Primary Care Coding Alert

Once you’ve read over the chart and coded it, compare your answers with the ones provided below:

Assessments: “Everything in the note indicates that the patient has been previously seen for all his conditions. So, I would not note any new conditions,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

“But I would document K21.9 [Gastro-esophageal reflux disease without esophagitis] for the GERD, as this visit is a follow-up to that condition,” Johnson continues. “I would also report E78.5 [Hyperlipidemia, unspecified] and R73.03 [Prediabetes] to reflect the patient’s past medical history that is still current and potentially relevant to the present visit. Lastly, I would note R10.9 [Unspecified abdominal pain] to reflect the final diagnosis on the chart and support the order for an abdominal ultrasound, and R12 [Heartburn] as another symptom that prompted the visit, which is reflected in the HIP.”

E/M Level — History

HPI: “I would document the chief complaint [CC] along with a four-element history of present illness [HPI] based on abdominal as the location; nausea, vomiting, and heartburn as associated signs and symptoms; ‘comes and goes’ as timing or duration; and ‘8/9’ as severity,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. This would qualify as an extended HPI.

ROS: Both experts document three elements for the system review (ROS): “the back and shoulder pain would count for musculoskeletal, while the notation that the patient ‘has no problem voiding, but appetite is poor’ would count for genitourinary and constitutional, respectively,” Holle observes. As the patient also complained of heartburn and stomach pain, the provider may well have inquired about the patient’s gastrointestinal system, adding a fourth element. However, the ROS you would document would be extended, regardless of whether you counted three or four elements.

PFSH: The note records all three components of the patient’s past medical, family, and social history (PFSH).

Per CPT^®, the note records an extended HPI, a “problem-pertinent system review with a review of a limited number of additional systems,” which qualifies as an extended ROS under the E/M documentation guidelines, and a complete PFSH “directly related to the patient’s problems.” These elements level to a detailed history.

Exam

Both experts agree that the provider’s notes indicate a brief organ system exam that encompassed the patient’s constitution, cardiovascular, respiratory, psychiatric, and gastrointestinal. But such is the nature of E/M levelling that Holle regards the exam component as expanded problem-focused, while Johnson maintains it is detailed.

Medical Decision Making (MDM)

Again, our experts have a slight difference of opinion over the level of MDM. Under the Marshfield system (which we discussed in Primary Care Coding Alert volume 20 number 8), both would score three points for the diagnosis and treatment options based on the patient’s established, stable problems (the abdominal pain, the hyperlipidemia, and prediabetes). Both would also score two points for the data review based on the provider’s order for the ultrasound and labs.

But Holle and Johnson disagree over the level of risk involved in the encounter, with Johnson regarding the patient’s presenting problems as low risk (a stable, chronic illness) and Holle regarding them as moderate, “because the presenting problem is chronic with a mild exacerbation.” This leads Johnson to view the risk and corresponding MDM as low complexity, while Holle sees them as moderate.

Putting It All Together

Despite their disagreements, our experts both levelled the encounter the same way. That’s because the patient is established, so only two out of the three elements (history, exam, and MDM) need to count to determine the level of service. In other words, each expert discarded the lowest element in their analysis (in Johnson’s case, the level of MDM; in Holle’s, the expanded problem-focused exam) to arrive at a level of 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …).

A Final Piece of Advice

However you code this or any chart, you should keep these words in mind: “Remember to stick to the facts and what is documented to keep your coding compliant and out of the sticky grey areas,” Johnson advises. “Use unclear documentation as a point of conversation with your physicians to help improve clarity and documentation for future records. Communication and sticking to the facts are the keys to success.”