Orthopedic Coding Alert

Many orthopedic practices are stuck reporting low-level new patient E/M codes even though they've performed higher-level services. The culprit: Some physicians don't appropriately document the patient's history, and cannot justify reporting a higher-level E/M code. If you can work with your orthopedist to spend just a few extra minutes on his new patient documentation, you may be able to report higher-level codes and boost your practice's bottom line.
 
Orthopedists occasionally see new patients who have  serious conditions and require high-complexity medical decision-making, which, when combined with a comprehensive exam and a comprehensive 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).
 
Suppose your orthopedist performs a comprehensive history, comprehensive examination and high-complexity medical decision-making (MDM) on a new patient. She documents the comprehensive exam and high-complexity MDM, but only documents a detailed history. What your practice could have billed as a 99205 (netting about $180) is now a 99203 (netting only about $100). Had she spent about five more minutes thoroughly documenting the comprehensive history, your practice could have collected an additional $80.
 
You should perform quarterly E/M self-audits to determine whether your physicians are leaving this kind of money on the table because they underdocument their services. If so, schedule a meeting with your physicians and nonphysician practitioners. Discuss the various levels of coding and remind them of the documentation necessary to report the higher-level codes. You should also provide an outline of the different reimbursement amounts for each code so they can see how much they're forfeiting by providing incomplete documentation.

Note the 4 Levels of History

Medicare and CPT both recognize four levels of history for an E/M service: problem-focused, expanded problem-focused, detailed, and comprehensive. See the chart on page 85 to determine which history level the physician's documentation warrants.
 
The chief complaint and related history of present illness (HPI) tend to be the areas where orthopedists 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 his own, or with a nurse's help. The chief complaint is a concise statement explaining why the patient is in the physician's office, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "All E/M services need a reason for the visit, which will be found in the chief complaint."
 
The HPI is a more thorough description of the patient's chief complaint, Jandroep says. It may include one or more of the following eight elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
 
A very brief sentence can convey several of these elements at once. A patient who complains of sharp pain (quality) in his lumbar spine (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 orthopedist merely documents lumbar pain that started six weeks ago, he only qualifies for two elements, reducing 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.
 
There is one caveat: The 1997 Medicare E/M guidelines allow an exception to the HPI requirements. If an orthopedist follows these more detailed guidelines instead of those published in 1995, an extended HPI can also consist of three or more chronic or inactive conditions instead of four or more of the HPI elements. So under the 1997 guidelines, you automatically qualify for an extended HPI if you document a patient's diabetes, hypertension and arthritis.

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 systems of the body. Most of the time, it is part of the patient intake form, says Gina Collins, billing supervisor at Northeast Billing in Hartford, Conn.
 
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; musculoskeletal; 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, orthopedists can usually quickly review the 10 systems needed for the comprehensive ROS. To indicate that he performed an ROS, however, the orthopedist should note his review of the form in the patient's medical record and note any significant findings, and 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). The patient probably answered many of these questions on the patient information form. Again, the orthopedist should indicate in both the patient's record and the patient information form that this area was discussed 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 orthopedist should write "no change" on the patient information form, sign and date it, and make a similar notation in the patient's medical record, Collins says.