Urology Coding Alert

Many urology visits that should score a level-four or -five E/M code are reported as level three or four, a problem that can often be traced back to mis-interpretations of the history documentation.

To move efficiently through the history of present illness (HPI) documentation of your E/M claims, you should know what elements you're looking for and the many ways physicians can document them.

The faster and more accurately you can find these elements, the more money you save, because an insufficient HPI can be a "very expensive problem," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

Here's a short review of the HPI elements, and tips on how to detect them and when to count them toward the history level:

1. Location is the place on the patient's body where the patient is experiencing signs and symptoms. Remember, location doesn't mean the place where the patient was when the injury occurred, but an anatomic geographic description, Thomas says. For example, "left flank pain" in the chart indicates location, but "while at work" doesn't.

2. Context means what the patient was doing when he or she experienced signs and symptoms. If a patient has an elevated PSA determination obtained shortly after a long bike ride, "after a long bike ride" serves as the context. Another example of context from a chart might be "occurred at work" or "while sitting down," Thomas says.

3. Quality describes the chief complaint or sign or symptoms. "We're looking for an adjective," Thomas says. So if the patient has a throbbing headache, "throbbing" indicates the quality. Other quality adjectives for this problem include "pounding," "shooting," "crushing" and "stabbing," he adds.

4. Timing is when the patient experiences the signs and symptoms. If the chart reads "nausea/vomiting in the morning," "in the morning" is your timing, Thomas says. Don't confuse timing and duration, he warns. Timing locates the time of day the problem occurred, and duration describes how long the patient has felt symptoms. If a patient comes into the office and says, "I've been short of breath since the morning," that statement actually describes duration because the statement reports a time period that hasn't ended. "In the morning" designates an exact time period that is over.

5. Severity describes how bad the patient's problem is. In the physician's history documentation, you will commonly see the severity reported on a scale of 1 to 10 that rates pain, Thomas says. On a handwritten chart, you might see a fraction like "7/10," he explains. Urological examples of severity of the problem or pathology include renal colic reported as very severe, 10/10, a PSA determination of 65 and a scrotal mass of 5 cm.

6. Duration is the time duration of the patient's signs and symptoms (explained above under "Timing"). An example of duration is when a patient reports, "I've been vomiting for the last two hours." "The last two hours" is the duration, Thomas says.

7. Modifying factors are the things the patient has done to alleviate the pain from signs or symptoms or the things that make the symptoms worse. For example, if a patient says that she has increased frequency with alcoholic intake, this represents a modifying factor. The physician's notes "relieved by" or "exacerbated by" will help you locate these factors, he says. The charts may also explain treatment prior to arrival, for example, "Patient has taken Tylenol for fever."

8. Signs and symptoms are any problem(s) in addition to the chief complaint that the patient complains of or denies. The chart might read, "Patient complains of urinary frequency, also some burning." Chest pain would be the chief complaint, and shortness of breath would be an associated sign or symptom, Thomas says. Remember to include documentation that discloses when a sign or symptom is not present. "We are not looking at the chart from a clinical mind-set," Thomas says. "We're trying to assign a value to the physician's effort," so the physician should get credit for determining the presence and absence of signs and symptoms.

Your HPI elements must come from physician documentation. Under Medicare's requirements, the physician must document the chief complaint (CC) and HPI, says Sandra Soerries, CPC, CPC-H, director of healthcare compliance services for Tait Advisory Services in Kansas City, Mo.

"Your nurse may obtain some of the information, but the ultimate responsibility for obtaining and documenting the HPI rests with the physician," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

Also, remind your physicians to specifically designate the chief complaint. "Without the chief complaint in the medical record there's no medical necessity," Soerries warns. Although guidelines permit the chief complaint to be included in the description of the HPI, for clear intent include a separate statement of the CC.

In whatever way seems appropriate for your practice, let your urologists know: Insufficient documentation means a brief instead of an extended or comprehensive HPI, Thomas says, and that, again, is an "expensive problem."

Double-dipping is not just a social faux pas; it can get your practice into compliance trouble. But don't be duped by your own fear. In certain circumstances, you can use the same E/M documentation statement twice.

Double-dipping for E/M claims counting the same documentation statement as two different elements is a no-no when the two elements are within one E/M component, Thomas says. The history components are the history of present illness (HPI), review of systems (ROS), and the past, family and social history (PFSH).

So, if you have the patient saying, "My problem started yesterday," you can't consider that single statement as the timing element and the duration element in the HPI. Or if the documentation states, "Patient has no chest pains," you cannot count it for the cardiovascular and muscular-skeletal elements in the ROS, Thomas says.

You can count the same statement, however, for two different elements in different components, say, the HPI and ROS, Thomas says. And this is what coders may not know or are afraid to follow. You can use the statement "Patient has no chest pains" for the cardiovascular element in the ROS andan associated sign and symptom in the HPI.

Ferragamo offers a urology-specific example: "No dysuria, no incontinence, and no fever can be used as associated signs and symptoms in the HPI, and these negative responses can also be used for genitourinary elements in the ROS."

"I have reviewed many charts over the years that could have been and should have been coded at a higher [E/M] level," Thomas says. And he credits the down-coding to the coder who works "under the myth of a double-dipping issue."