Instructions for coding for all Evaluation and Management (E&M) services have several elements in common. One should always base documentation and coding on the amount of work required to provide good patient care. The documentation should accurately reflect the service provided or, for coding purposes, the work performed.
One should never provide medically unnecessary services. The entire Medicare system was set up to provide and reimburse for “medically necessary” services for the diagnosis and treatment of disease. We should keep this in mind in everything we perform or order for our patients, including providing E&M services.
Having said that, coding for an established patient is significantly different than coding for a new patient. Not only does it pay less ($51 for an established patient [99213] vs. $93 for a new patient [99203]), the work required to satisfy each level is less.
The rules state that you must only meet the requirements for two of the three key components (history, physical, and medical decision-making). In plain English, that means you do not have to perform, or do not have to count, one of the three components-usually the physical exam. In addition, the requirements for each of the three key components are less for each level of the established patient than for a similar level for a new patient/consult.
For the majority of established patient visits, it is not medically necessary to perform a physical exam at the same level of “work” provided for medical decision-making and for history, as defined in the guidelines.
Since history should never be your limiting factor in charging for an encounter, medical decision-making should be the determining factor as to which level of E&M service to charge in the established patient for most coding. One exception to this general rule is that, if you perform a complete history and physical exam for any medically necessary reason, then you would code based on history and physical and not have to consider medical decision-making.
This article will focus on the history, as medical decision-making was covered previously, and the physical exam does not play a role in most established patient coding.
Five patient levels A chief complaint (CC) should be clearly documented at each encounter, with no exceptions. The history of present illness (HPI) must be documented for each encounter and cannot be “updated.”
To reach a fourth- or fifth-level HPI, you have two choices:
- document four sub-elements for the HPI
- or update three chronic illnesses (eg, erectile dysfunction-stable, carcinoma of the prostate-worsening, neurogenic bladder-stable).
The review of systems (ROS) and past medical, social, and family history (PFSH) can also be documented in two ways-re-document the information that day or document the date of a previous ROS and PFSH in the chart, update the information, and count a complete ROS and PFSH for the new encounter. (Refer to the chart above, which indicates the amount of work required for each level of established patient.)
One can reach a level three HPI with very little history, as in this example:
CC: BPH with obstruction
HPI: Obstructive symptoms are worsening
ROS: Frequency, nocturia (three times per night).
A level-four HPI can be reached in many patients, particularly if the patient has a new problem, established problem worsening, or many problems, as in this example:
CC: BPH with obstruction
HPI: Patient with increasing symptoms over the last 6 months. Has frequency and nocturia (three times per night).
Medication is not working. Also has mild urge incontinence.
ROS: No dysuria or hematuria. No constipation
PFSH: Recently divorced.
Again, I am not suggesting that you try to beat the system by unnecessary documentation and up-coding. However, I do encourage you to fully document the services rendered and charge the appropriate level for the documentation. You should be paid for the work provided.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
