Practice Management Alert

Question: Our office sees a lot of patients with multiple comorbidities, and many of these patients have contracted COVID-19. Can we bill for a higher-level E/M service to reflect these more complicated encounters?

New York Subscriber

Answer: As with any office or outpatient evaluation and management (E/M) service, you’ll establish the level of service based on level of medical decision making (MDM) or total time spent on the date of the encounter. The trick is to not get distracted by outside knowledge of complications and comorbidities. Stick to what’s documented.

That’s not to say comorbidities won’t ever move a COVID-19 E/M encounter from low to moderate, or even to a high level of MDM. That will depend on whether your provider establishes a connection between a patient’s COVID infection and the patient’s known comorbidities. Remember that “comorbidities/ underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed,” per the CPT^® guidelines for Office or Other Outpatient E/M Services.

For example, if a patient has a history of COPD and asthma, coding J44.- (Other chronic obstructive pulmonary disease) or J45.- (Asthma) for the current encounter is not appropriate unless the provider’s notes for that visit clearly indicate the conditions’ relevance to the projected treatment course. Further, as noted above, don’t count those problems toward the level of MDM unless the provider “addressed” them. Per CPT^® guidelines, “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.” If a provider’s notes are unclear, request clarification.