Otolaryngology Coding Alert

CMS says you no longer have to stick with only 1995 or 1997 rules. 

For some payers, you can now use the history of present illness (HPI) criteria from either the 1995 or the 1997 Documentation Guidelines for Evaluation & Management Services. That means you can combine the best history with the best physical examination to determine the level of service. That, in turn, gives your otolaryngologist more options for meeting the level of service. 

Read on for a look at the change and how it can make your coders’ and providers’ jobs easier.

Brush Up On Your ’95 vs. ’97 Knowledge

The HPI describes the development of a patient’s present illness from the first sign and/or symptom or from the previous encounter to the present encounter. 

1995 way: Under the 1995 guidelines, to assess the level of HPI, you count the number of HPI elements the provider reviewed and documented. The guidelines include eight elements:

1. location

2. quality

3. severity

4. duration

5. timing

6. context

7. modifying factors

8. associated signs and symptoms.

The medical record should describe one to three elements for a brief HPI. For an extended HPI, the medical record should describe four or more elements or associated co-morbidities. You can count co-morbidities in past history, ROS (review of systems), or HPI.

1997 way: With 1997 guidelines, you choose a level of HPI based on the number HPI elements documented as you did above for the ’95 guidelines or the number of chronic or inactive conditions your provider reviews with the patient. A brief HPI consists of one to three elements. An extended HPI consists of at least four elements or the status of at least three chronic or inactive conditions.

Know When the Change Took Effect 

Thanks to the guidance from CMS and HHS (Department of Health and Human Services), you can now mix and match the 1995 and 1997 guidelines for counting HPI with the physical examination and medical decision-making (MDM).

“Beginning for services performed on or after September 10, 2013, you are able to use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service,” announced CMS and HHS.

In other words: For services your physician has performed since Sept. 10, 2013, you may use the 1997 documentation guidelines for HPI along with the physical examination criteria from the 1995 guidelines, or vice versa, using the 1995 HPI criteria with the 1997 examination guidelines.

Although the guidance dates back to September 2013, you cannot refile claims retroactively to reach a higher code level and potentially higher reimbursement by mixing the 1995 and 1997 guidelines, because it’s beyond the timely filing limit. You can, however, use the approach if your practice is audited for claims back to that date.  

How it’s different: In the past, you had to choose either the 1995 or 1997 guidelines and apply your choice to the entire encounter. But now, you can use either the status of inactive or chronic conditions or the HPI elements for the history and still choose either the 1995 or 1997 guidelines for the physical examination portion of the encounter.

This change may make your job easier when you are reviewing your provider’s documentation and determining the best code to assign. 

“I find it beneficial in that providers may have been trained to document using either of the documentation guidelines,” says Lynn M. Anderanin, CPC, CPC-I, COSC, ICD10, senior director of Coding Compliance and Education for Healthcare Information Services in Park Ridge, Ill. “When auditing records, I can usually recognize which they are using. This allows me to able to use either/or to justify the level of service. Often, the 1995 guidelines for examination are easier to obtain than the 1997 guidelines, especially in the higher levels of service.”

“If the physician is a specialist, there might be times that the examination is targeted to the specific organ system, but there may be other times when a more general exam is warranted,” explains Suzan Berman (Hauptman), MPM, CPC, CEMC, CEDC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn.

Good news: Medicare contractors such as First Coast Service Options, Inc. (medicare.fcso.com/faqs/answers/197576.asp) and Noridian Healthcare Services (med.noridianmedicare.com/web/jeb/specialties/em) have announced they will recognize either the 1995 or 1997 guidelines for the HPI, no matter which guidelines were used for the examination. Make sure you check with your payers to see if they will recognize this guidance.

See How It Works In Real Life

Take a look at the following office visit scenario to see how the HPI/examination mixing option can help you reach a higher level of service in some cases. 

During an office visit, your physician documented only three HPI elements but documented the status of three chronic conditions (chronic maxillary sinusitis left, chronic sphenoidal sinusitis right, and bilateral conductive hearing loss). The visit didn’t capture four HPI elements, but the physician can still get credit for a comprehensive HPI with the status of the three chronic conditions. The physician also documented a comprehensive ROS and complete PFSH. This provides a comprehensive history. 

Since you can mix the 1995 and 1997 guidelines, you can base the exam on the ’95 exam body areas and organ systems instead of the bulleted, single system otolaryngology exam from the ’97 rules. 

The visit may include an excellent body area and organ system exam, which provides a “4x4” detailed exam. The “4x4” means documentation shows four specific, in-depth findings about four organ/body systems. Payers look for a “4x4” exam to differentiate from the expanded problem focused exam and the detailed exam. 

Let’s assume the documentation shows four in-depth findings for constitutional, eyes, ENT, and neurologic. If so, you have a “4x4” exam. The physician might also document additional information in the respiratory, cardiovascular, and head/neck areas. If so, the documentation exceeds a “4x4” for a detailed exam but does not meet the requirement of eight organ systems for a comprehensive exam. 

MDM calculation: You have a comprehensive history, detailed exam (history based on the ’97 guidelines and exam based on the ’95 guidelines). If you’re coding for an established patient and have verification that the detailed exam was medically necessary (as dictated by the nature of the patient’s complaint), you can submit 99214 without even considering medical decision making (MDM). 

Remember: When your physician treats chronic conditions, successful treatment may indicate a straightforward to low MDM when you still have the medical necessity supporting a detailed exam. Medical necessity may justify a higher history/exam than it appears the MDM may indicate. This is because you don’t have the MDM results until the end of the service. Your physician should not be penalized because she’s successful in controlling a chronic disease and the patient’s stability leads to low or straightforward MDM. You’ll never know that until the provider performs more extensive histories and exams if dictated by the chief complaint/presenting problem.