Pulmonology Coding Alert

Between 15 percent and 25 percent of the evaluation and management (E/M) charges submitted by pulmonologists should be coded as a 99214, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. These charges represent significant costs and HCFA has announced its intent to focus its audits in this area. E/M code 99214 has become a big issue within the last year, explains Callaway. Because of such close scrutiny and the confusion regarding which set of guidelines to use to determine the level of service (HCFA has issued two versions already and has a proposed third version available for review), pulmonology coders need to be especially aware of the codes reporting requirements to avoid unnecessary claims rejections and audits.

The AMA reports that nearly one-third of all services rendered by physicians fall under the E/M code grouping. E/M services are coded according to the content of the service provided and depend on the details found within the medical record documentation. Payers require reasonable documentation that the services provided are covered by their policies. For that reason, the payer can request documentation verifying the site of service, the medical necessity and appropriateness of the diagnostic or therapeutic services provided; or that services provided have been accurately reported.

Use E/M codes 99201-99215 to report evaluation and management services provided in the physicians office or in an outpatient or other ambulatory facility. Coders should use 99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity) only after carefully considering the medical record documentation.

Documenting E/M Services

CPT offers documentation guidelines for the three key components that make up the general content of the medical record documentation. The three key components include determining a patients history, providing and describing a patient examination, and providing a medical decision based on the complexity of the problems identified in the history and examination, the amount of data reviewed and risk to the patient. These components are key because they most often determine the appropriate E/M service level (e.g., 99214).

Additionally, four other factors affect E/M code selection. Three of these factors (counseling, coordination of care and the nature of the presenting problem) are considered contributory. The final component used to define E/M services is time, but only when more than 50 percent of the face-to-face patient encounter involves counseling or coordination of care.

Although CPT does not require a specific format for documenting the components of an E/M service, each patient encounter should include the chief complaint (CC) and/or reason for the encounter, relevant history of present illness (HPI), physical examination findings, and prior diagnostic test results. The medical record documentation also should include an assessment, a clinical impression (a diagnosis), along with a plan for care, and the date and verifiable legible identity of the healthcare professional providing the service.

Codes 99201-99215 specify a definition for each of the three key components: one of four history types, one of four examination types and medical decision based on one of four complexity types.

What Is Detailed History?

E/M service levels depend on one of four types of history (problem focused, expanded problem focused, detailed and comprehensive). Choosing the type of history depends on information the physician acquires during the patient encounter. The medical record documentation could include details documenting or referencing the chief complaint (CC), the history of the present illness (HPI), a review of systems (ROS), and past, family, and/or social history (PFSH).

To code for 99214, the recorded history must qualify as detailed. Evaluation and management guidelines define this as having an extended HPI, which would include notes covering where the presenting problem is located, the quality (sharp, dull, shooting), severity, and length of time the problem has existed, the timing (how often, how long), the context (does it increase while climbing stairs or near dogs), any modifying factors (after smoking) and any associated signs and symptoms (puffy eyes, shortness of breath, yellow skin color). HPI details also could include follow up on a previously diagnosed problem, medication management, and updates on chronic conditions. The 1997 Documentation Guidelines state that an extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

The medical record needs to address at least four of the elements in HPI and must also include an extended ROS that covers between two and nine of the recognized systems (e.g., constitutional symptoms and such organ systems as cardiovascular, respiratory and allergic/immunologic). Documentation guidelines define an extended ROS to include a brief ROS as well as a review of additional organ system(s). The patients positive responses and pertinent negatives for two to nine systems should be documented.

A detailed history also must include a pertinent past, family and/or social history (PFSH). A PFSH review covers the patients direct past experiences with the presenting problem, review of medical events in the patients family that might place the patient at risk, and an age appropriate review of past and current activities. For a PFSH to be classified as pertinent, the medical record must reflect details from at least one specific item from any of the three history areas.

The HCFA documentation guidelines point out that the CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. Additionally, the agency notes that a ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information . . . The review and update may be documented by: describing any new ROS and/or PFSH information or noting there has been no change in the information; and noting the date and location of the earlier ROS and/or PFSH.

An exception to the normal process of acquiring history exists for emergency care necessitating highly complex medical decision making. If the physician is unable to obtain a history from the patient or other source, the record should describe the patients condition or other circumstance that precludes obtaining a history.

Coding 99214 requires at least two of these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity. Both physicians and coders should let the record show enough information to prove these levels of patient evaluation and management.

With the E/M guidelines undergoing continuing revision draft E/M guidelines are posted on the HCFA Web site (www.HCFA.gov) its difficult for coders, physicians, etc., to keep up, Carol Pohlig, CPC, RN, a reimbursement analyst for the Office of Clinical Documentation at the University of Pennsylvanias Department of Medicine in Philadelphia points out. Failing an audit is expensive; fines can run roughly three (for the average number of years the service was performed) times the percentage of wrongly coded E/Ms in a sample of 25 medical records. Physicians and coders should choose the E/M level based on medical record documentation conforming to either the 1995 or 1997 guidelines. Auditors are also required to audit physicians based on either the 1995 or 1997 guidelines, whichever is more beneficial for the physician (as mandated by HCFA).

Note: This is part one of a two-part series. Part two will contain clarification on ways to document and determine the examination and the medical decision-making aspects of the E/M code.