Primary Care Coding Alert

Because documentation for E/M services is so closely scrutinized, family practice coders are understandably cautious about making sure the patient record supports the level of service reported. Unfortunately, this caution may result in diminished payment if coders become too conservative.

Downcoding is particularly prevalent, many experts say, when coders spot multiple references to an organ system and assume it cannot be counted twice.

Consequently, a lesser-paying code is billed by the practice.

This has been a particularly hot issue over the past few years when coders are faced with counting an organ system in both the history of present illness (HPI) and review of systems (ROS), notes Susan Callaway, CPC, CCSP, an independent coding consultant and educator in North Augusta, S.C. Both of these items are components of the history-taking element.

For example, a patient with symptoms indicating an upper respiratory infection, schedules an appointment with her family physician. During the HPI, the physician notes nasal congestion and he lists ears, nose and throat as one of the systems examined during the ROS.

Documenting Organ Systems

Some coders maintain that to count both HPI and ROS references would be double dipping a practice that might trigger a Medicare audit. But this isnt the case, according to Curt Hawkinson, PA-C, who practices with The Doctors Clinic in Salem, Ore. The Medicare guidelines for an E/M service note that the HPI covers the development of those symptoms that caused the patient to come into the office. On the other hand, the ROS is defined as an inventory of body systems, conducted in order to identify additional signs and/or symptoms that the patient may be experiencing or has experienced.

For instance, he says, the HPI of a patient with chest pains will note that the symptoms are localized at the front of the chest, have been occurring for the past five days and increase during physical activity. On the other hand, the ROS will provide more clinical information, like the presence or lack of shortness of breath, and whether the patient has dizzy spells as well.

Callaway also notes that the HCFA Documentation Audit Form, the form used by Medicare auditors, supports a practices right to count a system in both the HPI and the ROS. Its pretty clear that it can be counted twice, especially on the HCFA form, which is the tool Medicare uses to review a practices documentation and how it supports the level of services reported.

The form, she explains, prompts the auditor to review the chart notes and indicate on a checklist which systems were reviewed in the HPI or the ROS. Additionally, a subsequent section on the form asks the auditor to note specific systems examined in [...]