Pulmonology Coding Alert

3 scenarios from our experts help you improve E/M skills

Before you report any E/M procedures, look for documentation details on the patient's presenting illness, because this will make or break your patient's complete history.

Look at these three frequently asked questions related to review of systems (ROS) to determine whether you know how to deal with the most common questions on applying a patient's complete history to select the most appropriate E/M code. Write down your responses before looking to the correct answers below. 

Editor's note: Questions and answers presented in this quiz were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Question 1: A new patient who is unable to communicate clearly and to explain her medical problems came in to see the pulmonologist in our practice. Her condition prevented the pulmonologist from obtaining a complete history of present illness (HPI) and ROS from her. Therefore, the pulmonologist could not develop a definite assessment or plan for her treatment.

The pulmonologist called the patient's two previous physicians to discuss her medical problems. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the pulmonologist spent a total of 90 minutes on this patient on the same day.

How should I charge for this scenario? Which E/M codes and modifiers should I use to justify the extra time that the pulmonologist spent on the phone with other physicians on this patient's behalf?

Question 2: Can we use nurses' notes to satisfy elements of ROS and past, family, social history (PFSH), as long as the physician documents his review of the notes?

Question 3: When a pulmonologist lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can I use this as the ROS?

Question 4: A grandmother brings her granddaughter into our practice because her granddaughter has had some wheezing and coughing after exercise. The grandmother says the child has been complaining of the symptoms for the past week. The pulmonologist documents "no history of asthma." But he also notes that the patient was in the hospital to have her appendix removed after a motor-vehicle accident two years before this visit, which he believes is unrelated to the injury. Should the pulmonologist consider the history documentation part of the physician's ROS or PFSH?





Answer 1: You should bill the scenario based on the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient).

Note: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the [...]