Otolaryngology Coding Alert

Taking a patients history is probably the easiest component of an evaluation and management (E/M) to document, because both patient and clinical staff can be used to provide the information and documentation. Despite this, auditors are finding that poorly documented history is resulting in E/Ms being downcoded as much as three levels.

Otolaryngologists normally take an appropriate level of history, depending on the condition of their patient, but because they tend to be focused on the patients condition and dont want to waste time on other matters, that history doesnt always end up in the documentation. This may cause no harm to the patient but certainly will hurt the otolaryngologist in the pocketbook, says Arlene Morrow, CPC, a coding and reimbursement specialist in Tampa, Fla.

For example, the otolaryngologist sees a patient who complains of chronic sinusitis. A comprehensive history is taken, but all that is written in the documentation is,
Patient complains of sinus headaches and nasal congestion, occasional post-nasal drip, and rhinorrhea.

Because the documentation contains only a chief complaint and a history of present illness (HPI), but no review of systems (ROS), it could warrant only a problem-focused history, which in turn means only a level one new patient visit can be billed, irrespective of the level of examination and medical decision-making (the other two components of an E/M service).

Note: For established patients, a problem-focused history qualifies for a level-two visit.

On the other hand, had the otolaryngologist documented the patients history as follows below, it would qualify as comprehensive.

Patient complains of sinusitis; symptoms have been present for three years and gotten progressively worse last three months; symptoms seem to worsen during springtime; occasionally patient has increased pain in the sinus area; green drainage from the nose; pain in the front of the face; and fever. Patient has taken antibiotics and antihistamines in the past to relieve these symptoms. No positive personal or family history of allergies. Patient doesnt smoke. Reviewed patient info sheet for other review of systems and past medical history, all other systems negative except those noted above.

A comprehensive history means that it would support either a level-four or level-five new patient visit or consult (99204, 99205, 99244, 99245), as long as the exam and medical decision-making were documented at the same level and there is medical necessity for performing a level four or five. (An established patient visit requires only two of three categories.) A comprehensive history requires an extended chief complaint/history of present illness.

In the history cited above, such elements include: (1) site of chief complaint (sinuses); (2) context (worsening, chronic); (3) associated signs or symptoms (green drainage from nose, pain and fever); (4) timing (gets worse in spring); (5) duration (for the last 3 years, getting worse over the last three months); and (6) modifying factors (antibiotics and antihistamines have relieved symptoms in the past).

The comprehensive history also requires a complete past/family/social history, which requires two to three elements, and a complete ROS (10 or more). By writing that the patient has no positive personal or family history of allergies and doesnt smoke, the otolaryngologist has met the complete past/family/social history requirement.

Perhaps the trickiest element for otolaryngologists is the review of systems, particularly because ears, nose, throat and mouth all together are considered only one of 14 systems. Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Lakewood, N.J., notes that a review of systems for a history should not be confused with an examination.

In an examination, what you did, touched, or measured is important. In an ROS, what you asked is all that matters, Cobuzzi says, adding that if the physician asks about the nine other systems, even if the patient is asymptomatic, a complete ROS has been performed. In other words, if the system(s) related to the problems have been documented and there are no other significant findings in the other systems, the notation all other systems negative in the medical record fulfills the requirement and the individual listing of all the systems is not necessary.

Cobuzzi recommends that terms such as all other systems non-contributory not be used. It implies that systems may not have been reviewed. This can create concern among auditors as to whether the systems being referred to can be counted, she states. Whereas the statement all other systems negative, implies that the doctor did review those systems and there was nothing remarkable to report.

In short, if the physician has reviewed the systems and found nothing significant, all other systems negative should be used. If this statement is not present, then at least 10 systems must be separately documented to fulfill the requirement for a complete ROS (necessary for a comprehensive history, level-four or level-five E/M); alternatively, two to nine systems must be documented to describe an extended ROS (necessary for a detailed history).

Rely on Staff to Assist in Patient History

Of course, most otolaryngologists dont want to spend an inordinate amount of time taking a patients history. If the patient is unable to complete the questionnaire alone, office staff can help. The questionnaire should include three components of history: chief complaint/history of present illness (HPI); past/family/social history; and review of systems (ROS).

Section one of the questionnaire should include:

Location/site of the chief complaint,
Quality of the problem (for example, sharp or dull pain),
Severity of the problem (e.g., mild, moderate, extreme),
Timing (during exercise, at night, etc.),
Context (worsening, recurrent),
Modifying factors (heat/cold, rest, limb elevation),
Associated signs of symptoms.

If one, two or three of the above elements are documented by the patient, the history of present illness is classified as brief; four or more elements constitute an extended HPI. Section two should entail:

Past medical history (illnesses, operations, injuries,
treatments, etc.),
Family history (medical events, heredity),
Social history (marital status, occupation, habits,
activities, sexual history).

If no medical, family or social history is indicated, the history will be limited to problem-focused or expanded problem-focused.

Section three constitutes the ROS and should include a series of questions that help identify any signs or symptoms that the patient may be experiencing. This will determine any underlying problems that may be related to the chief complaint and identify any ongoing problems that might affect a choice of treatment for the current problem.

Once the information about the three categories has been gathered, the surgeon should review it with the patient and then sign off on it. On the form, or in a separate dictation, the otolaryngologist also should:

Review the information on the questionnaire, if it was
taken by someone else;
Note that the history was discussed with the patient;
Indicate what the significant findings were. For
example, the dictation might state, Patient has family
history of sinus problems. By discussing the findings,
the otolaryngologist gets credit for everything on the
questionnaire, regardless of its length, including
review of systems and past, family and social history;
Specifically note the chief complaint, which is a
requirement for any level of history. Without a chief
complaint, an auditor has no way of knowing why the
patient was treated.

When an established patient returns, the otolaryngologist can use a prior history in the chart, by noting, for example, reviewed history of April 3; the following changes have occurred ... , Cobuzzi says. If the April 3 history was a detailed history, the history currently performed and documented also can be classified as detailed.

History May See Modifications The Healthcare Financing Administration (HCFA) is proposing new E/M documentation guidelines and has set up pilot projects to test them. The history section has few changes, with the exception of the review of systems component. The review of systems modifications already have come under fire from coding specialists because the guidelines stipulate that all positive findings must be described; negative findings do not need to be individually documented except as appropriate for patient care. A notation indicating a system was negative is sufficient, and the name of each system reviewed must be documented. For example, the following notations would be acceptable: Pulmonary: cough x 4 weeks, otherwise negative Cardiac: negative ROS: cardiac, pulmonary, GI, GU, endocrine all negative. The following notations would not be acceptable: ROS: negative Pulmonary: positive All systems negative.