Stop losing money! Code better

September 15, 2006

If you want to get paid for the care you provide, you can't afford to ignore these coding tips.

Martin Fayette, a family physician, evaluated a 67-year-old patient for uncontrolled Type II diabetes, atrial fibrillation, and a new problem of knee pain. He documented a detailed history and examination, as well as moderately complex medical decision-making. But instead of billing a level 4 (99214) office visit, for which Medicare pays an average of $83, he billed a level 2 (99212) visit, which garners about $39. If Fayette did this with 10 patients a week, 50 weeks a year, he’d be losing some $22,000 annually. (Note: Medicare figures mentioned in this article are averages. Actual payment varies by location.)

When a patient came in for an annual checkup, internist Audrey Brock injected the patient’s knee with Celestone, but didn’t add modifier –25 to the E&M code 99396 to indicate that she had provided a separately significant, identifiable service. As a result, the claim for the checkup was rejected, and Brock lost $108. Such erroneous reporting, even if it occurred just once a week, would cost Brock’s practice $5,400 over 50 weeks.

Fayette and Brock are fictitious physicians, but the situations attributed to them occur frequently in medical offices. Coding mistakes-often due to confusion about coding nuances, use of out-of-date codes, or misunderstanding of documentation guidelines-are common, and they deprive physicians of revenues to which they’re entitled.

1. Get a comprehensive medical history, or an updated one, before every visit.

These help you determine the nature of the presenting problem, and reduce the likelihood that the visit will be undercoded. Use patient history and update forms that contain specific questions: Do you have headaches? Shortness of breath? Chest pain? Is the pain mild, moderate, or severe? Is it constant or intermittent? When you get it, how long does it last? Those sorts of queries will yield more helpful information than "Has there been any change in your health since you were last here?"

According to Stephen Levinson, an otolaryngologist in Easton, CT, and author of the book Practical E/M: Documentation and Coding Solutions for Quality Patient Care (American Medical Association, 2006), obtaining and evaluating histories and updates often reveal additional medical issues, some of which may warrant a higher level of care-and a higher E&M code-than the presenting problem. This higher level of care may include ancillary services, therapeutic procedures, or follow-up visits, all of which are separately billable.

2. Select the ICD-9-CM code that accurately identifies the illness.

Many doctors, in their haste to complete the billing form, dash off a general diagnosis code, and fail to include the details that are crucial for reimbursement. Be sure to use the specific-rather than the general-diagnosis (ICD-9) code, says David Zetter. For instance, the diagnosis code for asthma is 493, but you won’t be reimbursed unless you code five digits. Some possibilities: 493.00 (controlled extrinsic asthma), 493.02 (extrinsic asthma with acute exacerbation), 493.10 (intrinsic asthma), and 493.20 (chronic obstructive asthma).

3. Don’t stint on ICD-9 codes.

Fear of overcoding makes many physicians reluctant to bill for all care provided. "Claims allow for up to four ICD-9 codes," says Zetter. "Too often physicians only document the diagnosis the patient is currently being seen for, even if they review or provide ongoing management of meds and other issues with the patient." By noting these other diagnoses, you’ll be able to document and support a higher level of medical decision-making.