Eli's Rehab Report

Question: We had a new patient come in suspecting that he was suffering from carpal tunnel syndrome. During the evaluation, the physiatrist discovered that the patient had very high blood pressure. Most of the visit was spent trying to determine the cause of the high blood pressure, and the physiatrist wanted to code it as a level-four E/M visit. But to bill a level-four visit, HCFA states that the doctor must review at least four history of present illness (HPI) categories, and when talking about blood pressure, only one category was reviewed (plus one additional category for the patients carpal tunnel syndrome). This lowers the visit to a level two. Is there any way we can boost the level?

Arkansas Subscriber

Answer: If you havent met the criteria to bill a 99204 (office or other outpatient visit for the evaluation and management of a new patient, which requires a comprehensive history and examination, and moderate medical decision making), and it sounds as if you havent, you cannot bill the code based on your documentation, and you should refer to the more appropriate code (probably 99202 or 99203, depending on your documentation). There are circumstances under which you can code by time rather than by the three key elements (HPI, exam and medical decision-making). If the physiatrist documented that the time spent counseling and coordinating the patients care comprised more than half of the session, you can code according to the amount of time the physiatrist spent coordinating care or counseling.

For example, if the visit only warrants a 99202, but the physiatrist spent 30 minutes with the patient, 20 minutes of which involved counseling or coordinating care, the visit could be coded as 99203 because the 99203 definition reads, Physicians typically spend 30 minutes face-to-face time with the patient and/or family. The extent of counseling or coordination of care must be documented in the patients medical record. For example, you document the visit as you normally would, but you add, discussed the patients diet and exercise routine. Talked at length about his stress level at work and advised him on ways to reduce his blood pressure. Dis-cussed these issues with the patient for 20 minutes of 30-minute visit.