Ob-Gyn Coding Alert

Not certain how to calculate a patient's risk level? You could be guilty of undervaluing your ob-gyn's medical decision making and downcoding E/M visits. When the difference between a new-patient level-three and -four code is $49.77, that missing money could add up.

Warning: Some ob-gyn coders misinterpret the level of risk associated with the physician's care plan. They assume that the doctor must meet the criteria for all three categories of risk: presenting problem, procedure(s) ordered, and management option(s) selected. But a single bulleted item, and the item's position in the table,determines the level of risk.

You should follow Medicare's Table of Risk to select the patient's correct risk of complications. Note: CMS published the Table of Risk as one of seven tables in the 1995 and 1997 E/M Documentation and Coding Guidelines. Medicare providers are supposed to use the tables to calculate the history, exam, and medical decision making types, says Robert W. White, a practice administrator in Goldsboro, N.C.

The table has three risk categories:

- The patient's disease

- The ob-gyn's ordered tests and procedures

- The physician's considered options for management of the disease.

The table also includes four levels of risk: minimal, low, moderate, and high.

Review the following examples of conditions and treatments that meet Medicare requirements:

1. Minimal. Your ob-gyn treats a minor problem,such as a scrape or prescription renewal. Diagnostic procedures that meet the -minimal- criteria include laboratory tests requiring venipuncture, urinalysis, Pap smear collection, or ultrasounds. Management options include rest and simple bandages.

2. Low. Typically, the patient presents with two or more minor problems, one chronic illness, or an acute uncomplicated illness. For instance, the patient could be complaining of cystitis or vaginitis or could be presenting with non-insulin-dependent and controlled gestational diabetes. Diagnostic procedures can be things like breast cyst aspiration, urodynamic testing, colposcopy, a biophysical profile, or a vulvar/vaginal/cervical biopsy.Management options can include prescribing over-the counter medications, deciding on performing minor surgery with no risk factors, patient education with regard to stress urinary incontinence, or prescription renewal.

3. Moderate. The ob-gyn treats one or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms, or an acute complicated injury. For instance, a patient may present with gestational diabetes (648.83) and hypertension (401.x) -- or the physician is trying to rule out ectopic pregnancy. In this level, diagnostic procedures consist of physiologic tests under stress (such as a fetal CST), diagnostic hysteroscopy or laparoscopy with no risk factors, deep needle or incisional biopsy such as culdocentesis or an ovarian biopsy, or colposcopy with any type of biopsy.

Management options include minor surgery with identified risk factors such as severe obesity or a comorbid condition that puts the patient at risk when performing surgery, elective major surgery with no risk factors, and prescription-drug management. Drug management generally refers to managing more than one drug for control of the patient's condition(s).

4. High. The patient has one or more chronic illnesses with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status. Some examples of this include preeclampisa, severe depression, uterine rupture, premature labor, ectopic pregnancy, or severe hemorrhage.

Diagnostic procedures include diagnostic hysteroscopy or laparoscopy with identified risk factors or diagnostic tests performed for multiple gestation with fetal complications. Management options consist of elective major surgery with risk factors, emergency major surgery (such as an appendectomy or ruptured ectopicpregnancy), and drug therapy requiring intensive monitoring for toxicity.

Good advice: -I always encourage everyone to document in detail the what types of procedures, tests,surgical procedures that the ob-gyn plans on doing/ordering (for instance, if the surgical procedure is going to be diagnostic, invasive, etc.),- says Jamie Salup, CPC, CEMC, COBGC, a consultant in Melbourne Beach, Fla. -The physician should document if the patient has underlying diseases, which increase the complexity and risk. You shouldn't assume an auditor will look back into the patient's chart to look for their underlying diseases.-

Key: You should select a risk level based on the highest single criterion the ob-gyn has met, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Try this: A patient presents with a low-level risk under the Table of Risk's -Presenting Problem(s)- category, such as vaginal discharge (623.5, Leukorrhea, not specified as infective). The ob-gyn swabs the discharge material and sends it to the lab for testing, which qualifies as a minimal level of risk under -Diagnostic Procedure(s) Ordered.- But then the physician selects a moderate risk level of -Management Options,- such as prescribing an antibiotic.What level of risk should you assign in this case?

In any case, a higher level of risk may affect the medical decision making complexity and change the E/M code you report.

Solution: If you undervalued the ob-gyn's management options, which involved prescribing antibiotics, you may have determined that the visit had straightforward risk and reported a lower-level E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...), which pays roughly $37, according to national Medicare averages. But with the visit having a moderate risk, you may be able to report a higher-level code, such as 99213, which pays $61.

Caution: Medical decision making involves more than just risk, Pohlig points out. Just as there are three categories of risk, there are three categories of medical decision making to consider before selecting the final complexity level. These categories are number of diagnoses/treatment options, amount and/or complexity of data ordered/reviewed, and risk of complications and/or morbidity/mortality. You must meet or exceed two of the three categories associated with a certain complexity level to select that level of complexity, Pohlig says.