Part B Insider (Multispecialty) Coding Alert

Published on Tue Aug 16, 2011 PDF

Determine whether you need to hone your E/M coding skills with this quiz.

Evaluation and management services represent a large portion of most practices' reimbursement these days. So if your E/M coding knowledge isn't up to par, your practice could be missing out on major reimbursement or risking compliance issues.

Find out if you're properly billing the E/M services your physicians perform with these three quick quiz questions.

The physician puts an asthma patient on steroids and changes his inhaler settings after an exacerbation. The patient returns the next week for a scheduled follow-up. The provider asks the patient if he is having any breathing trouble since his medication change. What review of systems (ROS) level does this represent?

A. Problem-pertinent ROS

B. Extended ROS

C. Complete ROS

D. None of the above.

This is an example of a review of systems (ROS) that is problem-pertinent. The physician performs this ROS when he reviews only the system related to the patient's problem.

Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision making ...) or a level-three established patient E/M (99213, Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem-focused examination; medical decision making of low complexity ...).

Tip: Many follow-up visits for patients with plans of care in place result in problem-pertinent ROS.

Your physician sees an established patient with severe chronic allergies. The patient is not presenting with any symptoms currently. Your physician documents a detailed history, a detailed exam, and low complexity decision making. You can report 99214.

A. True

B. False

According to CPT rules, you need two out of three elements to support an established patient E/M service. In this case you have a detailed history and a detailed exam, which support a level-four office visit code, as long as there is medical necessity for a level-four established visit.

Important: Medical necessity must support the level of your coding. With this patient, due to his severe chronic allergies, the physician may be justified in performing a detailed exam and detailed history even though his medical decision making (MDM) is only low level.

If the nature of the presenting problem won't support a higher-level E/M service, you can't get paid for the service just because the physician documented a higher-level　history and exam. Medical necessity is the overriding factor that should determine the service　level.

Remember: MDM does not equate to medical necessity. Just because MDM is low for an established patient, that does not mean there is not medical necessity for the physician to perform (and bill) a level-four visit. Because of the way you must calculate MDM -- using the number of diagnostic options the physician considered, using the number of tests he ordered, and/or using the table of risk -- the MDM does not have a one-to-one equality for medical necessity, in particular for a patient who happens to be exhibiting control for previously uncontrolled chronic disease symptoms.

The physician sees a former patient who was in an automobile accident. The physician does a comprehensive history and examination and documents medical decision-making. The E/M medical necessity level meets the criteria for 99214. The physician spends additional time answering the patient's many questions and helping her to understand her options. The total visit takes 60 minutes. Which code(s) should you report?

A. 99214

B. 99214-22

C. 99214, 99354

D. 99354.

You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history, a detailed examination, and medical decision making of moderate complexity ... Usually, the presenting problem[s] are of moderate to high severity). Then, add prolonged services code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) along with 99214.