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 the ROS. In this section, the auditor is to check off one of five possibilities, Callaway says. One of the five is only the system related to the problem was examined as part of the ROS. This means that it can appear in the HPI and the ROS.

Conservative Approach Will Affect Reimbursement

While it seems to be a minor detail, Callaway says reporting an element in only one section can have a big effect on reimbursement. If a family physician can report the system only once, it might lower the code level that could be assigned. For instance, an extended HPI must include four or more elements. If you dont count one element because its also mentioned in the ROS, you might be left with only three elements in the HPI, which comprises only a brief HPI. This might make the difference between billing a 99214 and a 99213 (office or other outpatient visit, established).

Other coding experts recommend that physicians add detail to their chart notes to support counting a system twice. For instance, if they record lungs cough, duration of three days as the chief complaint in the HPI, they should expand that information in the ROS. An entry of lungs unproductive cough, no wheezing in the ROS may provide more information to justify the second reference.

Common Sense Negates Double-dipping

Besides indications in HCFAs auditing procedures, Callaway says common sense also supports a physicians counting these elements twice. Consider highly complex cases. If you took an opposing view and said elements could be counted only once, you might be assigning lower-level E/M codes for complicated cases. If a patient came in and four or more systems are documented in the HPI, for instance, you dont count them in the ROS. Coders should assign a more basic E/M service code.

For instance, an elderly patient is seen because of coughing, tightness in his chest, nasal congestion, severe headache and a skin rash. The HPI on this patient would include references to his lungs, heart, ENT, head and skin. If the physician could reference none of these systems during the ROS, the level of service might be lower even though the patient presented with multiple symptoms suggesting complex care.

Although most coding experts and Medicare carriers support this view, it is not universal, Callaway says. This issue has been challenged often and there has even been erroneous information printed in widely read publications. As a result, some local carriers have actually implemented policies disallowing family physicians to count elements in both the HPI and ROS even though its not supported by national policy. Coders should ask their Medicare medical directors which side of the issue they support.

Double-dipping Dangers Arise in Other Areas

The danger of double-dipping increases in a related area of E/M documentation. Hawkinson notes that physicians categorize elements within the HPI in terms of eight characteristics:

1) location
2) quality
3) severity
4) duration
5) timing
6) context
7) modifying factors
8) associated signs and symptoms

Physicians shouldnt use these descriptive words more than once to describe the same problem, Callaway points out. For instance, if the patient complains of a problem in the morning, after eating breakfast, the physician has to make a choice. He or she can use that description to fit timing the symptom occurs in the morning or context it occurs when the patient eats breakfast. But physicians cant use that characteristic in both. That practice would constitute double-dipping.