Determining the correct level of E/M services may sometimes resemble throwing darts at a board while blindfolded. With so much subjectivity, oncology practices should use a scoring system to ensure not only appropriate coding but uniform coding.
Scoring systems are not only used by hospitals and physician practices; they are also used by government auditors who look for inconsistencies in how providers code their E/M services, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a coding consulting firm in Dallas, Ga.
While scoring systems can aid in choosing the appropriate visit level, a scoring system is not a substitute for good documentation, warns Dianna Hoffbeck, president of Northshore Medical, a coding consulting firm in Atlantic City, N.J. "You have to show the severity of symptoms and reveal the details of the visit," she says.
Despite CPT guidelines, some practices have difficulty choosing a level because the combination of history, exam and medical decision-making levels does not always coincide with the descriptors for E/M codes, such as 99211-99215 (established patient; office or other outpatient visit).
For example, an established patient with lung cancer who comes in for chemotherapy undergoes a problem-focused history and exam. During the exam, a new problem a side effect of chemotherapy is dis-covered, requiring complex medical decision-making. Should the visit be reported as a 99212 or should it be coded at a higher level?
Parman's scoring system is modeled after those used by auditors and quantifies all the elements involved in determining the E/M level. (See the scoring sheet inserts for new and established patients. They may also be found on our Web site at
http://codinginstitute.com/docs, numbers 39 and 40.)
Documenting the History
The scoring system accounts for three elements:
1. History of present illness (HPI): During the visit or consult, oncologists may obtain one or more of the following regarding the patient's disease: location, quality, severity, timing, context, duration, modifying factors, and associated signs and symptoms.
Obtaining one to three equals a "brief" HPI, while four or more qualifies for an "extended" HPI. Because cancer is a potentially fatal disease, oncologists usually perform a detailed HPI, which requires them to cover four or more HPI elements.
"As a general rule, I can usually find extended history of present illness," Parman says.
2. Review of systems (ROS): Potential systems that may be reviewed are constitutional; eyes; ear, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; integumentary; musculoskeletal; neurologic; psychiatric; endocrine; hematologic/lymphatic; and allergies/immune system.
A ROS can be performed by a nurse, or patients may report their symptoms by completing a detailed questionnaire. ROS does not have to be performed by the oncologist, but he or she must review and sign the ROS, Parman says.
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