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 be the areas where ob-gyns document the most information. The patient intake form usually covers the review of systems (ROS) and the past, family and social history (PFSH). The patient usually completes this form on her own or with the nurse's help. The chief complaint is a concise statement explaining the reason for the patient's visit to the doctor's office, Ryan-Niemackl says.
 
The HPI is a more thorough description of the patient's chief complaint. The documentation for HPI may include one or more of the following eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
 
A brief sentence can convey several of these elements at once. A patient who complains of a sharp pain (quality) in her lower abdomen (location), which occurs after bending (context) and has been happening for the past six weeks (duration), has already given you an extended HPI because it includes four elements.
 
But if the ob-gyn documents only abdominal pain that started six weeks ago, he only qualifies for two elements, which reduces the HPI to "brief." Because you need to document an extended HPI to report codes 99203-99205, you would have to report 99201 or 99202 based on your documentation of only two elements for this visit.
 
On the other hand, keep in mind that the 1997 Medicare E/M guidelines allow an exception to the HPI requirements. If an ob-gyn follows these more detailed guidelines instead of those published in 1995, an extended HPI can also consist of the documented status of three or more chronic or inactive conditions instead of four or more of the HPI elements.

ROS and PFSH Carry Forward

The ROS consists of the positive and negative responses the patient gives to a series of questions designed to inventory the body's systems. Frequently, this is part of the intake form.
 
"The ROS, however, is the downfall of most physicians," Ryan-Niemackl says. "There is a high degree of concern because most downcoding is the result of the physician not taking the time to make sure there really are 10 ROS's when a comprehensive level of history is the choice the physician wants to make."
 
Medicare and CPT define the elements of a system review as constitutional (general appearance, weight loss, etc.); eyes; ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculo-skeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.
 
Because the patient intake form is an effective guide to document the ROS, ob-gyns can usually quickly review the 10 systems needed for the comprehensive system review. To indicate that he performed an ROS, however, the physician should note his review of the form in the patient's medical record and note any significant findings. He also must initial and date the patient information form.
 
The final aspect of the history is the PFSH, which is a review of the patient's experience with illnesses, injuries and treatments as well as age-appropriate questions about past and current activities (marital status, occupation, use of drugs, alcohol and tobacco, etc.). The patient probably answered many of these questions on the patient information form. Again, the ob-gyn should indicate in both the patient's record and on the patient information form that he discussed this area with the patient during the visit.
 
During a subsequent visit, if the patient has no significant changes, Medicare payers allow physicians to carry the PFSH and ROS forward from the initial visit. The ob-gyn should indicate in the medical record the date of the note he is carrying forward and a statement that shows "no change" and sign and date it, Ryan-Niemackl says. "If there are changes to the original history, the physician should indicate those and add a simple statement that says all other portions of the history from the original date remain unchanged," she adds. And make sure the ob-gyn signs and dates the notes in the patient's chart.