Cardiology Coding Alert

Warning: Not all payers accept 'all other systems reviewed and negative' If you're squeaking by without learning E/M history levels' laundry list of requirements, help is here. Break down your documentation one step at a time, and then use our handy history chart to choose the right level for your patient. You have four levels to choose from: • problem-focused • expanded problem-focused • detailed • comprehensive. When determining the appropriate history level for your E/M codes, consider the following elements. CC: Clarify Your Medical Necessity Every E/M history level requires a chief complaint (CC). According to CPT, this is a concise statement, usually in the patient's words, explaining the main reason for the appointment. Look for a symptom, problem, condition, diagnosis, or physician-recommended return. Documentation should note specific problems to support medical necessity for the visit. Even if your office asked the patient to return, look for the complaint that prompted the visit or the condition that brought the patient for a follow-up. Example: A patient presents for a coronary artery disease follow-up assessment, and the provider documents coronary artery disease (CAD) as her chief complaint. Bottom line: Look for a complete CC. Payers sometimes won't find "Here for follow-up" an acceptable chief complaint. Best advice: Your physician should specify the condition or complaint the patient is following up. HPI: Look for These Factors in Patient Timeline The second E/M history element, history of present illness (HPI), should be an actual chronological description of the patient's current illness, says Bill Dacey, MHA, MBA, CPC, in his presentation "E/M Auditing: Regulations vs. Reality" at the 2007 national American Academy of Professional Coders conference in Seattle. Check your documentation for location (e.g., chest), quality (e.g., dull pain), severity (e.g., her pain is 7 on a scale of 1-10), duration (e.g., CAD diagnosed in 1999), timing (e.g., mid-day her symptoms peak), context (e.g., while walking quickly), modifying factors (e.g., alleviated with nitroglycerine), and associated signs and symptoms (e.g., dizziness). If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI. ROS: Count Systems to Determine Proper Level For the third E/M history element, review of systems (ROS), the provider either analyzes a questionnaire filled out by the patient or support staff or directly asks the patient questions (or both). Keep in mind, however, that this section does not involve examining or touching the patient. Red flag: Payers and auditors who smell cloned documentation may hit your practice with fines and refund requests. Patient-completed ROS templates may be OK, but ask providers to make their documentation specific to each patient. The main purpose of the ROS is to be sure no [...]