Primary Care Coding Alert

Follow 1997 guidelines when counting elements, and ethically bump pay approximately $33.

The next time your FP sees a patient with a long list of chronic -- but stable -- problems, use this 3-step process to guide your coding -- and start recouping deserved revenue for these chronic condition visits.

Step 1: Choose Your Documentation Guidelines

In the past, you needed to think of the 1997 E/M documentation guidelines when your physician treated chronic conditions. The 1997 guidelines count recording the status of three or more chronic conditions as an extended history of present illness (HPI), which is one element of either a detailed or comprehensive history. By inference, the 1997 guidelines count documentation of the status of one or two chronic conditions as a brief HPI, which is one element of a problemfocused or expanded problem-focused history.

Now, however, you can code chronic conditions based on the 1995 guidelines instead, if that's your preference. "CMS has recently clarified that the status of three or more chronic conditions apply with both the '95 and '97 documentation guidelines," says Penny Osmon, BA, CHC, CPC, CPCI, PCS, director of educational strategies for Wisconsin Medical Society in Madison.

"I only use the '97 guidelines when I educate and audit my providers," says Jamie Kurrasch, CPC, with Primary Care Partners, PC in Junction City, Colo. "I like the structure of the '97 guidelines and feel they're more black and white, whereas the '95 are more vague. However, that very reasoning is why some prefer the '95 over the '97 guidelines."

Step 2: Peel Back the Layers of Documentation

Every detail the physician includes in his notes can potentially add to your HPI count.

Scenario: The FP sees a patient for follow-up of medical problems. In the HPI, he notes, "63-year-old female with hypertension. Blood pressure has been controlled. Denies headaches. Her back pain is stable, but she still has minor tingling after sitting for long periods. Her osteoporosis is now stable. Recent bone density test showed no further deterioration."

Under information regarding the patient assessment and plan, the physician documents the conditions' status as:

• Hypertension, stable, continue meds
• Back pain, stable, continue meds
• Osteoporosis, stable, continue meds.

Notes under past medical, family, and social history (PFSH) indicate that the patient is not exercising. Once you check the physician's documentation in each area of the chart, you're ready to count elements to the correct E/M level.

Step 3: Add Elements for Correct E/M

When coding for the patient visit above, you should consider elements in each of three principle areas.

History: The patient's HPI includes the status of three chronic conditions: hypertension, back pain, and osteoporosis. This supports an extended HPI. The scenario further suggests that the physician addressed elements of the ROS (Review of systems) related to the, cardiovascular ("Blood pressure has been controlled."), neurological ("Denies headaches."), and musculoskeletal ("Her back pain is stable, but she still has minor tingling . . . ) systems. Documenting three systems counts as an extended ROS. Finally, the notation about the patient's lack of exercise counts as a pertinent PFSH.

An extended HPI, plus an extended ROS, plus a pertinent PFSH equals a detailed history (when following either the 1995 or 1997 guidelines).

Decision: Under medical decision making (MDM), you have three stable problems (hypertension, back pain, and  osteoporosis), which earns three points for diagnosis and management options under most scoring systems. You also have review of a radiology test (the bone density test results), which is one point for amount and complexity of data reviewed. The three chronic conditions and prescription drug management point to a moderate level of risk. Considering all these factors gives you multiple diagnoses, moderate risk, and minimal data, which supports moderate complexity MDM.

A moderate complexity level MDM combined with a detailed history supports a level-four established patient visit, which requires 2 of the following 3 key components: detailed history; detailed examination; and MDM of moderate complexity. You should thus select an upper-level E/M code such as 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) for the encounter.

Comparison: Based on the 2011 national Medicare conversion factor of 33.9764, physicians can expect reimbursement of approximately $102.27 for code 99214 in a non-facility setting.

That's a big boost to your physician's bottom line, compared to the national average reimbursement of $68.97 for code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity).

If the family physician sees four patients per month whose visits merit 99214 instead of 99213, that garners almost $135 more for your practice. Add that over a year's time, and your physician could be looking at almost $1,600 dollars more in payments.