calculate the level of History, we take all our checked boxes, and if there are no categories with all there checks, to determine our level we then move to the furthest to the left to determine.

PO Coding Project

A Guided Walk Through for CPT/HCPCS Coding of Case013

Getting to know your document:

Since these PO cases were created, and not “authentic” records so they are not an entirely full patient record, thus some information may not be present that you would typically find in a patient encounter. However, there is enough information here to accurately assign procedure codes.

In this scenario, page one is a standard patient summary, or face sheet. We take note of things like that patient’s age, sex, etc. Also of importance, is the location, however you know this is a physician’s office record. In many cases you will need to determine if this is a new or established patient. The documentation on that will vary based on the type of EHR used. For the sake of this project, we are saying all patients are established.

What do you need to accurately assign an E/M procedure code:

You might remember from Chapter 7, there are some key criteria you need to know to accurately assign an E/M procedure code.

First question: What are the criteria for determining the level of service: 2/3 key components, 3/3 key components, time or other?

Our case is an established patient, so we need to meet 2/3 key components of a code to assign it.

This means, our code assignment is already narrowed down to the subsection within the E/M section to, Established Patient, 99211-99215.

What do you need to accurately assign an E/M procedure code:

Next question, What level of history was taken by the provider?

The history is designed to act as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter.  The history is composed of four building blocks:

Chief complaint (CC)

History of present illness (HPI)

Review of systems (ROS)

Past medical, family and social history (PFSH)

All levels of history require a chief complaint and some form of HPI (or Interval History), but not all levels of history require an ROS or PFSH.

The E/M guidelines recognize four “levels of history” of incrementally increasing complexity and detail:

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

There are many flowcharts/code builders that you can use to help identify these levels of history more clearly. See one example here:

Using our case, the following can be chosen based on documentation:

To begin, the HPI:

Our focus here is on the history of present illness. Related to his chief complaint, there is really only the “location” of pain or discomfort documented here. So, that gives us 1 element for HPI. This already directs us to the “Brief” column.

Next, the ROS:

Not all ROS are going to be labeled ROS so sometimes you need to read through the documentation to pick it out. It could look something like this:

REVIEW OF SYSTEMS:

GENERAL:  The patient complains of fatigue. No headaches or dizzy spells.

HEENT:  The patient does have glaucoma. She has decreased vision and is blind in the right. Sinuses:  No complaints.

CARDIOPULMONARY:  She gets swelling of the legs but no chest pain. She does have shortness of breath, no wheezing.

GASTROINTESTINAL:  She has frequent heartburns. Has known gastroparesis. Denies both diarrhea and constipation, blood or mucus.

GENITOURINARY:  She denies dysuria, bleeding and incontinence.

MUSCULOSKELETAL: She has a lot of arthritic complaints including stiffness, weakness.

She has slow healing. The patient seems to be feeling well

Or this:

REVIEW OF SYSTEMS:  The patient denies any fever, weight change. Denies any sore throat, ear pain, rhinorrhea. Denies any double vision, blurred vision or eye pain. Denies any shortness of breath, cough or pleuritic chest pain. The patient denies any nausea, vomiting or diarrhea. The patient does not have any dysuria, frequency or urgency. The patient does have myalgias in the back and legs from the sickle cell pain but no bony tenderness. The patient does have a history of anemia and has required transfusions in the past. He denies any bleeding or easy bruising.

NOTE: Our case does not have a documented ROS.

Our last element in the History is PFSH:

Past History

Prior illnesses or injuries

Prior operations

Prior hospitalizations

Current medications Note: Documenting these is part of the criteria for reporting Physician Quality Reporting System PQRS measure 130

Allergies

Age-appropriate immunization status

Family History

The health status or cause of death of parents, siblings and children

Diseases or eye problems of family members that may be hereditary or place the patient at risk, e.g., family history of diabetes, glaucoma, strabismus, amblyopia, cataracts before age 50 and age-related macular degeneration

Social History

Marital status and/or living arrangements

Current employment helpful for glasses selection/needs

Use of drugs, alcohol or tobacco

Our PFSH review covers the medications, previous illnesses, etc. All of these count as our Past History, for this patient. There is no Family History documented. The fact that his veteran status is mentioned is enough to also check “Social”. This brings us to the ‘Complete” level of PFSH with 2 areas being done.

To calculate the level of History, we take all our checked boxes, and if there are no categories with all there checks, to determine our level we then move to the furthest to the left to determine.

One element down, two to go!

Next is the physical examination:

The systems are broken out like this:

Our review of the Physical Exam:

So, the physician documents:

General appearance (patient is alert, oriented, not in any distress, pleasant)

Respiratory (chest is clear)

Cardiovascular (NSR – normal sinus rhythm)

Gastrointestinal (Abdomen: soft, benign, no masses felt and rectal exam)

Last component of our E/M Procedure is Medical Decision Making:

This is arguably the most important of the three key components because the Medical Decision-Making (MDM) reflects the intensity of the cognitive labor performed by the physician. The official rules for interpreting the MDM are identical for both the 1995 and 1997 E/M guidelines. There are four levels of MDM of incrementally increasing complexity:

Straightforward

Low Complexity

Moderate Complexity

High Complexity

Physicians must stratify the MDM into one of the above levels of complexity based on:

The nature and number of clinical problems

The amount and complexity of the data reviewed by the physician

The risk of morbidity and mortality to the patient.

Risk is determined by referring to the four levels of medical jeopardy