Urology Coding Alert

If your physician is stuck in a coding rut, give him the tools to get on track

Do you have one urologist on staff who reports level- four E/M codes for every visit? If you thought your practice was immune to this type of error, your self-audit might uncover problems you didn’t know you had.
 
If you code the charts of several physicians at the same practice, it may be difficult to notice trends in the urologists’ coding habits.
 
For instance, one physician might code every visit as a CPT 99214 , but because her charts are mixed in with other physicians’ in the practice, you don’t notice the pattern because you never code a stack of her charts at the same time. In addition, because many practices now have their urologists do their own E/M coding, you may have never reviewed an E/M chart to check on its accuracy.

E/M Coding Inaccuracies Can Be Costly

Your self-audit can bring this sort of problem into the light, and coders tell us that it’s their physicians’ number- one coding error.
 
“One of our urologists codes everything as 99214 (office visit) or 99244 (consultation) because he says that every patient he sees has a presenting problem of moderate to high severity,” one subscriber tells Urology Coding Alert. “He pointed out the notation in CPT Codes that states that 99214 and 99244 represent ‘presenting problems of moderate to high severity’ to show me that he’s correct in always billing those codes. The problem is, he doesn’t meet the other criteria of the codes,” she says.

Remind Your Physicians How to Choose a Level

Nationwide audit statistics show that physicians bill the appropriate E/M level to Medicare only 20 percent of the time, says Stephen Levinson, MD, author of the AMA’s Practical E/M: Documentation and Coding Solutions for Quality Patient Care.
 
If you find E/M coding problems in your chart review, you should remind your physicians how to select the correct level. First, reinforce to the physicians that the nature of the presenting problem will set the initial level of care that is warranted, Levinson says.
 
“After taking the patient’s history of present illness, previous medical history, social history, family history, and review of systems (including updates of PFSH and ROS for established patients), the physician should have a pretty good idea with what level of illness they’re dealing with,” Levinson says. “At that point, the physician should do the exam and medical decision-making that meet the level that’s warranted for that illness severity, based on the patient’s history.”

Complexity, MDM Vary With Each Patient

If you find that one of your urologists miscodes his E/M visits, remind him that even if he always sees the same diagnoses (which is unlikely), the complexity of the visit and the medical decision-making will vary from one patient to the next.
 
“Not every patient with a bladder infection will be a level four, just because the physician is a specialist,” says Stephanie Ellis, RN, CPC, of Ellis Medical Consulting Inc. in Brentwood, Tenn.
 
For instance, a 25-year-old female with a bladder infection and no other medical problems might qualify only as a level-two office visit (99212) because the physician only performed a problem-focused history and exam, and straightforward medical decision-making,
Ellis says.
 
However, suppose the physician sees a 22-year-old patient with a bladder infection, and the patient has a neurogenic bladder due to a spinal cord injury. The patient has already been on three rounds of antibiotics and it is not improving.
 
Although this patient also has a bladder infection, the coding changes from our previous example above. “This patient may qualify for a level-four or maybe even a level-five visit, depending on the number of treatment options, the tests ordered, the medications ordered, etc.,” Ellis says.
 
“The fact that the physician is a specialist does not determine the level of complexity,” she says. “If physicians chronically upcode their office visits, they can be charged with fraud at the worst, or owe a great deal of money to Medicare, BC/BS and other payers at the least. It is a very serious concern.”

Watch Out for Pitfalls

Although the nature of the presenting problem and the complexity of medical decision-making should drive the E/M level, some physicians fall short on documentation, leaving the coder stuck with reporting an E/M code that’s actually lower than the service that the physician performed.
 
“Billing a lower E/M code than what you performed can appear even more damaging than upcoding,” Levinson says. “It gives the impression that the physician provided poor quality of care, and the E/M structure was actually developed so doctors could reflect the appropriate level of care for each patient’s needs.”
 
But coders can only choose a code that’s as good as the physician’s documentation. So even if your urologist is seeing highly complex diagnoses, his exam might not be comprehensive enough to qualify for the level-four code.

Problem-Focused Exam May Lead to Level-2 Consult

“Subspecialists often see sicker patients, but they still may not conduct adequate exams because the visits can be very problem-focused,” says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
You can’t report 99244 (a level-four consult), for example, without a comprehensive exam, Cobuzzi says. “You need a detailed exam even for a level-three consult, so if the physician performs a problem-focused exam, you’re locked into 99241 and 99242 (expanded problem-focused exam), even if medical necessity, medical decision-making and history support level four.”
 
Problem: Often, the physician may perform a more comprehensive examination but doesn’t document it because the patient presents for a specific urological problem. “In these cases, if the physician is checking out things not in his area of subspecialty, there is a chance that he might not dictate that at all,” Cobuzzi says.
 
Solution: Remind the physician that he should document every area that he examines, not just the areas that are anatomically close to the presenting-problem area.
 
“My philosophy is, to perform good medical care, you have to do a comprehensive history to find out what is going on with that patient,” Cobuzzi says. “Once you find the nature of the presenting problem, that will drive the level of exam and medical decision-making and, thus, the E/M level.”