Otolaryngology Coding Alert

Teach otolaryngologists to write iron-clad MDM notes.

You can't get inside your ENT's head to know whether his MDM warrants the E/M service code that he reported -- but beware that Medicare auditors are zooming in on this area when examining E/M claims.

Auditors aren't scrutinizing the exam or history as much as they weigh [the audit] toward medical decision-making. But you can be your otolaryngologist's front line of defense and make sure his notes withstand scrutiny if you follow these tips.

Tip 1: Identify a Mismatch With This Strategy

In your next staff education meeting, remind your ENTs that medical necessity should be the overarching factor they use to select the E/M service level (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...). Just because a physician does a comprehensive history and examination doesn't mean he should report 99215. Medical necessity should drive the components that he performs. This is of particular importance with the implementation of EHR systems, which automatically code encounters without regard to medical necessity. It is very easy to document high levels of history and exams, particularly for established patients, which will result in level four and five services when the medical necessity may dictate only level two or three services.

You can help ensure your physicians are selecting appropriate codes by occasionally pulling a sample of their charts. Look at the patient's chief complaint (meaning the nature of the patient's presenting problem) and the encounter's outcome -- or its final diagnosis. If the primary ICD-9 code does not support a billed upper level of service, you should really read the chart notes, she says.

Example: A patient presents with a chief complaint (CC) of sinusitis, which is also the ICD-9 code that the otolaryngologist reported -- 461.1 (Acute sinusitis; frontal). Although the physician could have performed and documented the elements necessary for a detailed history and detailed examination, "the CC of sinusitis probably wouldn't warrant 99214," without any additional comorbidities or complicating factors.

Tip 2: Look for Potential MDM-Boosting Factors

But complicating factors could make 99214 and 461.x a match. The patient may have comorbidities or other chronic conditions. And medications that the patient is already taking or adverse reactions the patient had to previous medications could increase the level of MDM. Comorbidities, frequency of episodes of sinusitis, the plan of care, and so on, may complicate the medical decision making as well.

In addition, evaluation of symptoms possibly related to sinusitis, such as fatigue, headache, fever and cough, can increase the MDM. When you work up a sinusitis, if a patient also has these other symptoms, then you have to make sure he doesn't have any other problems that could be more serious.

The more involved workup usually makes the service a 99214.

Good idea: Ask your ENTs to list complicating factors. Unless the chart spells these out, you have no way of knowing that a comorbidity, chronic condition or medication played a role in raising an office visit's MDM from low (99213) to moderate (99214) complexity.

Tip 3: Uncover Extra Complexity in These Places

Medication can lead to a higher-level MDM another way. Look at the tests and medications the otolaryngologist ordered for clues to the extra complexity the physician may not be explaining. Two tips can make identifying increased complexity easier:

• Look in the history of present illness and review of systems to determine what the ENT is trying to rule out.
• Encourage your ENTs to state what diagnoses they hope to rule out or confirm. Be careful: Don't put such "rule-out" diagnoses on your claims. Doing so would be inappropriate coding.

Tip 4: Give Credit for Clear Management Options

Tell your physicians that they should clearly indicate when they're taking an intermediate step that they don't believe will solve the patient's problem. For example, they may try antibiotics before a more aggressive treatment.

Explaining that they're trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. Documenting the extra step shows that the physician considered more management options (one element of MDM).

Tip 5: Look at Patient's Complexity

Sometimes a low level of MDM (in conjunction with a detailed/comprehensive history and examination) can support a 99214. You can't just look at the MDM, experts say. You also have to look at the complexity of the patient.

In the above sinusitis examples, a highly complex patient with a sinusitis diagnosis could justify a level-four established patient office visit. For a diabetic patient with methicillinresistant Staphylococcus aureus (MRSA) who has suffered for a long time from chronic fungal sinusitis that is finally stable, medical necessity probably justifies the physician performing a comprehensive history and detailed examination, but the MDM will be at a low level.

You get only one point for the diagnosis; the conditions present moderate risk, and the physician won't be ordering a lot of tests. But because the patient's case is highly complex, the scenario does support 99214.