Wiki E/M Level of Service Problems

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KSeymour

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Good morning all!


I have a few questions from my providers at Greenville ENT and I am having trouble getting clarification. If anyone with an ENT or E/M background is able to read through this whole post, I know it is a lot, and I really appreciate your time.


The first situation is how to handle OTCs. We had pretty much decided that there aren't really any documentation requirements for OTCs other than mentioning that you want the patient to use them, since the patient does not need to go to the doctor to go pick up an OTC. We are considering OTC management to be a level 3. We have been instructed that we can bill a level 4 when the medication is altered in some way. Technically the boxes of nasal spray suggest that you should not use them for longer than 2 weeks. If our providers are suggesting use for much longer, can we bill a level 4 for these?


Secondly, the leveling table states "review and interpretation..." so in this scenario we were encouraged to have the doctors use that exact verbiage. Are you handling this a different way? Our providers do not feel they should have to stick to the verbiage and want to be able to just mention, for example, "CT results normal".


Another issue with verbiage and the leveling table is that our providers do not believe in the "decision for surgery" verbiage. They believe they should get credit for going over the options even if the patient declines. I feel this opens up the process to fraud and the verbiage regarding the decision was intentional. My providers want to bill level 4s even though the patient has not technically decided on a procedure. Is your office sticking to the verbiage in this case or is it enough to discuss the option?


Additionally I am seeing a fair amount of level 2s and I think this may just be the nature of ENT considering that the problems can be very minor, or require extended observation periods rather than jumping right into less conservative measures. How do you feel about level 2s? Should they be less common or more common? My providers had been educated by someone a few years ago that told them they should rarely have level 2s and that does not seem to be the case. Since they were already told otherwise there has been some pushback.


These are just a few problems we are having that we have not been able to resolve yet. Any insight into the situation is greatly appreciated!


Kiley Seymour - Greenville ENT
 
No specific ENT experience, but plenty of E&M.
1) OTCs are almost always low level. It is possible for an OTC med to be moderate risk, but the documentation should specify that risk. Simply instructing the patient to take an OTC for 3 weeks instead of 2 weeks I would not consider moderate risk. There's a thread from about a year ago discussing exactly this. My take is it is possible, but very, very unusual for an OTC med to be moderate risk and it must be documented well. Some coders will have the opinion it is not even possible.

2) "Review and interpretation". I'm not clear where on the AMA table you are seeing review and interpretation. There is independent interpretation which would be used if your ENT is looking not just at the CT report, but at the actual CT IMAGES and interpreting them. If the provider ordered the CT at a prior visit, then the review of the report is included.

3) Decision for surgery. Yes, if the provider discusses surgery as an option including the risks, then this is decision for surgery, even if the patient determines they do not want the surgery. However, if the physician merely mentions it without really discussing it, then I would not count it. Something like "patient could consider surgery if meds no longer effective" is NOT decision for surgery. Something like "discussed with patient in detail the option of laparoscopic ablation of endometriosis including risks of anesthesia, delayed wound healing due to her DM, and recurrence of endometriosis and/or worsening pain. Discussed laparoscopic approach and procedure method with patient. Patient has decided she will continue with OTC for now and reconsider surgery if meds are not effectively controlling her symptoms." That is a decision regarding surgery. It's a decision regarding, not necessarily a decision to have.

I can't speak to how common level 2 E&Ms are in ENT. In fact, you may even have some providers in the group that subspecialize and have less frequent level 2. There are references available from CMS showing in a particular specialty, where the distribution of levels are. If your practice or a particular provider is outside the "norm", that does not mean the coding is wrong. Each and every visit needs to be leveled based on the documentation of this particular patient's current situation.
 
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