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Pulmonology Coding Alert

The $55 Question:

Are You Downcoding E/Ms?

Published on Mon Feb 23, 2004

When pulmonology coders don't know how to calculate a patient's risk level, they could be undervaluing the physician's medical decision-making and downcoding E/M visits -- and getting paid $40 a visit, instead of $55.

Experts warn: Pulmonology coders often misinterpret the level of risk associated with the physician's plan of care, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. Coders may assume that the physician must meet the criteria for all three categories of risk: presenting problem, procedure(s) ordered, and management option(s) selected. But a single bulleted item, and the item's position in the table, determines the level of risk, she adds.
 
Solution: Get a Grip on Medicare Guidelines
 
You should follow Medicare's Table of Risk to select the patient's correct risk of complications. The table has three risk categories:

  •  The patient's disease
  •  The pulmonologist's tests and procedures
  •  The physician's general management of the disease. 
     
    The table has four levels of risk: minimal, low, moderate and high, says Darcy Crabb, a patient account representative for Pulmonary Associates in Sioux City, Iowa. Review the following levels and examples of conditions and treatments that meet Medicare requirements.

    1. Minimal -- Your pulmonologist treats a minor problem, such as a cold, Crabb says. As for diagnostic procedures that meet the "minimal" criteria, they include laboratory tests requiring venipuncture, x-rays, urinalysis, or ultrasounds. Management options include rest and simple bandages.

    2. Low -- Typically, the patient presents with two or more minor problems, one stable chronic illness, or an acute uncomplicated illness. Diagnostic procedures include superficial needle biopsies, laboratory tests requiring arterial puncture, non-cardiovascular imaging studies such as barium enema, and physiologic tests not under stress. Management options include over-the-counter drugs and minor surgery with no risk factors.

    3. Moderate -- The physician treats one or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms, or an acute complicated injury. For instance, a patient may present with asthma with exacerbation (493.22) and hypertension (401.x). In this level, diagnostic procedures include physiologic tests under stress, diagnostic endoscopies with no risk factors, deep needle or incisional biopsy, cardiovascular imaging studies with contrast and no risk factors, and obtaining fluid from the body.

    Management options include minor surgery with identified risk factors, elective major surgery with no risk factors, and prescription-drug management.

    4. High -- The patient has one or more chronic illnesses with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status. Diagnostic procedures include imaging studies with contrast and identified risk factors, and cardiac electrophysiological tests. Management options include elective major surgery with risk factors, emergency major surgery, and drug therapy requiring intensive monitoring for toxicity.
     
    Report 99213 With Higher Risk Levels
     
    When you are selecting a risk level, you should make your decision based on the highest criteria the physician has met.

    Try this: A patient presents with a low-level risk under the Table of Risk's "Presenting Problem(s)" category, such as allergic rhinitis (477.9, Allergic rhinitis; cause unspecified). The pulmonologist orders x-rays, which is a minimal level of risk under "Diagnostic Procedure(s) Ordered." But then the physician selects a moderate risk level of "Management Options," such as prescribing antibiotics.

    In any case, a higher level of risk may affect the medical decision-making complexity and change the E/M code you report.

    Example: If you undervalued the physician's management options (prescribing antibiotics), you may have determined that the visit had a low risk and reported E/M code 99212, which pays $40. But with the visit having a moderate risk, you may be able to report a higher-level code, such as 99213, which pays $55.

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