Four Quick Documentation Strategies to Satisfy E/M Guidelines

Despite the confusion over the implementation of the 1997 Evaluation and Management (E/M) Guidelines, EDs must still adhere to either the 1995 or 1997 version. The 1995 guidelines are considered most beneficial to emergency medicine. Here are some key tips to ensure ED physicians are providing the right documentation to justify the appropriate level of service.

Remind ED physicians to document vital signs, orders, ED course, critical care time in dictations. (Coders dont always get the nurses notes.) For templated records, review for consistency and accuracy in how templates are used. Routinely communicate problems to physicians until resolved. Provide copies of records that indicate inconsistency between stated problems or RN/MD notes.

Encourage physicians to discontinue use of term non-contributory, when documenting the history. Recommend, reviewed and negative. Ask them to indicate whether nurses notes have been reviewed, and include references to pertinent information.

Remind the MDs to always record their review of system(s) identified in the history of present illness, plus other related systems. Remind them also that they must have a review of systems for all E/M levels but the lowest (99281).

If patient information is unobtainable or unreliable, the physician must record the reason for this in order to satisfy stated requirements.

G0105, 45378: Use This Coding Combination For Your High-Risk Patients

Irrespective of findings, stick to V10.05 to define condition.

Correctly reporting colorectal cancer screenings on patients at high risk for the disease can depend on fine points like allocating the right V code. Read this expert medical coding article and know what ICD-9 codes apply in this scenario.

Examine the following given scenario and the medical coding advice that follows to ace these claims -- and recover your deserved reimbursement for these services:

Scenario: A patient has a personal history of colon cancer, went through treatment for colon cancer six years before, however she is presently facing no symptoms. Her 2006 colonoscopy came out clear, as well as her recent one carried out about a month ago. You billed 45378 for the procedure, and then you selected V10.05, from the ICD-9 codes, for the diagnosis. Though, the patient called complaining you should've billed the procedure as routine as her last two colonoscopies were clean. How would you resolve this?

Choose G0105 Or 45378, But Get The History Diagnosis Right

In case you're billing Medicare, you smust report the procedure as a high risk screening with code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Then, from ICD-9 codes, report V code V10.05 (Personal history of malignant neoplasm of large intestine) as the primary diagnosis.

Code V10.05 fits the bill for primary diagnosis as the patient presents to the office for a screening exam and not precisely for follow-up assessment of the cancer. In case the encounter's purpose is for cancer surveillance and follow-up at an interval close by the surgical treatment, you could, as an alternative, code V67.09 (Follow-up examination following other surgery) as your primary diagnosis. Though, keep in mind that this ICD-9 code is seldom used.

On the contrary, certain commercial carriers would need the code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with modifier 33 (Preventive services) appended to signify that the service was preventive, and the V code V10.05 as diagnosis.

Don't forget: From ICD-9 codes, you must list V10.05 as your primary diagnosis for both circumstances (Medicare and commercial payers), irrespective of the fact that the results were clear or not. Use this ICD-9 code if all treatment focused toward the cancer is complete and there are no symptoms of current disease . Don't make the error of reporting a cancer code (153.3, Malignant neoplasm of sigmoid colon) or the family history code (V16.0, Family history of malignant neoplasm of gastrointestinal tract).

Draw On Diplomacy To Confer With Patients

Complaints like this from patients on a screening colonoscopy are common in the gastroenterology practice. The best guidance is to talk it out with your patient, and make clear how their cancer history influences the medical coding.

PTCA, Stenting, and Cutting Balloon

Question: We have a coronary intervention operative report indicating that the physician performed a percutaneous transluminal coronary angioplasty (PTCA) in the LIMA graft to the first diagonal and placed a stent in the proximal left circumflex coronary artery. He next performed a cutting balloon angioplasty in the left anterior descending coronary artery. Which codes should I report?

Ohio Subscriber

Answer: You should report CPT 92980-LC (Transcatheter placement of intracoronary stent[s] ...; single vessel; left circumflex) for the stenting in the left circumflex coronary artery and +92984-LD (... each additional vessel [list separately in addition to code for primary procedure]; left anterior descending) for the PTCA in the left anterior descending coronary artery.

Even though the physician treated three coronary lesions (PTCA to the left internal mammary bypass that feeds the first diagonal, stent to the left circumflex, and PTCA to the left anterior descending), you would report only the stent to the left circumflex (92980-LC) and the PTCA to the left anterior descending (92984-LD).

You should list coronary interventions as being performed in one of the recognized coronary arteries (left anterior descending, left circumflex or the right coronary). And, you can report only the most intensive intervention the physician performed in each of these three recognized vessels.

You should report the PTCA in the LIMA bypass to the first diagonal as an intervention in the left anterior descending coronary artery, because the first diagonal is a branch of this recognized coronary artery. Since the physician performed a more intensive procedure in the left circumflex (that is, placement of a stent), you would not report this PTCA separately.  

Report the cutting balloon angioplasty as a PTCA rather than an atherectomy. The definition of atherectomy is the removal of atherosclerotic material (such as plaque). A cutting balloon is a PTCA balloon outfitted with three tiny blades. When the physician inflates the balloon, the blades score the inside of the plaque ring creating three incisions. These incisions allow the physician to dilate the ring of hardened plaque with much less force than if he made no incisions.       

The only modifiers you would report are the anatomic modifiers, which indicate the coronary artery in which the physician performed the interventions. There are no professional or technical component modifiers for these coronary interventions.

You Be the Coder: Re-Explantation and Revision

Question: We have a patient who had a dual-chamber pacemaker system inserted by one of our cardiologists. Four days later, the same cardiologist repositioned the ventricular lead. For this, the cardiologist had to explant the generator, test and reposition the lead, and reinsert the generator.  Should I report 33215-78? Three days after that lead revision, the same doctor had to put in a completely new lead. Should I use 33217-78 and 33235-78?

Idaho Subscriber

Answer: In the first scenario, you should report the lead repositioning using 33215 (Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator [right atrial or right ventricular] electrode) and the fluoroscopy using 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation; professional component) - as long as you have documentation that supports these procedures.

Don't separately report the explantation of the generator and its reimplantation, because the cardiologist reused the same device.

For the second service, removal of the old electrode and implantation of a new one, you are correct to use 33217 (Insertion of a transvenous electrode; dual chamber [two electrodes] permanent pacemaker or dual chamber pacing cardioverter-defibrillator) and 33235 (Removal of transvenous pacemaker electrode[s]; dual lead system). You should also report 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation; professional component) for the fluoroscopy.

You're also correct in appending modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 33217 and 33235, although some insurers may not require this modifier.

Bonus Question: Improve Your Prescription Drug Documentation

Find out what CMS has to say about the management options category
Calculating a patient's risk level helps the physician determine the appropriate medical decision-making level and avoids down-coding E/M visits. But all this work won't mean a thing if you don't understand the Table of Risk's management options category.

"One area of the Table of Risk that has been hotly debated by coding professionals is the meaning of the term 'Prescription Drug Management,' which is listed as moderate risk in the management options category," says Jennie L. Campbell, consulting senior manager with Pershing Yoakley & Associates, a public accounting firm with offices in Knoxville, Tenn.; Atlanta; Tampa, Fla.; and Charlotte, N.C.

Campbell asked CMS about these concerns. Noting that the medical documentation must fully support the reasons and rationale for all prescriptions, a CMS policy contact provided the following examples of "Prescription Drug Management":

1. Writing a prescription;
2. Reviewing and not changing current prescription medications and dosages;
3. Discontinuing a prescription medication; and
4. Decision not to prescribe drug(s) that may cause potential side effects or interactions with current medications. 
 "Further, it is clear from the background information provided by the CMS policy contact that a moderate risk level for prescription drug management can be assigned whenever a prescription drug has been prescribed for a patient," Campbell says. "It is not dependent on whether the drug is of short or long duration. 'Prescription Drug Management' can include an injection given in the office or an oral prescription drug that will be taken for two weeks."

You Be the Expert: Should You Factor Patient's Status?

Question: During an office visit, my doctor performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?

Washington Subscriber

Answer: The patient's status changes the office-visit level. That's because you must meet the requirements for two of the three components for established patient visits, but new patient services mandate that you meet all three components. And the documentation requirements for each level are not identical. A level-four established patient visit (99214), for example, requires a detailed history and exam and a moderate level of complexity.  The same level of new patient visit (99204) requires a comprehensive history and examination and a moderate level of complexity.  

Report a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...) if the physician evaluated an established patient. You should report 99201 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient. Disregard the lowest of the three components if billing an established patient visit. In the above scenario, you may ignore the problem-focused exam, which leaves you with low-complexity decision-making, and an expanded problem-focused history. The two highest components of the visit meet 99213's requirements.

New patient visits require all three key components, so you should report new patient E/M services based on the lowest component. In this case, the physician uses problem-focused exam, which qualifies for 99201.

Are You Next on the Feds' List?

If more than 35 percent of your ICDs are dual-chamber, you could be raising a red flag

The new Medicare coverage decision means more ICDs for the patients who need them, but you should tread carefully if your implanting physician is using more dual chambers rather than single chambers. Both services may warrant the same code - but database information could signal an audit.

Although you can code both single- and dual- chamber devices the same way with 33249 (Insertion or repositioning of electrode lead[s] for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator), your electrophysiologist (EP) should be inserting more single- than dual-chamber ICDs.

"Only two types of patients would be right for dual- chamber ICDs - 1. patients with atrial arrhythmias (so that the atrial lead will help diagnostically and possibly avoid shock therapy) and 2. patients with a bradycardia (427.89). They would only account for around 35 percent of the population," says Eric Prystowski, MD, director of the electrophysiology lab at St. Vincent Hospital in Indianapolis and the editor in chief of the Journal of Cardiovascular Electrophysiology.

Audit signals: Therefore, when the implanting physician enters the patient's information into the database, CMS may be able to tell if the hospital performed 80 percent dual chambers, which would be way over margin and could flag an audit, Prystowski says.