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Eli's Rehab Report

Avoid Undercoding:

Billing for High-Level, Single-System E/M Services

Published on Sat Sep 01, 2001

Most physiatrists rely on single-system examinations for their E/M services  -- either musculoskeletal or neurological -- and it's important that PM&R practices understand what each level of the E/M visit entails. Although the common belief is that many practitioners are upcoding their claims, the opposite can be true -- practitioners who aren't sure whether they can bill high-level, single-system exams are often undercoding and, therefore, missing out on reimbursement. CMS (formerly HCFA) offers examples primarily for other specialists in these categories (such as orthopedists and neurologists), but not physiatrists.
 
Some PM&R coders believe that their physicians are unable to meet the requirements for high-level visits. This is not true as long as the physician performs and documents enough of the elements or "bullets" identified in CMS' 1995 or 1997 documentation guidelines. Several examples are listed and explained in the guidelines. 
 
"A constitutional-system exam is a possible bullet, which means that the practice should measure any three of the following vital signs -- blood pressure, pulse, respiration, temperature, height or weight," says Laureen Jandroep, OTR, CPC, CCS-P CPC-H, owner of A+ Medical Management and Education, a coding and reimbursement consulting firm and a national CPC training curriculum site in Egg Harbor City, N.J.  "Practices are already checking these, so that bullet will be counted. Another bullet is for general appearance -- is the patient overweight? For a musculoskeletal exam, checking the patients' gait and station -- how are they walking, how is their posture?
 
"Those practices that think they shouldn't code to 99215 for a single-system exam are hurting themselves,'' Jandroep says. "If you perform and document all of the requirements for a high-level exam, then you should be paid for it. Undercoding is absolutely not correct coding.''
 
Jandroep says that practices with the single-system examination elements on hand during the exam via a checklist or form will be best-suited to document all of the appropriate points. Here are examples of how physiatrists should document the higher-level, single-system exams:

Level Three: 99213
 
According to CMS guidelines, to code for a level-three exam the physiatrist must document an expanded problem-focused history (which consists of a brief history of present illness and a problem-pertinent review of systems); an expanded problem-focused exam; and low-complexity medical decision-making. Below is an example of how that translates to a physiatrist and the documentation that would accompany the visit to justify level three.

Musculoskeletal Exam: A 36-year-old patient presents with a stiff neck (ICD-9 723.1 ) that has affected her for two days. 
  
History: The physiatrist takes a brief history to establish the location of the problem, its severity, onset, and duration of symptoms:
       
  • Chief complaint -- Neck pain, radiating from the left shoulder, often causing a headache.
           
  • History of present illness -- Patient woke yesterday morning with a stiff neck; it grew more painful throughout the day. She woke today with a severe headache, and her shoulder was affected.
           
  • Review of systems -- No fever; blood pressure normal; no pain in arms; allergic to penicillin.

    Expanded, Problem-Focused Exam: The physiatrist must examine at least six elements identified with a bullet on CMS' documentation guidelines:

    Constitutional: temp 99; BP 120/80; weight 140.

    Musculoskeletal: (Note: The following  musculoskeletal exam counts as five elements because with 99213 each examination of each body part counts separately.)

    1) Examination of head and neck shows that the patient has a limited range of motion and neck is tight on the left side.
                   
    2) She remarks on severe pain on neck palpation.
                   
    3)  Patient cannot raise her left arm above  her head.
                   
    4) Patient's spine appears properly aligned.
                   
    5) Patient's lower extremities are not affected.
       
    Neurological: Patient seems agitated and stressed, and states that her lack of sleep the prior evening has triggered a "blue" mood.

    • Medical Decision: Patient's neck and shoulder pain most likely caused by a pulled muscle. No sign of nerve or spinal irregularities. Patient should return in three days for more testing if the pain and/or headaches do not subside. The physiatrist prescribes a painkiller for the patient and asks her to call in three days to report her progress.
     
    "A problem we used to have with musculoskeletal exams was that the physiatrists were not examining four of the six areas listed in the musculoskeletal section," says Tamara Czyswski, coding manager for the Pain and Joint Center, a three-physiatrist practice outside of Chicago. "If the patient had foot pain, the physiatrist would examine the foot and the spine, sometimes the neck, but often not a fourth area, and we had trouble explaining that the documentation must show examination of four of those areas to get paid."
     
    Had the physicians tested a fourth muscle area, such as grip strength, they could have counted that as an extra bullet, thus possibly increasing the E/M level.

    Level Four: 99214
     
    Coding for a level-four patient requires a detailed history and exam and moderate medical decision-making.  The following is how this might translate into an actual encounter at a PM&R practice:
     
    Neurological Exam: A 65-year-old male established patient with a history of stroke (436) comes in with his son. The son explains that his father fell out of bed the previous night and has been slurring his speech ever since. He is concerned that his father may have neurological complications.
     
    History: Chief complaint: Stroke patient is slurring speech after a three-foot fall while sleeping.
        
  • Extended history of present illness: Patient woke briefly when he fell from bed last night in his home, but he did not complain of any pain. When he woke five hours later, he was slurring his speech so that his son could barely understand him. Son reports no other symptoms of neurological distress; patient says he feels fine.
        
  • Detailed review of systems (two to nine elements): patient's breathing, temperature, heart rate and blood pressure are normal; he reports no earaches or blurred vision; has pain in his throat.
        
  • Past history: Patient suffered a mild stroke 14 months ago and recovered with no paralysis or speech problems. Patient has been healthy ever since, on restricted diet and blood-pressure medication.
    •  
    Detailed Examination: (Note:The physiatrist must examine 12 elements identified with a bullet on the neurological examination. These elements have been numbered below.)
             
  • Constitutional: 

    1) Blood pressure 120/80; temperature 98.9; respiration normal; weight 145; height 5'10" 

    2) Patient appears slightly underweight and says he has not had an appetite recently because of constipation. On examination of the patient's mouth, I see that he has bitten his tongue quite severely in the back; it looks as though it is still bleeding slightly.
              
  • Eyes:
                  
    3) Patient's eyes appear normal, pupils not dilated, blood vessels normal.
               
  • Cardiovascular:

    4) Pulse is 88, no swelling or tenderness.
                
  • Musculoskeletal: 

    5) Patient walks well with no assistance. 

    6) Slight atrophy in patient's extremity muscles with very low muscle tone.
               
  • Neurological:
                  
    7) Patient is aware of the date and time, and knows he is in my office.
                  
    8) He recalls our first meeting over a year ago in the hospital, and also recalls his fall last night, what he wore to bed, and what time he woke up.
                       
    9) Patient speaks with a slur but is able to carry on a conversation with me without any problems.
                       
    10) Patient tells me where he was born, who is the current president, and his son's birthdate without problems.
                    
    11) Test of patient's 12th cranial nerve is normal but shows his severe tongue bite.
                       
    12) Patient is aware of vibrations and touch on his skin.

    • Medical Decision: The patient is slurring his speech because he bit his tongue, presumably during the fall from bed. Prescribed NSAIDs for tongue pain, and over-the-counter laxatives for constipation.

    Level Five: 99215 -- Record Every Element
     
    The neck-pain patient in the first musculoskeletal example returns to the physiatrist a week later with more severe neck pain, radiating to the right shoulder and to the cervical spine. The physician performs a comprehensive history and examination that involves highly complex medical decision-making. Because every element in the musculoskeletal exam template must be addressed, the physiatrist reports the information recorded previously, along with the further re-examination of the patient. 
       
    "Because we regularly deal with muscle and joint pain, we have a template stapled to the inside of each chart, listing the required elements for a musculoskeletal examination, and they just write down their analyses of each bullet next to it,'' Czyswski says. "The physicians appreciate having a template to remind them to document thoroughly. Often the bullets have been done but not documented -- these templates help capture the key aspects of the service."
     
    Although some practices find it easier to give their physicians a pocket-size card to carry that outlines the required elements for each level of exam, Czyswski says this doesn't work for everyone. "We went through so many because the doctors never kept the cards with them, so it's just easier for us to keep a copy in the charts."

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