Pulmonology Coding Alert

Look for more detailed statements, extra elements

You can't rely on the number of organ systems or body areas to figure out if your E/M visits with established patients meet the requirements for a 99214. But don't panic: You can bill the 99214s you deserve, if you pay attention to your pulmonologist's documentation and the guidelines from the CMS.

Realize No Set Requirement Exists

The written guidance from CMS is "extremely vague," says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J. CMS will never publish, in actual numbers, how many organ systems or body areas the doctor needs to examine for a level-four established patient office visit (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; medical decision-making of moderate complexity ... usually, the presenting problem[s] are of moderate to high severity; physicians typically spend 25 minutes face-to-face with the patient and/or family).

Compare Level-3, -4 Exam Difference

CMS does say you need a "detailed" examination for 99214, versus an "expanded problem-focused" examination for 99213 (... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity; ... usually, the presenting problem[s] are of low to moderate severity; physicians typically spend 15 minutes face-to-face with the patient and/or family).

An expanded problem-focused exam is a "limited examination of the affected body area(s) or organ system(s) and any other symptomatic or related" areas or systems.

Take note: CMS defines a detailed examination as "an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s)." In other words, the doctor needs to examine the affected area or system, plus at least one other area.

Verify Details Support Such an Exam

The only difference between physical exams for 99213 and 99214 is that one is "limited" and the other is "extended," according to the CMS guidelines. Your pulmonologist can review two to seven areas or systems for either code. What's different is how much detail the doctor goes into about each area or system.

Do this: "You cannot just make very short single statements and say that's a detailed exam,"  Brink says. "You have to say in more detail more specific things about the affected body area or organ system."

For example: A patient has a pulmonary problem. If the pulmonologist simply says, "lung fields are clear," that's not a detailed examination, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

But if the pulmonologist notes that "the patient has low diaphragms that move 2-3 cms with inspiration, has decreased breath sounds and develops expiratory wheezing with rapid expiration," that's more detailed, he says. The pulmonologist also checks for clubbing, edema and cyanosis in the extremities, examines the neck for displacement of the trachea and for use of accessory muscles of respiration, and examines the heart and abdomen for signs of cor pulmonale with heart failure.

The pulmonologist could also examine other areas, such as the central and peripheral nervous systems, but an auditor probably wouldn't take them into account because the patient has no problems in those other areas.

"Limited" versus "detailed" exams remain a subjective difference that leaves "a lot of discretion to the auditor," Brink says. "I could look at it and say, 'That looks like a detailed exam to me,' and another auditor could say, 'I don't think so.' "

Weigh Notes Against Both Guidelines

You shouldn't assume that just because you have five or more body areas or organ systems, that you have 99214, experts say. "A physician can document five organ systems and make a brief comment on each organ system, and Medicare will disallow it because it lacked a more extensive/detailed exam of the affected organ system," says Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa.

Tip: New coders should compare their pulmonologist's documentation to both the 1997 guidelines and the 1995 guidelines to see which set of guidelines supports the physician's documentation. 

Rule of thumb: The AMA and CMS have proposed that physician documentation should be weighed against both sets of documentation guidelines (1995 and 1997), says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "If the physician's exam meets the requirements for a 'detailed' exam by the 1997 guidelines (12 bulleted items from any combination of organ systems), the physician does not have to worry about meeting the less specific definition of the 1995 'detailed' exam."