Anesthesia Coding Alert

Thorough documentation of medical history can help your coding cause

Track down all the details you can about a patient's history of present illness (HPI), and watch your coding--and your bottom line--change.  Concise Is Good--But Detailed Is Better Every patient record needs a statement describing the patient's condition, symptoms and problem. The physician should keep this statement short and focused, but teaching physicians to dig a little deeper can help justify higher-level codes.
 
Example: The patient complains of back pain that has lasted two weeks. If this is all you know, you-ll have to report a problem-focused code because the statement only includes two criteria for HPI (type of pain and duration), says Julee Shiley, CPC, CCS-P, CMC, an anesthesia coding consultant in Columbia, S.C. Before reporting even a Level 1 code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making), be sure your provider documents some form of examination and/or medical decision-making. Otherwise, you don't have enough information to support your coding.

But asking questions about how and when the patient's pain began can lead you to higher-level--and more accurate and higher paying--codes. Asking Questions Leads to Higher-level Codes A thorough look at the patient's condition means understanding the problem from start to finish:  discussing signs and symptoms from their onset through the present visit, or getting details about changes since the previous encounter. Putting together a complete history includes asking questions about:

- The location of the problem
- The quality of the problem (what it looks or feels like--throbbing, sharp, radiating, etc.)
- The severity of the problem, based on a scale of 1-10
- How long the problem has existed
- When the problem occurs (after walking, after sitting for prolonged times, continuous, etc.)
- What the patient was doing when he first noticed the problem (walking, lifting something heavy, no specific onset)
- What makes the problem better or worse (lying down, taking ibuprofen, walking)
- Other signs or symptoms that are present (fatigue, leg pain, urinary problems). Co-morbidities such as diabetes, hypertension or cardiopulmonary problems help support a higher level of exam and medical decision-making. Documenting four or more of these details shows you-re dealing with an extended illness rather than a one-time acute problem, says Kathy Campbell, CPC, of the anesthesia billing firm Professional Economics Inc. in Bloomington, Ind.

In the example above, you already know the patient's pain has lasted two weeks. Answers to a few questions show that he doesn't remember exactly when the pain began, but a dull ache is always present. [...]