Coding Strategy

Sicker patients may not always mean higher MDM.

If your physician bills a lot of high-level office visits, he may be at risk of an audit — which may not be cause for concern — if his documentation justifies his code choices.

“Some physicians believe their patients are sicker than others’, so they feel they’re justified using more 99215s, when in fact that may not be the case,” says Crystal S. Reeves,CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. “The CPT manual outlines the requirements of the E/M codes, there are clinical examples in the back of CPT, and CMS publishes a Table of Risk that can help guide you, so use all of those resources to determine whether you’re billing properly,” she advises.

Training is Key: If you advise your physician that he is overbilling the high-level codes and he says, “But all of our patients are really sick,” show the doctor CMS’s Table of Risk, “which can be an eye opener for physicians,” Reeves says.

When it comes to MDM for high-level E/M services, “look for how many diagnoses or management options the doctor is treating,” Reeves says. “If a patient presents with a brain tumor and is on chemotherapy but is doing well, his condition may ultimately be terminal but this visit may not qualify for a level five. But if a patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there will be more data to review, which may qualify for a higher MDM level.”

Make diagnosis coding a priority: If your claim doesn’t convey the status or complexity of the condition, an auditor won’t be able to infer it, advises Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y. “The best way to do this is to report your diagnosis codes to the highest level of specificity.”

If a diagnosis code isn’t listed on your superbill, research to find it rather than just using one that you do list on your encounter form.

“Certain diagnoses may not be listed on a physician’s superbill, so the doctor may just circle the closest unspecified code,” Fiedler says. For instance, a physician might circle the standard controlled diabetes code on a superbill because it’s there, “but any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for — and oftentimes, they don’t,” she says.

“Without the more specific code, the physician isn’t conveying the acuity of what he’s doing, so the diagnosis may not support the claim.”

@ Part B Insider, Editor: Torrey Kim, CPC

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Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.

Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.

Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.

Watch for Chronic Conditions

“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.

The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.

Be Alert to Counseling Time

When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.

Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused history, an expanded problem focused examination, and low complexity medical decision making, which qualifies as 99213 based on HEM. The pediatrician documents she spends 15 minutes counseling the patient on hypertension management and the visit lasts 25 minutes.

Because counseling comprises the majority of the encounter’s total face-to-face time, you can code the visit using time as the controlling factor and select 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity … Physicians typically spend 25 minutes face-to-face with the patient and/or family). If you had overlooked this fact and instead coded 99213 based on HEM, you would have sacrificed approximately $31* in pay.

*Note: The 2009 Medicare Physician Fee Schedule, which you can use as a benchmark to judge private payers’ fees, assigns 2.56 relative value units to 99214.

Using the conversion factor of 36.0666, 99214 pays approximately $92. Code 99213 has 1.70 RVUS, which equates to approximately $61.

Heads Up on Other Disorders, Diseases

Some other examples of chronic conditions that might warrant an updated history, exam, and counseling are diabetes (for instance 250.01, Diabetes mellitus without mention of complication; type 1 [juvenile type], not stated as uncontrolled) and ADHD (314.01, Hyperkinetic syndrome of childhood; attention deficit disorder; with hyperactivity).

@ Pediatric Coding Alert

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