Pulmonology Coding Alert

Question: My physician bills his E/M services using the 1997 Documentation Guidelines. As a certified coder, I have found that his services could be reported at a higher level if he used the 1995 Documentation Guidelines. Which ones may he use, and with which ones will he be audited?

Colorado Subscriber

Answer: The physician has the option to use either the 1995 or the 1997 guidelines. Most physicians, however, find the 1995 guidelines easier to use. CMS has an initiative to update the guidelines that will be field-tested, but the agency has not yet begun the project. As for the documentation review, CMS has instructed all carriers to audit the physician using the 1995 or 1997 guidelines, whichever benefits the physician the most.

The exam is the most significant difference between the two sets of guidelines. The 1997 guidelines include a pulmonology-specific exam. Although some physicians believe that this is more beneficial for their practice, most do not. The 1997 guidelines include specific exam elements that must be addressed in the documentation. If a physician addresses elements other than those specified in the guidelines, the physician will not necessarily receive "credit" for that element in the level of service. Also, if the language pertaining to an exam element included in the documentation differs from the language included in the guidelines, an auditor who has not had much clinical experience may exclude the element from being credited in the level of service.

The 1995 guidelines are much less restrictive. They allow the physician to make any comment in any of the designated body areas and/or organ systems. What the physician examines within the areas and systems and the wording he or she chooses to document are ultimately decided by the physician.

The answers to Reader Questions and You Be the Coder were provided by Carol Pohlig, BSN, RN, CPC, at the University of Pennsylvania department of medicine in Philadelphia; Anthony M. Marinelli, MD, FCCP, chairman of the American Thoracic Society's Clinical Practice Committee; and Mary Mulholland, RN, BSN, CPC, a senior coding and education specialist for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.