Orthopedic Coding Alert

Many orthopedic practices are stuck reporting low-level new patient E/M codes even though they've performed higher-level services. The culprit: Some physicians don't appropriately document the patient's history, and cannot justify reporting a higher-level E/M code. If you can work with your orthopedist to spend just a few extra minutes on his new patient documentation, you may be able to report higher-level codes and boost your practice's bottom line.
 
Orthopedists occasionally see new patients who have  serious conditions and require high-complexity medical decision-making, which, when combined with a comprehensive exam and a comprehensive history, could warrant reporting 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination; and medical decision making of high complexity).
 
Suppose your orthopedist performs a comprehensive history, comprehensive examination and high-complexity medical decision-making (MDM) on a new patient. She documents the comprehensive exam and high-complexity MDM, but only documents a detailed history. What your practice could have billed as a 99205 (netting about $180) is now a 99203 (netting only about $100). Had she spent about five more minutes thoroughly documenting the comprehensive history, your practice could have collected an additional $80.
 
You should perform quarterly E/M self-audits to determine whether your physicians are leaving this kind of money on the table because they underdocument their services. If so, schedule a meeting with your physicians and nonphysician practitioners. Discuss the various levels of coding and remind them of the documentation necessary to report the higher-level codes. You should also provide an outline of the different reimbursement amounts for each code so they can see how much they're forfeiting by providing incomplete documentation. Note the 4 Levels of History Medicare and CPT both recognize four levels of history for an E/M service: problem-focused, expanded problem-focused, detailed, and comprehensive. See the chart on page 85 to determine which history level the physician's documentation warrants.
 
The chief complaint and related history of present illness (HPI) tend to be the areas where orthopedists document the most information. The patient intake form usually covers the review of systems (ROS) and the past, family and social history (PFSH). The patient usually completes this form on his own, or with a nurse's help. The chief complaint is a concise statement explaining why the patient is in the physician's office, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "All E/M services need a reason for the visit, which will be found in the chief complaint."
 
The HPI is a more thorough description of the patient's chief complaint, Jandroep says. It may include one or more of the [...]