Ob-Gyn Coding Alert

Details can make or break a complete history

Excessive effort trying to provide the best care for a patient doesn't always translate into higher reimbursement -- but here's some good news: you may be able to use your nurse's notes for new patient documentation.

Check out these two frequently asked questions to determine your review-of-systems (ROS) savvy.
 
FAQ: Does Extra Time Merit Higher Code?

If your ob-gyn has to exert excessive effort to obtain an appropriate patient history, you may not be able to choose your E/M code based on time. Find out why:

Example: A new patient who cannot speak English and explain her medical problems presents to your practice. The patient's inability to communicate prevents your ob-gyn from obtaining her complete history of present illness (HPI) and ROS. After examining the patient, the ob-gyn orders some diagnostic tests but cannot develop a definite plan for her treatment.

Your ob-gyn calls the patient's two previous physicians to discuss her medical problems and discovers that she also has diabetes. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, your ob-gyn spends a total of 90 minutes on this patient on the same day.

What to do: You should select the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient) based on the information your physician was able to obtain from the patient and her physicians.

Note: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Warning: In most cases, you cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Normally, communication barriers do not meet the criteria for counseling/coordinating care.

The physician may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. The physician may then receive credit for the -unobtainable- history in the area of medical decision-making.

If the physician documents service time when the patient is not physically present (such as postexam calls toother physicians), you will probably be unable to report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Most payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the E/M service payment.

FAQ: Can Nurse's Notes Satisfy New Patient Info?

Your ob-gyn may delegate some tasks to a nurse while he's seeing other patients, but can you use a nurse's notes to satisfy elements of ROS and past, family and social history (PFSH) for a new patient visit, as long as the physician documents that he reviewed the notes?

What to do: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, CMBS, CCP, owner of Healthcare Consulting & Coding Education LLC, in Beeghly, Ohio. -I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes,- she says.

You-ll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the level of information the physician gathered about the patient's history.