Published in the October 2008 issue of Today’s Hospitalist
EVEN PHYSICIANS WITH YEARS of coding experience fall prey to misconceptions about CPT codes. Given how confusing the rules governing these codes are, it’s no wonder that doctors are left scratching their heads. Add to that confusion the “coding legends” that start out as rumors passed among colleagues, and it’s surprising that physicians don’t make even more coding mistakes.
Those rumors, however, can contradict the regulations from the Centers for Medicare and Medicaid Services (CMS) “and jeopardize how much you will be paid. Here’s a look at several common misconceptions, along with advice to steer you straight.
1. Observation codes. Observation codes take the prize for being confusing. Here’s a frequent mistake: Physicians use the code set for same-day admission and discharge (99234-99236) in conjunction with a 99217 discharge code. The problem? The 99217 code can be used only for discharge from observation on a different calendar day.
Add to that confusion the fact that codes 99234-99236 encompass both admission and discharge, so these codes do not require any other E/M service (or CPT code) to be complete. Instead, use 99217 only in conjunction with the 99218-99220 code set, which applies to admission and discharge from observation on different calendar days.
Another common mistake: using 99238 “the code for a standard inpatient discharge “instead of 99217 for a discharge from observation. If you confuse the two, you can count on racking up unnecessary denials.
2. Prolonged service codes. Prolonged service codes are add-on codes used to bill E/M services for patients who require more time than average patients, but who aren’t sick enough to qualify for critical care codes. You need to tailor your choice of a prolonged service code depending on whether you’re providing an outpatient (think ED) or inpatient service; how long you spend providing that service; and whether you and the patient have face-to-face contact during the prolonged service.
Physicians often use the wrong code set for the service setting. For prolonged outpatient services, use 99354-99355; for inpatient services, use 99356-99359.
Another common misconception: You need to bill the highest possible level of E/M before using the add-on code. Instead, your E/M code can reflect a less detailed history or exam or a lower level of medical decision-making. You can report a moderate E/M service level code while documenting the extra time you’ve spent. When using an inpatient prolonged service code, remember to identify whether you provided the service directly to the patient or through non-face-to-face contact.
3. The “non-contributory” trap. Time and time again, auditors find ambiguous statements like “noncontributory” being used to document the elements of patient history. That simple statement, however, does not meet CMS documentation requirements.
Take the category of family history, for example. When a physician writes that family history is “noncontributory,” what does that mean? Does it mean that the physician believes the family history wasn’t relevant to his or her review because of the patient’s condition? Or does it mean that the history was reviewed but not pertinent to the patient’s condition? Here’s a better alternative: “reviewed and non-contributory to patient’s illness.”
4. The wrong caveat. Another common pitfall: using “all negative” as a caveat for indicating negative findings during a complete review of systems.
To qualify for doing a comprehensive history, you need to document that you did a 14-point review of systems and that the review was negative, except for any problems noted. Here are some examples of the right caveats to use:
- The remainder of the systems were reviewed and are negative.
- All other systems are negative.
- A complete review of systems was otherwise negative.
- The balance of the systems reviewed is negative.
5. The body area-organ system mix-up. When dictating findings for the physical exam, physicians often mix up body areas with organ systems.
Doctors must examine eight or more organ systems to qualify for a comprehensive exam. Auditors are often able to take a body area that has been documented and realize that it qualifies for an organ system. Documenting an exam of the neck, back with spine and each extremity, for instance, can meet the requirement for examining the musculoskeletal system.
However, if look at the list below, you will see how much more in-depth the organ systems are.
- Body areas: head & face; neck; chest including breast & axillae; abdomen; genitalia/groin/buttocks; back with spine; and each extremity.
- Organ systems: constitutional; eyes; ENT; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurologic; psychiatric; and hematologic/ lymphatic/immunologic.
- Check all the templates that you use for exams (dictation or otherwise) to make sure that when doing a comprehensive exam, you refer to the necessary systems.
6. Too many assumptions. Physicians also assume that coders can infer the level of medical decision-making that they used to determine a patient’s treatment, instead of clearly spelling that out in their documentation.
You qualify for higher-level, better-paid codes by documenting all diagnoses (either stable or acute conditions) that you treat and by listing all the data you order and/or review.
Don’t assume that coders or auditors can glean that information. Instead, document the following as they occur:
- the review and/or order of clinical lab tests;
- the review and/or order of radiology tests;
- the review and/or order of other tests in the medicine section (ECGs, pulmonary function tests, etc.);
- the discussion of test results with a performing physician;
- a decision to obtain old records and/or history from someone other than the patient;
- a review and summary of old records and/or history from someone other than patient and/or discussion of case with another health care provider; and
- the independent visualization of image, tracing or specimen itself from test performed/interpreted by another physician (not simply review of report).
To avoid misconceptions, don’t assume that your practice partners have a solid understanding of what is and isn’t acceptable. Instead, look to an appropriate source “such as the CPT manual or your CMS carrier “to maintain compliance and maximize what you should be paid.
Tamra McLain is an independent coding consultant in Southern California who is available for in-house training for physicians and coders. E-mail her your documentation and coding questions at email@example.com. We’ll answer your questions in a future issue of Today’s Hospitalist.