Otolaryngology Coding Alert

Let history, medical necessity determine your code selection

Make sure your physician's documentation shows medical necessity when she performs a comprehensive history and examination before you report 99214 and 99215--otherwise, you could be opening yourself up to allegations of unethical coding.

Medical Necessity Should Drive History

When determining a visit's history, the type of history--problem-focused, expanded problem-focused, detailed or comprehensive--that the allergist claims must be medically necessary based on the encounter. -The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s),- states CPT's E/M guidelines section, -Instructions for Selecting a Level of E/M Service- (page 3--Ingenix 2005 Expert).

Even though a nurse may take the information necessary to support a comprehensive history, the physician's clinical judgment and the patient's problem should determine the amount necessary. -Coding too many 99214s and 99215s could trigger an audit, especially if these codes are associated with one minor diagnosis,- says William H. Ward, MD, IAFP, associate director of St. Francis Family Practice Residency Program in Beech Grove, Ind.

Example: An allergist sees an otherwise healthy established patient for exercise-induced bronchospasm. In this scenario, no medical need exists to collect a comprehensive history. You would report 99213 for a routine established patient exam, says Beverly Ramsey, CMA, CPC, CHCC, CHBC, at Doctors Management in Asheville, N.C.

In fact, coding a comprehensive history for such a simple problem could prove unethical, even if your staff has gathered more history than necessary. -Payers and auditors may view such conduct as -gaming the system---obtaining a higher-level component than medically necessary just to charge a higher-level E/M service,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

Exam's Extent Hinges on Problem

You also have to consider medical necessity when determining the E/M service's exam type. CPT's instructions on selecting the exam type echo its history component guidelines. -The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s),- states CPT's E/M guidelines.

Translation: A physician's decision to perform a comprehensive exam should stem from the patient's problem(s). Simple problems don't warrant this component level or the physician's time.

Example: Your allergist evaluates an established patient with a common cold (460, Acute nasopharyngitis [common cold]) and no comorbidities. A comprehensive exam isn't medically necessary in this case.

Other examples that may not warrant a comprehensive exam, Ramsey says, include an established patient visit for the following:

- stable chronic asthma requiring regular drug therapy.

- office visit for a patient who experienced a reaction following administration of immunotherapy at a previous encounter and the allergist is adjusting the dosage.

- atopic dermatitis and food sensitivity follow-up. 

Taking a comprehensive exam when the patient's problem doesn't warrant this level isn't customer-friendly. -It subjects the patient to a more extensive exam than necessary,- Cobuzzi says. You should instead allow the patient's problem to drive the examination.

Don't Confuse MDM With Medical Necessity

To bulletproof your 99215s, stress medical necessity's role in E/M-level selection. -Medical necessity always has to come into play,- Cobuzzi says. -You shouldn't code 99215 just because the physician performs and documents two of the three components.- The history and exam have to be medically necessary.

Problem: Some coders confuse medical necessity and medical decision-making (MDM). -They-re not the same thing,- Cobuzzi says.

This myth leads coders to think that MDM must always steer the E/M level. -But you may ethically have a level-five established patient office visit without high- complexity MDM,- Cobuzzi says.