Wiki E/M Coding Question w/ ROS

[MichelleBursavich]

The physician and I disagree because I challenged his coding for an E/M service based on the documentation that he provided in the chart notes. Any feedback is appreciated.
The documentation of both encounters that I have listed is shortened and only includes the info necessary for the purpose of my question in this post. My question is at bottom of post. We are a Dermatology specialty.

Encounter #1: Patient A - New Patient - DOS 10/9/2017
CC:
1. wart 2. mole check 3. molluscum contagiosum

HPI:
1. right hand; x4 months; asymptomatic; previously treated at home with OTC Compound W; no improvement with at home treatment
2. whole body; moled on chest positive for growth; no previous treatment; asymptomatic other than growth; cleanses skin with dove soap
3. trunk; x1 year; treated at home with OTC Tea Tree oil; no improvement with at home treatment

ROS:
Skin - no other skin problems
Constitutional: denies wt. gain/loss, fever, chills, night sweats, loss/increase of appetite, patient reports he sleeps well

PFSH: (documented)
Physical Exam (Body Areas): 15 areas documented
MDM: 1. verruca vulgaris x3 lesions on right index finer and right middle finger - treat w/ SA 60% paste and tape x2 weeks then RTC for follow-up

CPT Billed: 99203

Encounter #2: Patient A - est. patient - DOS 10/19/17

CC: verruca vulgaris f/u
HPI: right hand; one new lesion on left middle finger; SA 60% paste for treatment is causing improvement
ROS: Constitutional - denies wt. gain/loss, fever, chills, night sweats, loss/increase of appetite, patient reports he sleeps well
PE: 2 body areas documented
MDM: 1. verruca vulgaris - shave down warts on right index and middle fingers with #15 blade; continue SA 60% paste x3 days then discontinue;new verruca vulgaris lesion on left middle finger - begin treatment with SA 60% paste w/ tape x2 weeks and RTC for follow-up

CPT Billed: 99213


>> I disagree that encounter #2 on 10/19/17 supports a 99213 level of billing. In my opinion, this is a 99212. My argument lies in the ROS. Physician states that Constitutional is pertinent to the follow-up and can be documented and used again although it was just documented and used 10 days ago in the new patient encounter. I disagree and think that upon initial encounter, constitutional can be used as 1 ROS; however, upon follow-up for verruca vulgaris with the treatment plan that the patient is on, Constitutional is an inappropriate ROS to support up-coding. Wt gain/loss, fever, chills, appetite, etc. is not pertinent to the eval/mgmt of warts in my opinion. Physician does not have patient on any type of oral medications that would alter these factors and I feel that these questions cannot be asked at every encounter just to justify the documentation of 1 ROS to up-code. How does everyone else feel about this?? Am I incorrect and Constitutional CAN be used in the second encounter to meet the 1 ROS necessary for 99213 in the history or is this 1 ROS not pertinent and needs to be discounted for documentation considered when choosing the correct E/M to bill ?

 

[thomas7331]

I do think the documentation of the second visit is rather marginal to support a 99213 level, but I would let this go. Although you may or may not be correct, what you're doing by saying that a constitutional ROS is not pertinent is basically challenging the medical necessity of a provider's work and documentation, and that really isn't within the scope of a coder's role or training - I'm a strong believer that medical necessity decisions should be left to a peer-to-peer review. Selectively disqualifying parts of a provider's documentation for the purposes of choosing an E&M level is a very tricky undertaking. If the provider thinks it is appropriate to review these symptoms with the patient for this problem and treatment, that's their decision and their way of practicing their profession. As an isolated instance, and for the difference between a 99213 and a 99212, I don't think this is a case of abusive up-coding. In situations like this, I tend to give a provider an FYI about this just to let them know this is something that could potentially be challenged in a medical necessity review, (or simply ask them if they think their peers would do the same thing in the same situation) but if they feel it is defensible under standards of medical practice, then there is unlikely anything to worry about. In my experience, audits that target upcoding are focused on the providers that consistently bill higher levels of service than what is required for the severity of illness of the patients they treat. They normally don't involve going after E&M level choices based on individual elements of the history or exam.

 

[MichelleBursavich]

I do think the documentation of the second visit is rather marginal to support a 99213 level, but I would let this go. Although you may or may not be correct, what you're doing by saying that a constitutional ROS is not pertinent is basically challenging the medical necessity of a provider's work and documentation, and that really isn't within the scope of a coder's role or training - I'm a strong believer that medical necessity decisions should be left to a peer-to-peer review. Selectively disqualifying parts of a provider's documentation for the purposes of choosing an E&M level is a very tricky undertaking. If the provider thinks it is appropriate to review these symptoms with the patient for this problem and treatment, that's their decision and their way of practicing their profession. As an isolated instance, and for the difference between a 99213 and a 99212, I don't think this is a case of abusive up-coding. In situations like this, I tend to give a provider an FYI about this just to let them know this is something that could potentially be challenged in a medical necessity review, (or simply ask them if they think their peers would do the same thing in the same situation) but if they feel it is defensible under standards of medical practice, then there is unlikely anything to worry about. In my experience, audits that target upcoding are focused on the providers that consistently bill higher levels of service than what is required for the severity of illness of the patients they treat. They normally don't involve going after E&M level choices based on individual elements of the history or exam.

Thank you for feedback, Thomas