Pulmonology Coding Alert

Question: Our pulmonologist recently saw an established pneumonia patient.

Her office visit note says:

CC: Resolving pneumonia.
Pt here today for recheck. Pt diagnosed with pneumonia 11/09. Last CXR 12/7/15 showed minimal infiltrate in rt lower lobe. No coughing, SOB. Lungs: Clear to auscultation.
Resolving pneumonia. Patient has finished medication. Repeat CXR.
What level of E/M should I submit? Is 99213 appropriate with pneumonia being a serious diagnosis?

Missouri Subscriber

Answer: No. Based on the limited information, the note does not describe 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity…). Rather, you would be better off billing 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…). You have a problem-focused exam and straightforward medical decision making (MDM). Depending on how you count the phrase “no coughing, SOB,” you could have a problem-focused history or an expanded problem-focused history. Either type ultimately does not change the E/M selection. Although the case involves pneumonia, the condition is resolving and does not require as much history, examination, and MDM. Treatment for the same condition may involve different levels of care, depending on the work involved in the encounter -- and where in the treatment phase (initial work-up, worsening, resolving, etc.) the patient is. Breaking down the documentation’s components:

You could count “no coughing” and “no shortness of breath (SOB)” as associated signs and symptoms under history of present illness (HPI). Some auditors might instead give credit for reviewing the respiratory system, giving the pulmonologist a problem-pertinent review of systems (ROS) (1 system: respiratory -- no coughing, shortness of breath). If you instead put the phrase under HPI, you have an extended HPI) (4 elements: duration -- since 11/09; severity -- minimal; location -- right lower lobe; associated signs and symptoms -- no coughing, no SOB). You have no past medical, family, and social history (PFSH). Using the phrase under ROS, rather than HPI, gives you an expanded problem-focused history (extended HPI, problem-pertinent ROS, and no PFSH).

You could argue that the history is problem-focused (extended HPI, no ROS, no PFSH). The documentation supports a problem-focused exam: 1 organ system examined (respiratory).

You have straightforward medical decision making (MDM), which Medicare considers the overarching driver for code selection. A recheck of a known problem that’s resolving gives you one point under Number of Diagnoses or Treatment Options (ND/TO). You have one point for amount and/or complexity of data to be reviewed for review of chest x-ray. The chest x-ray order gives you a minimal risk level. 1 ND/TO + 1 data + low risk (Acute uncomplicated illness or injury, since the pneumonia has not completely resolved) = straightforward MDM.