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: [...]