Pulmonology Coding Alert

HCFA Transmittal B-00-74 (Dec. 21, 2000) cleared the path to provide sanitized patient documentation to Aspen Systems Corp., which will use it to create vignettes for the draft 2000 evaluation and management (E/M) documentation guidelines. The carrier-provided patient scenarios will be reviewed and compared to what was billed to create the vignettes. Consequently, if pulmonologists are downcoding their E/M services, the vignettes will not represent the appropriate amount of work for each code.

Coders and physicians should view this as unfortunate in that it creates a set of checklists that could adversely affect patient care, says Walter J. ODonohue Jr., MD, FCCP, FACP, a representative to the AMA CPT Advisory Committee for the American College of Chest Physicians (ACCP) and CPT/RUC Committee chair of the ACCP. The checklist approach in E/M coding already causes significant coding issues and inconsistencies in carriers responses.

Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvanias department of medicine in Philadelphia, believes theres a tendency to undercode, which is typically the case as physicians want to avoid trouble with the government. Pulmonologists need to avoid downcoding by documenting their patient encounters to meet the most stringent requirements. Coders need to be certain of the details within the medical record documentation, especially when looking at the level-four codes (e.g., 99214).

Aspen will gather Medicare beneficiary claims and medical records from carriers including National Heritage Insurance Company (northern California, Massachusetts, Maine, New Hampshire and Vermont), Empire Medicare Services (New York and New Jersey), First Coast Services Options for Florida, TrailBlazer Health Enterprises (Texas, Delaware, the District of Columbia, Maryland and Virginia), Wisconsin Physicians Service (Wisconsin, Illinois and Michigan) and Noridian Government Services (Arkansas, Oregon, Washington, Iowa, Arizona, Colorado, Hawaii, Nevada, North Dakota, South Dakota and Wyoming).

Reviews will include examples based on specific E/M codes and physician specialties. Codes include:

99201-99215 (excluding 99211) office or other outpatient services
99221-99223 hospital inpatient services
99231-99233 subsequent hospital care
99241-99245 office or other outpatient consultations
99251-99255 initial inpatient consultations
99281-99285 emergency department services

Each E/M code from 99201-99215 specifies a definition for each of the three key components: one of four history types, one of four examination types and medical decision-making based on one of four complexity types. For example, 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 reviewing the medical record documentation, considering the Office of Inspector Generals stated intent to review this codes use for potential fraud and abuse.

Consider this scenario: A patient with chronic bronchitis comes in to the office with an acute exacerbation. The physician obtains a detailed history (an increased productive cough for the past two days accompanied by an increase in dyspnea on exertion; no fever/chills; no edema; patient has been taking bronchodilators with no sustained relief), performs a detailed exam (vital signs stable; no jugular venous distention; heart regular rate and rhythm; rhonchi and wheezes present bilaterally; positive accessory muscle use; no cyanosis; no pedal edema), and orders a chest x-ray, pulmonary function tests, as well as a complete blood count. The physician also increases the bronchodilator dose and begins nebulizer treatments (moderate risk to the patient). Because of the detailed history, detailed exam and moderate complexity of decision-making, this scenario would be coded 99214.

When determining the correct level of examination, HCFA guidelines vary, depending on the version you use. Currently, two sets of instructions, the 1995 or 1997 guidelines, provide instructions for determining the appropriate E/M service level. The 1997 guidelines are much more specific concerning the exam portion of E/M services. Remember that HCFA has instructed carriers to use whichever set of guidelines are more beneficial to the physician when performing an audit.

Determining the Level of History

E/M service levels depend on one of four types of his-tory (problem focused, expanded problem focused, detailed and comprehensive). Choosing the type of history depends on information the physician acquires during the patient encounter. The medical record documentation could include details documenting or referencing the chief complaint (CC), the history of present illness (HPI), a review of systems (ROS), and past, family and/or social history (PFSH).

To code for 99214, the recorded history must qualify as detailed. The current E/M guidelines define this as having an extended HPI, which would include notes covering the location of the presenting problem; the quality (sharp, dull, shooting), severity and length of time the problem has existed; the timing (how often, how long); the context (does it increase climbing stairs, near dogs); any modifying factors (after smoking); and any associated signs and symptoms (puffy eyes, shortness of breath, yellow skin color). Alternatively, a pulmonologist could note in the patients record elements such as a followup on a previously diagnosed problem, medication management and updates on chronic conditions.

The medical record needs to address at least four of the elements in HPI unless using the chronic condition alternative and must include an extended ROS that covers between two and nine of the recognized systems (e.g., constitutional symptoms, and such organ systems as cardiovascular, respiratory and allergic/immunologic). Extended reviews also might include reviewing and documenting the status of more than three chronic or inactive conditions.

A detailed history also must include a pertinent PFSH. This review covers the patients direct past experiences with the presenting problem, review of medical events in the patients family that might place the patient at risk, and a review of past and current activities. For a PFSH to be classified as pertinent, the medical record must include details concerning at least one specific item from any of the three history areas.

The medical record documentation also should include assessment, clinical impression or a diagnosis, along with a plan for care, and the date and verifiable legible identity of the healthcare professional providing the service.

An exception to the normal process of acquiring history exists for emergency care necessitating highly complex medical decision-making. If the physician is unable to obtain a history from the patient or other source, the record should describe the patients condition or other circumstance that precludes obtaining a history.

Showing a Detailed Examination

Code 99214 requires a detailed examination, defined by CPT as an extended examination of the affected body area(s) and other symptomatic or related organ system(s). HCFA redefines a detailed examination to include affected body area or organ system and additional systems (up to a total of seven systems), equals expanded problem focused exam or detailed exam based on [the auditors] judgment about the extent of the exam (per the 1995 guidelines).

These guidelines do not have any specific amount of information that must be recorded for a given level, as long as the particular number of body systems is addressed. This leaves a vague area when choosing between expanded problem-focused or detailed exams, Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North August, S.C., points out. Because of the vagueness, Callaway recommends you choose the detailed exam level only when the documentation contains detailed, specific information about at least one body area or organ system, and that all areas have more than just basic information.

HCFAs 1997 guidelines are more specific, referring to a designated list of exam elements required for a detailed examination, which should include at least two items in six organ systems or body areas or 12 items in at least two organ systems or body areas. It is important to note, however, that since the requirements for level of service state that only two of the three key components must be met to qualify for an established patient service, the amount of examination is not always crucial to the choice of code, Callaway stresses.

What Is Moderately Complex Decision-making?

The complexity of medical decision-making depends on the possible diagnoses and management options; the medical records, diagnostic tests and other information that must be analyzed; and the risk of significant complications, morbidity or mortality associated with the patients presenting problem, the diagnostic procedure and the possible management options. To qualify as a moderately complex medical decision, the values of two of these three categories must meet or exceed a classification of multiple, moderate, extensive or high.

The amount and complexity of data to be reviewed is based on the types of diagnostic tests ordered or reviewed. These diagnostic services should be documented specifically, including review of lab, radiology and/or other diagnostic tests. This can be noted as an entry in a progress note or by initialing and dating the report containing the test results.

Finally, the risk of significant complications, morbidity and/or mortality must be assessed and documented. The documentation guidelines state that the comorbidities/underlying diseases or other factors (e.g., the number and type of medications) that increase the complexity of medical decision-making by increasing the risk of complications, morbidity, and/or mortality should be documented. Surgical or invasive diagnostic procedures ordered, planned, scheduled or performed during the E/M encounter should be documented as well.

With these E/M guidelines undergoing continuing revision draft E/M guidelines are posted on the HCFA Web site (www.hcfa.gov) its difficult for coders, physicians, etc., to keep up, notes Pohlig. Pulmonologists should scrutinize their documentation to meet the most stringent requirements. And coders need to be certain of the details in the medical record documentation, especially when looking at the 99214 requirements.