Otolaryngology Coding Alert

Don’t make the same mistakes as this practice did—keep collecting for your E/M visits.

It happens—your otolaryngologist is in such a hurry to get from one patient to the next that he doesn’t appropriately record a patient’s E/M visit, even with the help of the EHR. But that mistake can cost your practice money in some cases, and you can’t afford those kinds of errors.

Read the following E/M note from an otolaryngology practice and determine whether you can find the problem with the code that the coder submitted.

Code reported:  99212

Chief complaint: None recorded.

Problems: None recorded.

Allergies: Allergic to all penicillin

Medications: None other than daily multivitamin

Social history: This 14-year-old patient is a student in the ninth grade. She rides her bike for exercise and takes gymnastics once a week.

Family history: The patient’s parents are alive and healthy. Her maternal grandmother has diabetes and her maternal grandfather had melanoma but recovered. Her father is adopted and she therefore does not history on her paternal grandparents.

Review of Systems: None recorded.

Physical exam: None recorded.

Testing: Spontaneous nystagmus testing while patient was wearing glasses revealed normal amplitude, direction, and effect of fixation on the target. No nystagmus observed.

Assessment/Plan: Dizziness R42 (Dizziness and giddiness). She is advised to stop riding her bike and performing gymnastics until the symptoms pass. Return in one week to evaluate whether the symptoms are gone. If not, we will order further tests.

Did You Spot the Problems?

Unfortunately, this chart cannot be coded with any E/M service code as it stands, since the only element documented is the medical decision-making section. The physical exam section is blank, and the history is missing a chief complaint. The reason for a medical visit cannot be inferred, thus making this chart non-codeable.

Chief complaint primer: The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient’s own words. An example would be an “evaluation for dizziness” or “burning sensation in sinus cavity.”

Although some coders were trained to only look for a chief complaint in one particular section of the documentation, that is inaccurate. The chief complaint may actually be listed as a separate element of the history, or it may be included in the History of Present Illness (HPI). The chief complaint can sometimes be found in the assessment and plan. Every E/M note must have a chief complaint, but it does not matter where the chief complaint is found (although it is much preferred to be documented in the beginning of the note).

Unfortunately, in this case, the otolaryngologist did not record a history of present illness or review of systems either, leaving question as to the chief complaint.

Solution: In this case, you’ll have to report only the testing that the physician performed, which is 92531 (Spontaneous nystagmus, including gaze), linked to the diagnosis code that he recorded (R42).