Part B Insider (Multispecialty) Coding Alert

2 expert scenarios help hone your E/M coding skills

Before you report any E/M procedures, look for documentation details on the patient's presenting illness. This information can make or break your patient's complete history--and affect your coding and your physician's bottom line.

Check out the following two frequently asked questions to determine your review-of-systems (ROS) savvy. Then check your answers against our experts- opinions on how to deal with the situations.

Don't Let Language Barrier Keep You From Full HPI

Question 1: A new patient who cannot speak English presents to your practice. The patient's inability to communicate prevents your physician from obtaining a complete history of present illness (HPI) and ROS from her. Your physician treats the patient's migraine but cannot develop a definite plan for her treatment.

The physician calls the patient's previous two physicians to discuss her medical problems and discovers that the patient also has a history of stroke and seizure. Your physician spends a total of 90 minutes on this patient on the same day, including face-to-face patient time and telephone calls to the other providers.

How should you charge for this scenario? Which E/M codes and modifiers should you use to justify the extra time your physician spent on the phone with other physicians on this patient's behalf?

Answer 1: You should select the appropriate E/M service level from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) based on the information your physician obtained from the patient and her previous physicians.

Be careful of time: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Watch out: In most cases, you cannot bill based on time if a communication barrier extended your physician's face-to-face time with the patient. Normally, communication barriers do not meet the criteria for counseling/coordinating care.

The physician may document the excessive effort in trying to obtain an appropriate history with the reason for the excessive effort and a reason why he was unable to get the full history. The physician may receive credit for the -unobtainable- history.

If the physician documents his service time when the patient is not physically present (such as this physician's postexam calls to the patient's other physicians), you will probably be unable to report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Here's why: Most payers consider extra time (as in this example) to be part of the pre- and postservice work associated with the E/M service payment.

Ensure Your Doctor Signs the Nurse's Notes 

Question 2: Can you use a nurse's notes to satisfy elements of ROS and past, family, social history (PFSH) for a new patient visit, as long as the physician documents his review of the notes?

Answer 2: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with info from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator at Beeghly Medical Park in Ohio. (See PBI, Vol. 8, No. 11.)

-I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes,- she says.

You-ll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the level of information the physician gathered about the patient's history--which helps determine your coding.

The ROS is basically an inventory of the body so your physician knows where to direct the physical examination. The inventory might include evaluations of any of the following systems or parts:

Allergic/immunologic; Cardiovascular; Constitutional symptoms; Ears/nose/mouth/ throat;  Endocrine; Eye; Gastrointestinal; Genitourinary; Hematologic /lymph; Integumentary; Musculoskeletal; Neurological; Psychiatric; and/or Respiratory.

For a problem-pertinent ROS, the physician needs to review a single system or part and will usually follow the guidelines of E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history, a detailed examination, and medical decision-making of low complexity).

Multiple systems: If your physician reviews two to nine systems, you should consider the ROS -extended,- which means the visit usually translates to 99203. If he reviews at least 10 systems, the ROS is -complete,- which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

A -pertinent- PFSH consists of a comment in any one of the histories--information about the patient's past health history, family history or social history--and helps you on your way to a 99203. For a -complete- PFSH, the physician's documentation must include information that involves all three of the histories; if so, you-ll report either 99204 or 99205.