Orthopedic Coding Alert

3 scenarios from our experts help you improve your E/M skills

Before you report any E/M procedures, look for documentation details on the patient's presenting illness, because this information can make or break your patient's complete history.

Check out the following three frequently asked questions to determine your review-of-systems (ROS) savvy. Write down your responses before looking to the correct answers below.  Question 1: A new patient who is unable to speak English and to explain her medical problems presents to your orthopedic practice. The patient's inability to communicate prevents the surgeon from obtaining a complete history of present illness (HPI) and ROS from her. The orthopedic surgeon treats the patient's fracture, but cannot develop a definite plan for her treatment.

The orthopedic surgeon calls the patient's two previous physicians to discuss her medical problems and discovers that the patient also suffers from diabetes and previous fractures. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, the surgeon spends a total of 90 minutes on this patient on the same day.

How should you charge for this scenario? Which E/M codes and modifiers should you use to justify the extra time that the orthopedic surgeon spent on the phone with other physicians on this patient's behalf? Question 2: Can you use a nurse's notes to satisfy elements of ROS and past, family, social history (PFSH), as long as the physician documents his review of the notes? Question 3: When an orthopedic surgeon lists an organ system and documents past medical/surgical history instead of current signs or symptoms, can you use this as the ROS? Check Your Answers Answer 1: You should select the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient) based on the information you were able to obtain from the patient and her physicians.

Note: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

Warning: In most cases, you cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Normally, communication barriers do not meet the criteria for counseling/coordinating care. 

The physician may document the excessive effort of trying to get an appropriate history with the reason for excessive effort and a reason for why he was unable to obtain the full history. The physician may receive credit for the -unobtainable- history.

If the physician documents service time when the patient is not physically present (such as post-exam calls to other [...]