Ob-Gyn Coding Alert

Work with your ob-gyn to document factors that will boost your bottom line Is your practice stuck reporting low-level new patient E/M codes even though your ob-gyn has provided higher-level services? The most likely culprit is your physician's documentation of the patient's history. But if the doctor takes just a few extra minutes, you can ethically capture those higher-level codes and their higher payment.
 
Ob-gyns occasionally see new patients who have serious conditions that require high-complexity medical decision-making. This, combined with a comprehensive exam and history, could warrant reporting 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).
 
For example, your physician performs a comprehensive history, comprehensive examination and high-complexity medical decision-making (MDM) on a new patient. He documents the comprehensive exam and high-complexity MDM, but only records a detailed history. Although your practice should have been able to report 99205 (receiving approximately $180), you're now reduced to billing 99203 (paying out at roughly $100). If the ob-gyn had spent just an extra few minutes thoroughly documenting the comprehensive history, your practice could have collected an additional $80.

To determine if your physician(s) is regularly leaving this kind of money on the table because of underdocumentation, you should perform quarterly E/M audits, says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs in Fargo, N.D. If the audit shows that your doctors and nonphysician practitioners aren't documenting properly, schedule a meeting to discuss the various coding levels and remind them of the documentation necessary to report the higher-level codes. You should also provide an outline of the different reimbursement amounts of each code so they can see how much they're forfeiting by providing incomplete documentation.
 
"Many physicians who have been practicing for many years still think that time is the basis for choosing E/M services," says Lynn M. Anderanin, CPC, senior coding consultant for Health Info Services in Des Plaines, Ill. "Time can only be used when at least 50 percent of the visit was spent on counseling and coordination of care. The time must be documented to use this method for choosing the E/M service." Know the 4 History Levels Medicare and CPT both recognize four levels of history for an E/M service: problem-focused, expanded problem-focused, detailed and comprehensive. (See the box below to determine which history level the physician's documentation deserves.)
 
"Documentation of the patient's history is a common problem with many specialists," Anderanin says. "I am confident that although providers are discussing the patient history with the patient, they are not documenting what was said."
 
The chief complaint and related history of present illness (HPI) tend to [...]