Part B Insider (Multispecialty) Coding Alert

Warning:  Just a mention in the history isn't enough

Don't count out absent organs when it comes to E/M coding--or you could be cutting yourself off from extra revenue.

Opportunity: If your physician examines a patient who has had an organ removed, you can still count that organ toward the physical exam or review of systems (ROS) in scoring the evaluation and management level, say experts.

For example: A patient has had her uterus and cervix removed. The physician does a breast and pelvic exam.  You can count the uterus and cervix as two out of seven required areas for billing G0101, according to Jan Rasmussen, president of Professional Coding Services in Eau Claire, WI.

Part B carrier HealthNow NY covered this example in a May 2004 article, which you can find online at www.cms.hhs.gov/mcd/viewarticle.asp?article_id=20466&article_version=3&show=all. "In order to allow for post-surgical or other variations, it is allowed to count the absent part, if the exam documentation specifically describes that absence as it is noted on the examination," HealthNow wrote.

Watch out: Some physicians think it's enough to document in the patient's history that she had a hysterectomy, and then they can count this as an organ system. In fact, they have to document that the uterus is absent in the physical exam itself, or you can't give them credit for it, says Rasmussen.

You can count an absent organ in the physical exam if the physician examines that area of the body and notes any findings. "If the physician notes the absence of an organ in the ROS, either surgically or congenitally," you can also count it as a system, adds Pati Trites with Compliance Resources in Augusta, MI.

Another example: The physician performs a digital rectal exam (DRE) on a patient who's had his prostate removed. The physician examines sphincter muscle tone and looks for masses, then notes that the prostate is absent. The physician can get credit for two body systems, say coding experts.