Part B Insider (Multispecialty) Coding Alert

1 tell-tale sign that a follow-up visit may be a level four

Myth: If an established patient comes back for a -routine- visit, you should automatically code that as a level-three evaluation and management visit.

Reality: You should always code based on what your physician actually documented and performed. There's no rule that says a routine follow-up must be a level three, notes Peter Jensen, a physician and founder of EMUniversity.com.

Many physicians and coders wrongly believe that a -routine- visit should always fall smack dab in the middle of the bell curve, Jensen complains. -Most doctors don't give it a second thought,- he says. They just circle the middle E/M code for what they perceive to be a routine patient.

If you-re new to E/M coding, you should score visits carefully, using the Marshfield Clinic score sheet or something similar, says Jensen. In particular, you should look at the complexity of the medical decision-making (MDM) and consider -the number and nature of the problems you-re addressing.-

Example: A patient's chief complaint may be -something kind of innocuous, like -follow-up to hypertension,-- says Jensen. The physician didn't make any changes in medications, reach a new diagnosis or make a referral. This looks like a fairly uneventful visit, but -sometimes the smartest thing to do is nothing.- The physician is continuing to monitor the patient, reviewing test results and checking the patient's medications.

A level-four E/M, after all, requires an MDM of -moderate complexity,- not high complexity, notes Jensen.

Dead giveaway: The most important factor to look for in deciding whether you may have a level-four visit is the risk to the patient, according to Jensen: -The risk is the most underestimated dimension of medical decision making.- Just the presence of two chronic stable problems is enough to qualify a patient as moderate risk, he notes. If the patient also has other problems, then the visit could easily amount to a level four.

For specialists, the complexity of the physical exam and the history are more likely to bump a visit up to level four, notes Deborah Churchill with Churchill Consulting in Killingworth, CT. A specialty physician is less likely to be making changes to all of a patient's medications, she points out. A very detailed physical examination and history may lead to a higher level for specialists, even in a routine follow-up.

But Churchill advises caution because the most important thing is for you to code based on what the physician actually did.