Gastroenterology Coding Alert

Hint: Don’t overlook including history captured in previous visits.

If your gastroenterologist is not documenting all aspects of past medical, family and social history (PMFSH), you might be losing out on opportunities to report a higher level E/M – watch out for instances wherein your clinician might be missing out on required documentation especially when mentioning history previously captured.

Determine the Level of PMFSH

For coding purposes, the history portion of an E/M service  requires all three elements — history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH). 

Therefore, the PMFSH helps determine patient history level, which has a great effect on the E/M level you can report. If you do not know the PMFSH level, you will be unable to decide which level of E/M code you should use on the claim.

There are three levels of PMFSH: none, pertinent, and complete, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Pertinent: To reach a detailed level of history for the encounter, you need a pertinent PMFSH. According to Medicare’s Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PMFSH areas to achieve the pertinent level. When the provider asks only about one history area related to the main problem, this is a pertinent PMFSH.

Complete: A complete PMFSH includes, per Medicare’s Documentation Guidelines, at least one specific item from two of the three areas for the following categories of E/M services:

• Established patient office/outpatient services
• Emergency department services
• Established patient domiciliary care
• Established patient home care.

For all other E/M services, a complete PMFSH includes at least one specific item from each of the three areas.

Pointer: You need only one element of PMFSH to receive some credit for the history component of the encounter. Best bet: “Document it all. You never know what may be pertinent to the patient’s current situation!” Gross advises.

Choose a Code Based on PMFSH Element Requirement

Once you determine the level of PMFSH your provider’s documentation contains, you can see which codes that history element supports.

Beware: If your provider does not document any PMFSH elements, you can only reach an extended problem-focused level of history, warns Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. That means the highest codes you’ll be able to report are a level-two new patient code (99202) or a level-three established patient code (99213). Reporting 99202 pays $74.51 (the national unadjusted rate based on the Medicare Physician Fee Schedule assignment of 2.19 RVUs times the 2013 conversion factor of 34.023) and 99213 pays $72.81 (2.14 RVUs).

Pertinent PMFSH supports a detailed history level. With detailed history you can report a level-three new patient code (99203) and a level-four established patient code (99214). You’ll earn $108.19 for 99203 (3.18 RVUs) and $106.83 (3.14 RVUs) for 99214.

To get to level-four and five new patient visits and level-five established patient visits, you need to have a comprehensive level of history, Cobuzzi says. To do that, you must find complete PMFSH in your provider’s documentation. If you can achieve 99204 or 99205, you’ll earn $164.67 (4.84 RVUs) and $203.80 (5.99 RVUs), respectively. You can expect $142.90 (4.20 RVUs) for 99215 — just over $70 more than if you’re forced to report 99213 because you didn’t have enough PMFSH.

Imagine this scenario: Your provider sees a new patient with complaints of dysphagia and abdominal tenderness from the past three days. He captures extended history of present illness, complete review of systems, one point of past history, one point of family history; performs a comprehensive exam; and reaches moderate complexity medical decision making due to a new acute problem with lab and x-ray orders and a new prescription medication started. But the doctor forgets to review social history with the patient because the paper template he still uses doesn’t have a place for social history notes.

Money matters: You only have detailed history and can only report 99203 versus 99204 if the doctor had captured comprehensive PMFSH – a loss of $56.48.

Note: Since established patient office visits require two of three key components, a higher level service is still possible based on the service’s examination and medical decision making (MDM) types. “For an established patient, you may decide to leave history off and count only the exam and MDM and then just have the low history,” Cobuzzi says. “So, if you have a weak history, you might still reach the higher level E/M.”

Count Unchanged PMFSH in Current Encounter

Based on E/M guidelines, if a patient’s PMFSH has not changed since a prior visit your provider doesn’t have to document the information again. He does, however, need to document that he reviewed the previous information to be sure it’s up to date and also note in the present encounter’s documentation the date and location of the initial earlier acquisition of the PMFSH. Some payers will give no PMFSH credit if you overlook one of these criterion.

In writing: Both the 1995 and 1997 E/M documentation guidelines include the following: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and

noting the date and location of the earlier ROS and/or PFSH.

For example: Your provider may note, “PFSH: Same as documented in my note of January 7, 2011.” If there’s been a change, he should record it, such as: “PMFSH: Same as documented in my note of January 7, 2011, except the patient no longer drinks alcohol.”

Good news: As with the review of systems (ROS), Medicare states that either the patient or nurse can fill out a history form for PMFSH. “The patient usually will get a questionnaire to fill out with these questions, and often the nurse or assistant will expand on the answers.” Gross says. “However, the physician must document that he or she reviewed these answers to receive credit.” As long as the physician signs the form or nurse’s notes and documents that he reviewed them, you can meet the requirements for PMFSH with that information.