Neurosurgery Coding Alert

Read through this documentation thoroughly and determine the coding problem.

Neurosurgeons are notorious for producing extremely thorough, detailed E/M documentation, often due to complex workups. When you review a particularly thorough E/M note, your first instinct may be to agree with an EHR’s selection of a high-level code for the doctor’s extensive work. But if just one element of a particular code isn’t met, you won’t be able to report it — even if the rest of the documentation is perfect.

Review this detailed E/M note and determine how you would code the chart, and whether you see any problem with how it was coded by the original biller.

Code reported: 99214

Chief complaint:  Follow-up for neck pain following completed physical therapy. Patient says she is much better due to therapy combined with the medicine.

HPI: This is a 16-year-old female who is a competitive swimmer. She presents for a follow-up for neck pain. We last saw the patient six weeks ago. She was diagnosed with cervical radiculopathy and was started on anti-inflammatory and icing regimen, and was referred for formal PT in the hope that she could prevent surgical intervention. She has been going to therapy for the past five weeks and has completed the regimen. States that she did very well with the therapy and was happy with the outcome. Her pain is markedly decreased and she has a full range of motion with improved strength. She denies any new complaints today.

PMFSH: She currently has no other conditions and has never had any surgeries. She does not drink and has never smoked. Her mother has diabetes and hypertension, her father has high cholesterol. She lives with her parents in her home with no pets, and is a full-time student. She swims competitively, and also plays tennis and walks for exercise. She has no allergies and is not sexually active.

ROS: Patient reports no fever, no night sweats, no weight gain or loss, and no exercise intolerance. She reports no dry eyes, no irritation, and no vision change. She reports no difficulty hearing and no ear pain. She has never had a nosebleed and has no nose or sinus problems. She reports no sore throat, no bleeding gums, no snoring, and no dry mouth. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, and no shortness of breath when resting or lying down. She has no cough, no wheezing, no shortness of breath, and no coughing up blood. She reports no abdominal pain, no vomiting, normal appetite, no diarrhea, and not vomiting blood. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no muscle aches, no muscle weakness, no arthralgias/joint pain, no back pain, and no swelling in the extremities. She has no abnormal moles, no jaundice, and no rashes. She reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, and no headaches. She reports no depression, no sleep disturbances, and no alcohol abuse. She reports no fatigue. She denies swollen glands or bruising. She reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing.

Physical Exam:

General:  Patient is a 16-year-old very pleasant female.

Constitutional: General appearance: Healthy appearing, NAD, and normal body habitus.

Psychiatric: Oriented to time, place, and person. Normal mood and affect, and active and alert.

Cardiovascular: Arterial pulses right: subclavian normal and compression test negative and carotid normal, radial normal, brachial normal, and halstead maneuver negative. Arterial pulses left: carotid normal, radial normal, brachial normal, subclavian normal, and halstead maneuver negative. Edema right: none. Edema left: none. Varicosities right: no varicosities and capillary refill test normal. Varicosities left: no varicosities and capillary refill test normal.

Lymph nodes: Inspection/palpation right: no cervical LAD, supraclavicular LAD, or axillary LAD. Inspection/palpation left: no cervical LAD, supraclavicular LAD, or axillary LAD.

C-spine/neck: Active range of motion: no crepitus or pain elicited on motion and flexion normal, extension normal, rotation normal, and lateral flexion normal. Passive range of motion: flexion normal, extension normal, rotation normal, and lateral flexion normal. Inspection of the cervical spine showed no misalignment, atrophy, erythema, induration, swelling, or warmth.

Musculoskeletal: Patient has a normal range of motion in all extremities and is not experiencing any pain.

Skin: Normal on both left and right upper extremities.

Assessment/Plan: Cervical radiculopathy (M54.12). We are very happy with the way the patient has progressed with therapy. She has been advised to continue her home exercise program. We will see her again on an as-need basis.

Find Out Where This Neurosurgeon Went Awry

Did  you  spot  the  problems  with  this  chart? Based on the chart alone, the EHR coded it with 99213 due to the detailed history and an expanded problem-focused exam (three vital signs were not documented) and, using the musculoskeletal exam, a detailed level of examination was not met. Although the medical decision-making for this follow-up patient is of low complexity, a follow-up visit only requires meeting or exceeding the level of complexity in 2 of 3 areas among history, exam and medical decision making, which only qualifies this encounter for 99213.

Here’s why: Medical necessity is always an overarching factor that your doctors should consider when selecting the E/M service level. Just because the neurosurgeon completes a higher-level history and examination doesn’t mean he always should report a higher-level code. Medical necessity should drive the components that he performs. Comorbidities, the need for diagnostic testing, the plan of care, and so on, may complicate the encounter and increase medical decision-making, and warrant additional history and exam as well. However, in this case, the medical decision-making was not complicated for this otherwise healthy patient. In addition, each note (no matter how it is created) should be specific to the patient, the encounter, and the problem.

What  to  look  for: In this case, in which the neurosurgeon was examining a mostly resolved neck issue, your suspicion that he may have overdocumented the history would be piqued when you saw that the doctor reported on whether the patient had conditions such as frequent sneezing or vomiting blood. If she had other issues that may have caused these problems, then these would be relevant to the spine exam, but in this case, the medical necessity to recheck a neck problem would not typically drive the physician to perform such a robust history and exam.

Bottom line: If your EHR prompts you to record all areas of history and exam — or worse yet, doesn’t let you exit a record until you’ve covered all of the areas — then it’s time to tweak your system.

Financial outcome: This practice likely collected about $108 for reporting this service as a 99214, when in reality the practice should have collected about $74 for 99213 instead, based on the 2017 Medicare Physician Fee Schedule amounts. Therefore, this practice collected about $34 too much for the service, which it would have to reimburse if someone in the practice or an auditor discovered the problem.

Have a note to share? If you’d like Neurosurgery Coding Alert to evaluate one of your E/M notes and determine the coding accuracy, send it to editor Jan Milliman (janm@codinginstitute.com).