Practice Management Alert

If your physician is stuck in a coding rut, give him the tools to get on track.

Do you have one physician on staff who reports level- four E/M codes for every visit? If you thought your practice was immune to this type of error, your self-audit might uncover problems you didn't know you had.

If you code the charts of several physicians at the same practice, it may be difficult to notice trends in the physician's coding habits.

For instance, one physician might code every visit as a 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), but because her charts are mixed in with other physicians' in the practice, you don't notice the pattern because you never code a stack of her charts at the same time. In addition, because many practices now have their urologists do their own E/M coding, you may have never reviewed an E/M chart to check on its accuracy.

Remind Your Physicians How to Choose a Level

If you find E/M coding problems in your chart review, you should remind your physicians how to select the correct level. First, reinforce to the physicians that the nature of the presenting problem will set the initial level of care that is warranted.

After taking the patient's history of present illness, previous medical history, social history, family history, and review of systems, the physician should have a pretty good idea what level of service he'll be performing based on the presenting illness or injury. At that point, the physician should do the exam and medical decision-making that meet the level that's warranted for that illness severity, based on the patient's history.

Complexity, MDM Vary With Each Patient

If you find that one of your physicians miscodes his E/M visits, remind him that even if he always sees the same diagnoses (which is unlikely), the complexity of the visit and the medical decision-making will vary from one patient to the next.

For instance, a 25-year-old female with an ear infection and no other medical problems might qualify only as a level-two office visit (99212) because the physician only performed a problem-focused history and exam, and straightforward medical decision-making.

However, suppose the physician sees a 22-year-old patient with an ear infection, and the patient has hearing loss and balance issues due to a head injury. The patient has already been on three rounds of antibiotics and it is not improving.

Although this patient also has an ear infection, the coding changes from our previous example above. This patient may qualify for a level-four or maybe even a level-five visit, depending on the number of treatment options, the tests ordered, the medications ordered, etc.

Remember: If you bill for a surgeon or specialist, the fact that the physician is a specialist does not determine the level of complexity.

Watch Out for Pitfalls

Although the nature of the presenting problem and the complexity of medical decision-making should drive the E/M level, some physicians fall short on documentation, leaving the coder stuck with reporting an E/M code that's actually lower than the service that the physician performed.

Coders can only choose a code that's as good as the physician's documentation. So even if your physician is seeing highly complex diagnoses, his exam might not be comprehensive enough to qualify for the level-four code.

Beyond the audit: This practice could give the impression that the physician provided poor quality of care.

Problem-Focused Exam May Lead to Level-2 Consult

Subspecialists often see sicker patients, but they still may not conduct adequate exams because the visits can be very problem-focused.

You can't report 99244 (a level-four consult, Office consultation for a new or established patient ...), for example, without a comprehensive exam. You need a detailed exam even for a level-three consult, so if the physician performs a problem-focused exam, you're locked into 99241 and 99242 (expanded problem-focused exam), even if medical necessity, medical decision-making, and history support level four.

Problem: Often, the physician may perform a more comprehensive examination but doesn't document it because the patient presents for a specific problem.

Solution: Remind the physician that he should document every area that he examines, not just the areas that are anatomically close to the presenting-problem area.