, requires an MDM of "moderate complexity," not high complexity, notes Jensen.

Dead giveaway: The most important factor to look for in deciding whether you may have a level-four visit is the risk to the patient, according to Jensen: "The risk is the most underestimated dimension of medical decision making." Just the presence of two chronic stable problems is enough to qualify a patient as moderate risk, he notes. If the patient also has other problems, then the visit could easily amount to a level four.

For specialists, the complexity of the physical exam and the history are more likely to bump a visit up to level four, notes Deborah Churchill with Churchill Consulting in Killingworth, CT. A specialty physician is less likely to be making changes to all of a patient's medications, she points out. A very detailed physical examination and history may lead to a higher level for specialists, even in a routine follow-up.

But Churchill advises caution, because the most important thing is for you to code based on what the physician actually did.