Primary Care Coding Alert

Use medically necessary history, exam in E/M code selection If you select 99215 when your physician performs a comprehensive history and examination, medical necessity must justify these component levels - otherwise, you could be gaming the system. Medical Necessity Should Drive History When determining a visit's history, the type of history - problem-focused, expanded problem-focused, detailed, comprehensive - that the family physician (FP) claims must be medically necessary based on the encounter. "The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s)," states CPT's E/M guidelines section, "Instructions for Selecting a Level of E/M Service" (page 3 - Ingenix 2005 Expert).

Even though a nurse may take the information necessary to support a comprehensive history, the physician's clinical judgment and the patient's problem should determine the amount necessary. "Coding too many 99214s and 99215s could trigger an audit, especially if these codes are associated with one minor diagnosis," says William H. Ward, MD, IAFP, associate director of St. Francis Family Practice Residency Program in Beech Grove, Ind.

Example: An FP sees an otherwise healthy established patient for an earache. In this scenario, no medical need exists to collect a comprehensive history for a routine earache, says Daniel S. Fick, MD, director of risk management and compliance at the University of Iowa in Iowa City. 

In fact, coding a comprehensive history for such a simple problem could prove unethical, even if your staff has gathered more history than necessary. "Payers and auditors may view such conduct as 'gaming the system' - obtaining a higher-level component than medically necessary just to charge a higher-level E/M service," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, N.J.

Best practice: "FPs should obtain and document the medically necessary history and use that in their coding," Fick says. The physician should "not just code for everything he or she can collect."

Exam's Extent Hinges on Problem You also have to consider medical necessity when determining the E/M service's exam type. CPT's instructions on selecting the exam type echo its history component guidelines. "The extent of the examination performed is dependent on clinical judgment and on   the nature of the presenting problem(s)," states CPT's E/M guidelines.

Translation: A physician's decision to perform a comprehensive exam should stem from the patient's problem(s). Simple problems don't warrant this component level or the physician's time.

Example: An FP evaluates an established patient with a common cold (460, Acute nasopharyngitis [common cold]) and no comorbidities. "Even if the FP performs and documents a comprehensive exam, no one would claim it was medically necessary," says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in [...]