Ob-Gyn Coding Alert

Checking both the 1995 and 1997 guidelines can make a difference

If you-ve been relying on the safety of 99213 for established patient E/M visits, you could be flagging your practice for an audit.

Read the following example, fill out the chart, and see how your coding measures up against 99214's (Established patient office visit -) history and exam components. Your office could be sacrificing $30 for visits that really qualify as 99214 rather than 99213.

Don't Overlook History and Exam Elements

Ob-gyns often perform history and examination elements but fail to record that information. They may not realize that jotting down these details could justify a 99214 instead of the safety of 99213.

Every visit isn't going to be a 99213, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. -In fact, some insurers put up red flags when a practice never bills any other E/M codes. They wonder what type of patient care a practice is providing when it never, ever bills anything higher than that. Or they wonder why every visit warrants a 99213 and none ever justifies a 99214.-

Rule of thumb: If your documentation supports billing 99214, you should report it, says Betty Carpenter, CCS-P, coding and compliance manager for a practice in Grand Rapids, Mich.

Break Down This Ob-Gyn's Documentation

Read the following visit details and documentation, and see which E/M code you would choose:

Example: Wanda, a 40-year-old G5, P4 who has had a tubal ligation, comes in for a follow-up regarding a number of issues related to her cycles. The ob-gyn comes in and asks about:

- her history of irregular cycles, dysmenorrhea and menorrhagia in the past.

- her medications. She was well controlled on DepoProvera, but she developed mood dysfunction and stopped the Depo.

- her cycles. In the past year, she has had to return to cycles every three to four weeks with dysmenorrhea for four days and intermittently menorrhagia, although she is not heavy with every cycle.
 
- other medical issues. She has a pituitary microprolactinoma and thyroid dysfunction, which is being followed by another physician but she is not now taking any specific medication for her pituitary. She is not allergic to anything.

Then the ob-gyn asks her:

- If she has had any headaches, visual changes, dizziness.

- If she has had any chest pain or palpitations.

- If she has had any shortness of breath or cough.

- If she has gastrointestinal issues, such as diarrhea, constipation with spasm and pelvic pain. She says she recently had a colonoscopy and was diagnosed with diverticulosis and visualized bowel spasms. She just started a bowel regimen in the past few days.

- If she has any vaginal bleeding or discharge, any stress urinary incontinence symptoms.

- If she has noted any spots, rashes, or lesions, or is experiencing any muscle pain.

- If she smokes. She smokes one pack per day and does not desire to quit. 

The physician notes that HEENT is normal and examines the neck and thyroid. The lungs are clear, and the heart has a regular rhythm without murmur. The breasts are normal, the abdomen has no masses, and the liver and spleen appear normal. He performs a pelvic exam and notes that (1) there are no lesions or discharge, (2) the uterus is retroverted, and (3) the ovaries are not enlarged or tender. He also performs a Pap smear.

Documentation reads: -It is not clear if her pain is entirely from bowel problems or if there is a compounded gyn issue related to ovulatory dysfunction or possible endometriosis. She does not desire surgery and had questions about ablation. I cautioned her that this is reasonable for bleeding control but would be expected to solve her pelvic pain issues. We talked about progesterone with Aygestin but will wait and reassess after several weeks on the bowel regimen.-

Capture Work With History Breakdown

Fill in the blanks of the following template to decide whether to report 99213 or 99214.
 
Hint: Remember to capture all the ob-gyn's work with this template.

S    CC: _____________________________________
      HPI: ____________________________________ 
      ROS: ____________________________________
      PFSH: ___________________________________

O _________________________________________

P__________________________________________

Check Your Template Against This
 
Your template should look like this:

S  CC: irregular cycles with dysmenorrhea and intermittent menorrhagia

HPI: cycles (location), discontinued DepoProvera (modifying factor), intermittent heavy periods (severity), dysmenorrhea lasting four days (duration)

Break it down: If you take all four of these details into account, the HPI moves from brief to extended. An extended HPI is one of the elements needed to meet the requirement for a detailed history.

ROS: Eyes (negative for visual changes); ENT (negative for lesions or rash); Neurological (negative for headaches or dizziness); Cardiovascular (negative for chest pain or palpitations); Respiratory (negative for SOB or cough); Gastrointestinal (intermittent diarrhea, constipation, with spasm and pelvic pain); Genitourinary (negative for vaginal bleeding or discharge, SUI symptoms); Integumentary (negative for spots, rashes or lesions); Musculoskeletal (negative for pain); Allergies (none).

Don't forget: Accounting for just two of these areas equals an extended ROS, rather than a pertinent ROS. And if you remember to count asking about allergies, the ROS becomes complete. An extended or complete ROS is another requirement toward a detailed history.

PFSH: personal past history (tubal ligation, DepoProvera, colonoscopy, diverticulosis,); social history (smoker); family history (none documented).

Keep in mind: Counting any one of these elements makes the PFSH pertinent instead of NA. Since the ob-gyn documented no family history, PFSH will never be greater than pertinent, but this still supports a detailed history--the last requirement for billing 99214 if you-re thinking medical decision-making is of moderate complexity.

O HEENT     normal
Neck            without thyromegaly
Lymph          no adenopathy in neck
Lun gs           clear
Heart            RR and no murmur
Breasts           normal
Abdomen       obese, soft, nontender, no masses or organomegaly (liver and spleen)
Pelvic            external genitalia, vagina, uterus, ovaries

Important: If you look closely, you will notice that the ob-gyn performed only a limited pelvic exam. Under the 1995 documentation guidelines, this would equate to an expanded problem-focused examination. Under the 1997 criteria, however, the ob-gyn documenting 12 bulleted elements qualifies as a detailed exam. Moral of the story: Checking both sets of criteria can make a difference. But because you already have a detailed history, you can ignore an exam that is less than detailed.

P: Unknown if pain is from bowel problems or from gyn issues (new problem to the physician, but he plans no further workup); no lab or diagnostic tests reviewed; discussed surgery and medication as a management option.

Heads up: Here you have multiple diagnostic and management options, no data reviewed, and moderate risk due to management options that include prescription drug management or invasive surgery. In other words, medical decision-making is of moderate complexity in this case.

Bottom line: This encounter meets the requirements for 99214.