Pulmonology Coding Alert

These 3 scenarios will help improve your E/M skills.

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

Check out the following three frequently asked questions to determine your review-of-systems (ROS) savvy, then determine your coding tactics before reading the correct answers below.

Question 1: A new patient who is unable to speak English and fully explain her medical problems presents to your pulmonologist. The patient's inability to communicate and lack of a translator prevents your physician from obtaining a complete history of present illness (HPI) and ROS. Your pulmonologist treats the patient but cannot develop a definite plan for her treatment.

After the visit, the pulmonologist calls the patient's previous physician to discuss her medical problems and discovers that she also has diabetes and asthma. Including face-to-face patient time (45 minutes) and telephone calls to other providers (45 minutes), your physician spends a total of 90 minutes on this patient during the same day.

How should you charge for this scenario? Which E/M codes and modifiers should you use to justify the extra time your physician spent on the phone?

Answer 1: You should select the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) based on the information your physician obtained from the patient and her previous physician.

Time it: If you want to bill based on time, the pulmonologist must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Warning: In most cases, you cannot bill based on time if the pulmonologist states that a communication barrier extended the face-to-face time with the patient because the time did not involve counseling or coordination of care. The pulmonologist may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. He may receive "comprehensive" credit for the "unattainable" history.

If your physician documents service time when the patient is not physically present (such as the post-exam call to the other physician), you cannot report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Most payers consider both telephone calls and charting time part of the pre- and post-service work already included in payment for the E/M service. If you submit a charge for this extra time to a payer that does not cover the service, the carrier might hold the patient responsible for the fee.

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

Answer 2: As long as the pulmonologist initials and dates the nurse's notes or documents in the progress note that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator in Beeghly Medical Park in Ohio. "I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes," she says.

Use ROS and PFSH, along with the physician-documented HPI, to decide the level of information the physician gathered about the patient's history.

The ROS is basically an inventory of the body symptoms so the physician knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional, ears/nose/throat/mouth, endocrine, eye, gastrointestinal, genitorurinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

Tally systems: For a problem-pertinent ROS, the physician reviews a single system that correlates to the guidelines of E/M codes 99202 (... which requires these 3 key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision making ...). An extended ROS requires review of two to nine systems and is associated with a detailed history as in 99203 (... a detailed history; a detailed examination; medical decision making of low complexity ...). A complete ROS requires review of 10 systems and is required for services with comprehensive histories: 99204 (... a comprehensive history; a comprehensive exam; medical decision making of moderate complexity ...) and 99205 (... a comprehensive history; a comprehensive exam; medical decision making of high complexity...).

A "pertinent" PFSH consists of a comment in any one of the histories -- information about the patient's past health history, family history, or social history -- and helps you on your way to a 99203. For a "complete" PFSH, the doctor must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205, depending on the extent of your physician's medical decision making.

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

Answer 3: CPT guidelines state that past medical history indicates a patient's previous experiences with an illness or injury. By contrast, an ROS is an inventory of questions based on the history of the patient's current medical status. For example, a pulmonologist might perform an extended system review. In addition to the respiratory system, he notes that the patient has hypertension (PMH) and documents the absence of chest pain (ROS).

The answers to the ROS questions may determine the type and extent of the exam your physician conducts. Encourage your physicians to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.

Therefore, if your physician does not document information about the patient's current symptoms, but only mentions the patient's history, you will not be able to count that information in your ROS tally.