Coding Cues: Answers to your questions about...

Key Points

Mixing the E&M guidelines

We decided to have a certified coder review our charts to help us straighten out any coding and documentation problems. The auditor used the 1995 evaluation and management guidelines. She told me that when I documented the exam portion of a visit, I included both body areas and organ systems in the note and that's inappropriate. I can't see why that's a problem. Is she right?

Yes, she is. The CMS E&M guidelines indicate that you shouldn't combine body areas and organ systems in the same note-you have to use one or the other.

Lengthy office visits

I occasionally encounter a Spanish-speaking patient who has a complex problem that requires an extensive explanation, and I spend a great deal of time making certain he comprehends what I'm telling him. Can I get compensated for the extra time I spend during these visits?

Probably. If more than 50 percent of the visit was spent in counseling and/or coordination of care, you may choose the level of E&M service based upon time instead of the key components of history, exam, and medical decision-making. For example, if you spent 25 minutes face-to-face with an established patient, and more than half of that time was spent explaining treatment options, you could submit code 99214. Your documentation should include the start and stop times for the visit, as well as the portion of time you spent on the counseling and coordination of care. Also note the content of the discussions.

But if you didn't spend more than half the visit on counseling, and the encounter exceeded the typical time for a particular level of service by at least 30 minutes, it would be appropriate to use the prolonged care codes (99354 or 99355). These codes are add-on codes, so they're reported in addition to the E&M code. For instance, the typical time for a 99215 established-patient visit is 40 minutes. If you spend an additional 35 minutes with the patient, the correct coding would be 99215, and 99354, for the additional 35 minutes. Medical necessity must require the extra time, and the patient's inability to communicate falls within that criteria. Remember to clearly document the reason for the visit.

Disrupted anesthesia services

Our group employs an anesthesiologist. Sometimes he'll perform the pre-anesthesia service in our ambulatory surgery center, only to have the surgery cancelled because of a particular medical reason. Can we get paid for his work?

It depends upon the patient's insurer. If he's a Medicare beneficiary, follow the carrier's guidelines regarding the process. You should be able to find them on their website. Some carriers suggest using a level of outpatient E&M that the documentation supports. Some will allow you to submit the unlisted E&M service code 99499 along with the pre-anesthesia evaluation worksheet. Most carriers will price the service based upon the documentation.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.