Primary Care Coding Alert

CPT outlines the three key components for choosing an E/M levelhistory, examination and medical decision-makingof outpatient visits for both new and established patients. But there are many factors that affect each of the three components and can drive a code to a higher or lower level and cause confusion.

Note: Although this article focuses on evaluation and management (E/M) codes for outpatient visits by established patients99211-99215 (office or other outpatient visit for the evaluation and management of an established patient)most of the same considerations apply to new patients. The major difference is that all three key components must be satisfied for new patients while only two of the three are necessary for established ones.

Cindy DeVries, RN, CPC, coding and reimbursement coordinator for Lee Physician Group, a 140-provider, multi-specialty practice in Fort Myers, Fla., says concerns about overcharging patients and confusion about E/M codes cause undercoding. Its the financial impact of a higher code that may cause an FP to choose a lower level of service, she says.

Some FPs undercode because they know the price will suit the patient, but you have to be careful, warns Terry Fletcher, CPC, CCS-P, a healthcare coding consultant with McVey Associates, a national specialty coding seminar company in Novato, Calif., because that is considered fraudulent billing. If Medicare continually sees undercoding, it may send up a red flag. Medicare, however, does not fine for undercoding, DeVries says.

Fletcher also believes that some family doctors dont realize when they have reached key levels of service. If you can document service, you shouldnt be afraid to code at a higher level, she adds.

Factors Affecting the Three Key Components

Follow these four rules when determining the appropriate level of outpatient visits for established patients:

Rule 1: For 99211 and 99212, there is usually a self-limited or minor problem, such as a cold (460, acute nasopharyngitis [common cold]) or insect bite (919.4, insect bite, nonvenomous, without mention of infection or 919.5, insect bite, nonvenomous, infected) that requires a brief history of present illness and a discussion of the chief complaint. The examination is limited to the affected body area or system. The number of diagnoses/manage-ment options (i.e., rest or gargling), number/complexity of data and risk of complicationsall elements of medical decision-makingare minimal, resulting in straightforward medical decision-making.

Code 99211 has no history, examination or medical decision-making associated with it. It simply represents a face-to-face encounter with a patient that may not require the presence of a physician and typically involves minimal presenting problem(s). That is why it is often referred to as a nurse visit.

Example 1: A mother brings in her nine-month-old baby girl with diaper rash. The visit simply requires a brief history, a limited exam and straightforward medical decision-making, such as prescribing an over-the-counter medication. The code should be 99212.

Rule 2: For 99213, the condition typically constitutes two or more self-limited or minor problems, one stable chronic illness such as well-controlled hypertension or an acute, uncomplicated illness or injury such as a simple ankle sprain (845.00-845.09). The history is expanded problem-focused, with a brief history of present illness revolving around the chief complaint and a review of body systems pertinent to the problem. Remember that history is comprised of the history of the present illness, review of body systems, and social and family history. The examination is usually limited to the affected body area/system and other symptomatic or related organ systems. The number of diagnoses/manage-ment options and amount/complexity of data is minimal, while risk is low, making medical decision-making one of low complexity.

Example 2: A 55-year-old woman with bronchitis is treated for an upper respiratory infection. Her condition is generally under control, so it is considered an acute, uncomplicated illness. The history is expanded problem-focused as the FP discusses the primary complaint and reviews the pertinent systemrespiratory. The examination is limited to the affected body system. She is treated with short-term antibiotics, but since she is given prescription drugs, and no additional workup is planned for the new problem, medical decision-making is of low complexity. The appropriate code is 99213.

Rule 3: Level four (99214) typically consists of one or more chronic illnesses with mild exacerbation, progression of side effect of treatment; two or more stable chronic illnesses; undiagnosed new problem with uncertain prognosis; acute illness with systemic symptoms; or acute complicated injury. The history is detailed with a discussion of the chief complaint, review of two to nine body systems, and pertinent past, family and social history. The examination is detailed, covering the affected body/system and other symptomatic or related organ systems, more extensively than the expanded problem focused examination associated with 99213. Finally, medical decision-making is of moderate complexity with multiple diagnoses/management options and moderate number/complexity of data and risk.

Example 3: A 75-year-old man has heart disease and diabetes and visits his FP to review his medications. The FP takes a detailed history because the patient has not visited in a year, but conducts only an expanded problem focused examination. On the other hand, the FP adjusts the patients insulin levels, increases his dose of Coumadin to thin his blood and prescribes antidepressants to decrease his anxiety over his conditions. The prescription drug management is associated with medical decision-making of moderate complexity. Fletcher says this could be coded as 99214 if documentation can support it; otherwise, stay at 99213, she says. FPs do a lot of prescribing and should remember that if they are modifying many existing ones or adding new drugs, decision-making may increase to moderate complexity and can drive up the level for outpatient visits, Fletcher says.

FPs fail to address and document risk factors such as age and forget to document minor procedures such as drawing blood (to gauge the Coumadin level). Test results can contribute to decision-making if the FP is taking the time to discuss lab results, she explains.

Rule 4: For 99215, there typically must be one or more chronic illnesses with severe exacerbation, progression of side effects from treatment; acute or chronic illnesses or injuries that pose a threat to life or bodily function; or abrupt change in neurologic status. The comprehensive history consists of the chief complaint, a complete review of at least 10 body systems and a complete past, family and social history. The examination covers a comprehensive single system or general multi-system review. The number of diagnoses/management options and number/complexity of data are extensive and the risk of complications is high, driving medical decision-making to one of high complexity. The highest level of outpatient service (99215) is harder to meet, DeVries says. Its not used too often and may signal a potential audit.

Example 4: Examples requiring 99215 include transient ischemic attacks (mini strokes) or a change in neurologic status; multiple trauma; psychiatric illness with potential threat to the patients or anothers well-being; and severe respiratory distress. For instance, an elderly established patient with diabetes and hypertension presents with a two-month history of increasing confusion, agitation and short-term memory loss. The FP takes a comprehensive history and does a comprehensive general multi-system examination targeting both the patients chronic conditions (i.e., diabetes and hypertension) as well as the new problemsconfusion, agitation and short-term memory loss. If documented, this would qualify for 99215, even if the medical decision-making turned out to be less than one of high complexity.

Time is also an important element contributing to the level of service. CPT states: When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or the outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. (See Time is Key Element in Getting Payment for Prolonged Service on page 18 of the March Family Practice Coding Alert.)

The five levels of outpatient visits have corresponding typical times, 5, 10, 15, 25 and 40 minutes, respectively, and by virtue of the time spent with a patient, the level of service may increase. DeVries recommends FPs make a guesstimate of time rather than use a stopwatch to calculate the exact amount. She also cautions family doctors not to rely too much on timed visits because they may raise a red flag with payers.