Orthopedic Coding Alert

Determine how many body systems you must examine to qualify for 99214

If your practice's new year's resolution involves submitting audit-proof E/M claims, we-ve got good news for you. Check out the following three frequently asked E/M coding questions and our expert responses to keep your E/M payments accurate.

Go Above and Beyond for E/M With Procedure

Question: How can we determine if our hand surgeon's evaluation before a procedure (such as an EMG test) is separately billable, or if it is included in the procedure?

Answer: If you have a hard time determining what constitutes a separate E/M service when your surgeon performs a procedure, remember that the physician needs to document a significant, separately identifiable service.

For every procedure your physician performs, he must complete at least a cursory history and physical (H&P) on the day of the procedure. So, to report a separate E/M service, your physician must document a service that is above and beyond the pre- and postoperative care associated with the procedure.

For example: A patient with carpal tunnel-like symptoms arrives for an initial consultation with the hand surgeon. The physician takes a full history, examines the patient and conducts electromyography and nerve conduction studies.
 
In this case, you should report the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas, and 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), along with 99243 (Office consultation for a new or established patient ...) for the E/M service.

Because you are billing the test codes and the E/M service on the same date, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99243.

Keep in mind: Modifier 25 still applies, even if the patient presents twice in the same day, once for a service and once for an E/M. For example, suppose a patient presents early in the day for an injection (for example, 20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]) for neck pain (723.1) and the physician does not perform a separate E/M during that visit. Later in the day, the patient begins to feel dizzy and nauseated. Fearing an adverse reaction to the injection, the patient returns to your office. The physician evaluates the patient and documents a level-three E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

In this case, you must still append modifier 25 to 99213. Although the injection and E/M service occurred at separate patient encounters, they still occurred on the same date of service.

Don't Forget Medical Necessity

Question: The E/M guidelines as I interpret them say that I can bill a level 99215 based on history and examination if I can substantiate in the record that I performed a comprehensive history and examination on this patient, even if the medical decision-making is low risk and there is no data to review. Nowhere does it say I must -justify- the code after meeting the criteria. Therefore, I perform comprehensive histories and exams for all of my patients and bill higher-level E/M codes for all of them to collect my rightful reimbursement. Am I interpreting the E/M guidelines correctly?

Answer: No. Some physicians do believe that the E/M guidelines offer them a legal -loophole- by allowing them to ignore medical necessity as long as they perform comprehensive histories and exams. However, insurers do not agree.

-CMS indicates in its Carriers Manual that -Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code,- - says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions forQuality Health Care.

-The nature of the presenting problem is CPT's measure of medical necessity for E/M services,- Levinson says, -and this important contributory factor is included for every level of every type of service that measures care using the three key components. And the Clinical Examples in Appendix C of CPT have been developed and approved by our own specialty societies to illustrate the level of care warranted by representative patient problems, and CPT directly tells us that the clinical examples -are provided to assist physicians in understanding the meaning of the descriptors and selecting the correct code.- -

And, contrary to what some physicians believe, the E/M documentation guidelines do make several references to medical necessity, says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass. Schwalm refers to the following references from the 1995 E/M Guidelines:

Page 2: -The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.-

-The key word here is -relevant,- - Schwalm says. For example, if an established patient presented with a sprained toe and no other symptoms, a comprehensive history and exam would not be relevant to the reason for the encounter.

Page 10: -The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).-

-The clear message here is that the history, exam, and medical decision-making performed should correlate with the presenting problem(s),- Schwalm says.

Examine 2-7 Organ Systems for 99214

Question: I recently read in my carrier's bulletin that I need to examine 5 to 7 organ systems for my physical exam to qualify for a 99214. Is this accurate?

Answer: No. In fact, the 1995 E/M guidelines as interpreted by CMS only call for two to seven organ systems or body areas.

Watch out: This misconception appears to be widespread. At least one Blue Cross/Blue Shield plan has said you need at least five systems or areas for a 99214. And this guidance also appears on the Web sites for the American College of Emergency Physicians.

This is an error that many consultants blame on large public accounting firms, which have been intimidated by a wave of audits of 99214s, for spreading this overly conservative guidance. Therefore, the large CPA firms decided to adopt that rule at one point.

Just because specialty societies or CPA firms may state that you need five systems, it doesn't mean that Medicare or payer audits will follow suit.

Most carriers say you only need two to seven body areas or systems for a 99214, including Empire, TrailBlazer and HGSAdministrators.

Private payers may follow their own guidelines, so you should get those in writing.