Part B Insider (Multispecialty) Coding Alert

Know how chief complaint factors into code decision.

Question: When a patient comes in complaining of chest pain, we often order lab work and an ECG and send the patient to the hospital. These instances involve moderate to high risk, but we do not perform a complete review of systems (ROS)due to the problem's emergent nature. Will these be level-four or -five established patient office visits?

Answer: No rule stipulates the level E/M code you'll use every time for the same chief complaint. Instead, you will choose the appropriate level based on the medically necessary history, exam, and medical decision making (MDM) that you perform and document at each encounter. Probable combos for a patient presenting with a possible heart attack include detailed history + detailed/comprehensive exam + mod/high MDM. Since an established patient visit requires 2 of 3 key components, the MDM, plus the amount of exam, may ultimately determine whether the encounter is a level four (99214) or five (99215). Here are the breakdowns:

MDM: Assuming chest pain is a new problem, you would receive four points in the "Number of Diagnoses or Treatment Options" area for the new problem with additional work-up planned on the standard documentation worksheet. You'll receive a point for ordering lab work and a point for ordering the ECG for a total of two points in the "Amount and/or Complexity of Data to be Reviewed" section. The risk will determine whether MDM is high or moderate complexity.

History: You indicate that these scenarios do not involve performing a complete ROS (10 or more systems, or some systems with statement "All others negative"), which a comprehensive history requires. Your history taking, however, probably involves asking the patient about the severity, duration, quality, context, etc. of the pain (history of present illness [HPI]) and any past personal or family history of heart disease (past medical, family, social history [PFSH]). Therefore, your HPI will probably involve at least four (extended) HPI elements and 1 (pertinent) PFSH element. The doctor probably asked questions about the constitutional and cardiac systems. Reviewing 2-9 systems (extended) counts as detailed ROS. Extended HPI + extended ROS + pertinent PFSH = detailed history.

Examination: If you examine eight or more systems (such as constitutional, eyes, ENT, detailed cardio, respiratory, skin, neuro, and psychological), you'll be at a comprehensive exam. If the severity didn't allow for anything other than constitutional (vitals, general appearance) and detailed cardio, it may still be at a detailed exam.