Most urologists do not need a course in “E&M Documentation 101,” but two specific documentation issues are worth clarifying. For some of you, this may be old hat. However, a lot of clinicians still do not understand two important points: the guidelines on how to document and code for an established patient visit and the value of the use of the 1995 documentation guidelines for the physical exam.
The 1995 and the 1997 guidelines, for all practical purposes, are the same for history and medical decision making. The big difference is in the physical exam. To refresh your memory, the different levels for a physical exam for the 1995 guidelines divided the exam into the examination of the affected organ system, the examination of a related organ system, and a complete exam.
The different levels in the 1995 guidelines were determined by the extent of the examination performed. The criteria were:
Limited: Examination of one or more elements
Extended: Examination of more than three (our interpretation has been four or more)
Complete: Examination of eight body/ organ systems with one or more element for each system.
Many of us switched to the 1997 guidelines when they came out because of the standardized bullets. We at Physician Reimbursement Systems were originally told that, in order to perform a complete exam using the 1995 guidelines, one had to have an extended exam (four or more examination points) for a minimum of eight systems. That changed 2 to 3 years ago. Medicare has instructed its auditors to check for one element in each of eight systems when auditing charts.
The use of the 1995 guidelines will allow you to reach a higher-level physical examination in a new patient with less work and documentation. This is true for both the second- and third-level new patient/consult codes. However, the real advantage is in performing a complete exam, which is required for a level four or five new patient or consult code.
Using the 1995 guidelines, a physician only has to examine eight body/ organ systems with one element each, and you can determine those examination points. Compare this with the 1997 guidelines, which required the complete genitourinary exam, with the shaded and unshaded areas, or the multi-system exam that required nine systems with at least two elements predetermined by the documentation guidelines, and you will see a significant difference.
Implementing the 1995 guidelines –
To implement the 1995 guidelines, start by building your own 1995 physical exam forms, one for male and one for female patients. Next, develop your own set of bullets for the eight systems that you would normally check if you were performing a complete physical exam. Add to it the extra ex-amination points that you normally would examine in the genitourinary system and the abdomen, plus any other frequently checked areas (check http://PRScoding.com/ for a sample form.). The form should not only allow for the patient you are completely examining, but also provide for an ex-tended exam in the genitourinary system and one related system for other patients.
The bottom line: It’s easier to use the 1995 documentation guidelines. For those who have not attended one of the PRS or AUA seminars in the last 2 years and who may not have an updated pocket card and wall chart, Watson Pharmaceuticals will be delivering the latest version to your offices in the future. Ask your Watson sales representative for copies.
The established patient –
In the established patient, you only need two of the three key components (history, physical examination, and medical decision making). Because “medical necessity” should be the underlying factor that determines the level of service we provide in all services, medical decision making should be the determining factor for coding most established patient E&M visits.
Therefore, for the vast majority of your established patient visits, you should document and code using two of the key components, history and medical decision making. Medical decision making should be the determining factor.
The documented history should always be at or above the level of medical decision making. History should never be the limiting factor on a charge. Physical exam becomes strictly a matter of “good patient care.” Perform and document the physical exam that you feel is necessary. A limited exam will not decrease your coding level.
The major exception to the history/medical decision-making rule occurs when an established patient is to be admitted to the hospital and requires a complete history and physical. In this case, history and physical, by medical necessity, would become the two key components on which to base your coding.
If you are performing a level four or level five new patient or consult visit, as determined by medical decision making, and a complete physical is indicated, as determined by a medical necessity, then be sure you have examined at least one of eight systems. If a complete exam is not indicated, then you can reach a level three new patient/consult code by having an extended exam in the affected organ system (examine at least four elements in the genitourinary system) plus an extended exam in a related organ system element (examine at least four elements in a related system or at least one item in four or more additional systems).
In summary, become streamlined by coding your established patient visit based on your medical decision making, collect adequate history to support that level, and perform the physical exam only as indicated by good patient care.
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.
