Otolaryngology Coding Alert

Tip: ‘New’ problem doesn’t always need a work up.

Coding for routine E/M services every day doesn’t mean you automatically report the same codes. Be sure you’re up-to-date on the criteria for deciding when “additional work up” and “moderate” decision making apply to your claims by following the advice from this real-life scenario. 

Encounter: The physician sees Mrs. Johnson, an established patient, for a new problem. The documentation reads, “Diagnosis: established patient with headaches and nasal congestion.  Patient does not work up  (nasal endoscopy) due to her acute headache today. Suspect sinusitis. If pain persists tomorrow, she will call and she will return for a nasal endoscopy and possible sinus CT depending on the endoscopic findings. Patient agrees. We did not prescribe any medication at this time since we did not get a good look at the sinuses. She will continue to take over the counter antihistimines and ibuprofen.”

How would you code this visit?

Step 1: Evaluate Medical Decision Making

“This situation represents moderate medical decision-making,” says Dawn Silva, CPC, CCP, compliance officer with Marin Medical Practice Concepts in Novato, Cal. “You have an undiagnosed, new problem with an uncertain prognosis.”

“At first glance, you might think this is just a minor problem since the provider didn’t push for testing and was fine with the patient going home to take over-the-counter antihistamines and ibuprofen,” adds Linda Vargas, CPC, CEMC, coding and reimbursement specialist at Cass Regional Medical Center in Harrisonville, Mo. “But since there was no definitive diagnosis, and the possibility of testing, you should consider this a ‘new’ problem even without a work up.”

Remember: A new problem with no diagnosis supports moderate complexity medical decision making both in terms of the diagnosis and management options and in terms of the risk involved. Since the level of medical decision making involved depends on meeting two of the three medical decision making elements (i.e., diagnosis and management options; amount and complexity of data reviewed; and risk), this documentation appears to support a moderate level, even though the amount and complexity of data reviewed is minimal or none.

Step 2: Choose the Best Code

A good place to start is E/M code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) because it notes “medical decision making of moderate complexity.” However, that shouldn’t be your automatic code choice since the level is dependent on 2 out of 3 factors, the history, exam and medical decision making.

Caution: If this case were on your desk, you would need to verify that the physician also performed and documented a “detailed” history or exam before you could submit 99214.

The overreaching factor of medical necessity should also be considered. Medical necessity and medical decision making (MDM) are not always equal. Keep in mind that there may be cases when you have low MDM, particularly with the follow up for chronic conditions and still have the medical necessity to support performing a detailed exam. This is why Medicare and the AMA require 2 of the 3 elements of History, Exam and MDM and do not require that one of the elements include MDM. But always keep in mind that medical necessity and the nature of the presenting problem are the overreaching factors and may be a reason to down code an encounter even if two of the three elements support a higher level.

Backup plan: If the history or exam does not support a detailed level, the EM level may have to be coded lower than 99214. The ultimate E/M level is determined by the highest documentation supported of the history or exam, up to detailed. This means that a detailed history or exam supports a 99214 (given this moderate MDM), an expanded problem focused history or exam supports a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity) or a problem focused history history or exam supports a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.)

Based on the documentation in our example, you can report diagnoses 784.0 (Headache) and 478.19 (Other disease of nasal cavity and sinuses) for the nasal congestion. You cannot code a sinusitis yet since the doctor has yet to definitively determine that this is the diagnosis.