Suffering From Incorrect E/M Billing? Find Out Fast

Medical Office Front Desk Pro 2009

See if you need to hone your E/M coding skills with this quiz.

Evaluation and management services represent the bulk of what most practices bill these days. So if your E/M coding knowledge isn't up to snuff, your practice could be missing out on major reimbursement or risking compliance issues.

Find out if you're properly billing the E/M services your physicians perform with these five quiz questions, then see below for the answers.

Question 1: The physician puts an asthma patient on steroids and changes his inhaler settings after an exacerbation. The patient returns the next week for a scheduled follow-up. The provider asks the patient if he is having any breathing trouble since his medication change. What review of systems (ROS) level does this represent?
A. Problem-pertinent ROS
B. Extended ROS
C. Complete ROS
D. None of the above.

Question 2: A patient who is new to the area makes an appointment with the physician for a yearly physical and to discuss chronic diagnoses of asthma and depression. The physician performs the preventive medicine service and has a long discussion with the patient regarding the chronic diagnoses. The documentation supports the annual physical code and also has enough stand-alone documentation to bill an E/M with the visit. Which of the following should you bill?
A. New patient physical only.
B. Established patient physical only.
C. A new patient physical with the appropriate-level new patient E/M.
D. A new patient physical with the appropriate-level established patient E/M.

Question 3: Your physician sees an established five-year-old patient with severe chronic allergies. The patient is not presenting with any symptoms currently. Your physician documents a detailed history, a detailed exam, and low complexity decision making. You can report 99214.
A. True.
B. False.

Question 4: A patient comes into your practice in the morning for some lab draws and an echocardiogram. Later the same day the patient comes back and sees another physician (in the same specialty) for coordination of care based on the findings. How would you report these services?
A. Report a separate E/M code for each visit.
B. Report just one E/M code that represents the combined service levels of both visits.
C. Report just one E/M code, ignoring the second visit all together.
D. None of the above.

Question 5: The physician sees a former patient who was in an automobile accident. The physician does a comprehensive history and examination and documents medical decision-making. The E/M medical necessity level meets the criteria for 99214. The physician spends additional time answering the patient's many questions and helping her to understand her options. The total visit takes 60 minutes. What code(s) should you report?
A. 99214
B. 99214-21
C. 99214, 99354
D. 99354.

Answer 1: A. This is an example of a review of systems (ROS) that is problem-pertinent. The physician performs this ROS when he reviews only the system related to the patient's problem.

Depending on the other encounter specifics, a problem-pertinent ROS can support up to a level-two new patient E/M (99202, Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision- making ...) or a level-three established patient E/M (99213, Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision- making of low complexity ...).

Tip: Many follow-up visits for patients with plans of care in place result in problem-pertinent ROS.

Answer 2: C. You should report a new patient physical and new patient E/M. The patient remains new throughout the initial encounter. So you should code such encounters with 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual ...) and 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the new patient E/M code (99201-99205) if you have separate documentation that supports both services.

In the October 2006 CPT Assistant's Q&A, the AMA confirmed that if a physician provides a preventive medicine service and an office or other outpatient service during the same patient encounter, you can appropriately report both services as new patient codes if the patient meets CPT's definition of a new patient as one "who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Therefore, you should consider the patient's status for the encounter, not for the individual portions of the overall encounter.

Answer 3: True. According to CPT rules, you need two out of three elements to support an established patient E/M service. In this case you have a detailed history and a detailed exam, which supports a level-four office visit code, as long as there is medical necessity for a level-four established visit.

Important: Medical necessity must support the level of your coding. With this patient, due to his severe chronic allergies, the physician is justified in performing a detailed exam and detailed history even though his medical decision- making (MDM) is only low level.

If the nature of the presenting problem won't support a higher-level E/M service, you can't get paid for the service just because the physician documented a higher-level history and exam. Medical necessity is the overriding factor that should determine the service level.

Remember: MDM does not equate to medical necessity. Just because MDM is low for an established patient, that does not mean there is not medical necessity for the physician to perform (and bill) a level-four visit. Because of the way you must calculate MDM -- using the number of diagnostic options the physician considered, using the number of testing tests he ordered, and/or using the table of risk -- the MDM does not have a one-to-one equality for medical necessity, in particular for a patient who happens to be exhibiting control for a previously uncontrolled chronic disease symptoms.

Answer 4: B. Medicare 30.6.5 Physicians in Group Practice (Rev. 1, 10-01-03) states that physicians in the same group practice who share the same specialty have to bill and be paid as though they were a single physician.
If a patient receives more than one same-day E/M (face-to-face) service by the same physician -- or more than one physician in the same specialty in the same group -- you can report only one E/M service. The only exception would be if the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a service level that represents the combined visits and submit the appropriate code for that level.

Tip: Physicians in the same group practice who are in different specialties can bill and be paid even if they're members in the same group.

Answer 5: C. You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history, a detailed examination, and medical decision making of moderate complexity ... Usually, the presenting problem[s] are of moderate to high severity). Then, add prolonged services code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient evaluation and management service]) along with 99214. Note that CPT deleted modifier 21 this year.

-- Answers provided or reviewed by Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.