This encounter is coded as 99243 because it included:
- Detailed history: extended history of present illness, complete review of systems, two out of three past medical, family, and social history;
- Comprehensive examination: 12 systems; and
- Moderate complexity decision making: new problem with uncertain prognosis (primary or secondary Raynaud’s phenomenon); extensive laboratory studies ordered; prescription medication therapy initiated.
What Is Different?
When compared to last month’s “Coding Corner,” this scenario is missing documentation of social history—changing the level of this consultation visit and lowering the history level from a comprehensive to a detailed level. Consultation visits require history, examination, and medical decision-making levels.
The change in this scenario is small but significant enough to change the level of the visit. Similar omissions happen quite often in rheumatology practices. Understanding the nuances of coding will ensure that your visits are at the proper level to provide a fair reimbursement for your practice’s services.
Documentation—It’s All in the Details
How many times have you seen charges for an office visit on a super bill that do not match the documentation in the chart? In such cases, you may be tempted to bill out the charges as is, thinking that the physician must have done what he checked off on the super bill.
There is an adage in the coding and billing world: “If it is not documented, it is not billable.” If the practice is audited by a carrier or the Office of Inspector General, there will be no documented proof of what was done during that visit. If there is no documentation to support the level of visit, the visit could be downcoded or even denied as not medically necessary.
There are three key components to building an office visit level: history, examination, and medical decision making.
History is made of up of four parts: chief complaint (CC), history of present illness, review of systems, and past family social history. All four of these elements are needed in order to obtain the level of history. For example, if there is a CC, an extended history of present illness, and a complete review of systems, but no past medical, family, and social history was documented, the history would be brought down from a possible comprehensive level to an expanded problem focused level.
Examination
There are two types of examination documentation: 1995 and 1997. The 1995 version is based on organ systems that include:
- Constitutional;
- Eyes;
- Ears, nose, mouth, throat;
- Cardiovascular;
- Respiratory;
- Gastrointestinal;
- Genitourinary;
- Musculoskeletal;
- Skin;
- Neurological;
- Psychiatric; and
- Hematologic/lymphatic/immunologic.
The 1997 version can be done as a single–organ system exam, such as musculoskeletal, or as a general multi-system exam. The 1997 exam is based on bullets, which are symbols used in each area of the organ systems to reach a particular level (e.g., three vital signs is equal to one bullet). Your level of exam is determined by how many bullets are documented from the different systems.
Medical Decision Making
Last of all is the medical decision making (MDM). Conceivably, the MDM is the most important part of the office visit. There are three components to the MDM:
- Number of diagnoses or treatment options;
- Amount and/or complexity of data to be reviewed; and
- Risk of complication and/or morbidity or mortality.
The level of medical decision making is based on a point system. Points are given based on how sick the patient is and the amount of work the physician has to perform during that visit. Unlike the history, the MDM only needs two out of the three above components to determine the level of a visit.
In the end, the physician must remember that documentation has to speak for the visit. The documentation should be done as if the payer or auditor is standing in the examination room with the physician. If it is clear and concise, there should be no worries if the practice is ever audited.
If you have questions about documentation, contact Melesia Tillman, CPC, CRHC, CCP, at (404) 633-3777 or [email protected].
