Pulmonology Coding Alert

Between 15 percent and 25 percent of the evaluation and management (E/M) charges submitted by pulmonologists should be coded as a 99214, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. These charges represent significant costs and HCFA has announced its intent to focus its audits in this area. E/M code 99214 has become a big issue within the last year, explains Callaway. Because of such close scrutiny and the confusion regarding which set of guidelines to use to determine the level of service (HCFA has issued two versions already and has a proposed third version available for review), pulmonology coders need to be especially aware of the codes reporting requirements to avoid unnecessary claims rejections and audits.

The AMA reports that nearly one-third of all services rendered by physicians fall under the E/M code grouping. E/M services are coded according to the content of the service provided and depend on the details found within the medical record documentation. Payers require reasonable documentation that the services provided are covered by their policies. For that reason, the payer can request documentation verifying the site of service, the medical necessity and appropriateness of the diagnostic or therapeutic services provided; or that services provided have been accurately reported.

Use E/M codes 99201-99215 to report evaluation and management services provided in the physicians office or in an outpatient or other ambulatory facility. Coders should use 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) only after carefully considering the medical record documentation.

Documenting E/M Services

CPT offers documentation guidelines for the three key components that make up the general content of the medical record documentation. The three key components include determining a patients history, providing and describing a patient examination, and providing a medical decision based on the complexity of the problems identified in the history and examination, the amount of data reviewed and risk to the patient. These components are key because they most often determine the appropriate E/M service level (e.g., 99214).

Additionally, four other factors affect E/M code selection. Three of these factors (counseling, coordination of care and the nature of the presenting problem) are considered contributory. The final component used to define E/M services is time, but only when more than 50 percent of the face-to-face patient encounter involves counseling or coordination of care.

Although CPT does not require a specific format for documenting the components of an E/M service, each patient encounter should include the chief complaint (CC) and/or reason for the encounter, relevant [...]