Orthopedic Coding Alert

3 scenarios from our experts help you improve your E/M skills

Before you report any E/M procedures, look for documentation details on the patient's presenting illness, because this information can make or break your patient's complete history.

Check out the following three frequently asked questions to determine your review-of-systems (ROS) savvy. Write down your responses before looking to the correct answers below. 

Question 1: A new patient who is unable to speak English and to explain her medical problems presents to your orthopedic practice. The patient's inability to communicate prevents the surgeon from obtaining a complete history of present illness (HPI) and ROS from her. The orthopedic surgeon treats the patient's fracture, but cannot develop a definite plan for her treatment.

The orthopedic surgeon calls the patient's two previous physicians to discuss her medical problems and discovers that the patient also suffers from diabetes and previous fractures. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the surgeon spends a total of 90 minutes on this patient on the same day.

How should you charge for this scenario? Which E/M codes and modifiers should you use to justify the extra time that the orthopedic surgeon spent on the phone with other physicians on this patient's behalf?

Question 2: Can you use a nurse's notes to satisfy elements of ROS and past, family, social history (PFSH), as long as the physician documents his review of the notes?

Question 3: When an orthopedic surgeon lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can you use this as the ROS?

Check Your Answers

Answer 1: 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 you were 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 receive credit for the -unobtainable- history.

If the physician documents service time when the patient is not physically present (such as post-exam calls to other physicians), you may not be able to report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Some payers consider extra time, as noted in the example above, to be part of the pre- and postservice work associated with the payment for the evaluation and management service. 

If you submit a charge for this extra time to a payer that does not cover the service, the carrier may hold the patient responsible for the fee. 

Make Sure the Surgeon Signs the Nurse's Notes

Answer 2: 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, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in 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.

The ROS is basically an inventory of the body so the physician knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

For a problem-pertinent ROS, the physician needs to review a single system or part and will usually follow the guidelines of the E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history; a detailed examination; and medical decision-making of low complexity).

If the physician reviews two to nine systems, you should consider the ROS -extended,- which means it usually translates to 99203. If he reviews at least 10 systems, the ROS is -complete,- which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

A -pertinent- PFSH consists of a comment in any one of the histories--information about a patient's past health history, family history, or social history--and helps you on your way to a 99203. For a -complete- PFSH, the doctor must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205.
 
Answer 3: The CPT guidelines state that the past medical history indicates a patient's previous experiences with an illness or injury. But, in contrast, an ROS is an inventory of questions based on the history of the patient's presenting illness.

The answers to the ROS questions determine the type and extent of the exam the surgeon conducts. Answering the inventory questions can provide the orthopedic surgeon with the past medical history. Encourage your physician to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.

Therefore, if your surgeon does not document information about the patient's current symptoms, but only mentions the patient's past history, you might not be able to count the information in your ROS tally.