Coding & Documentation


Fam Pract Manag. 1998 Sep;5(8):23-24.

Documenting decision making for a new problem


Some of my colleagues claim that score sheets used by Medicare reviewers to evaluate the “diagnosis and management options” component of medical decision-making documentation define a new problem as one that is new to the examining physician. Are they correct?


Physicians at the 600-physician Marshfield Clinic, a regional 32-site multispecialty group based in Marshfield, Wis., use the definition you've described, and so do other physicians across the country.

The documentation guidelines were beta-tested at Marshfield Clinic before HCFA released them in 1994, according to Catherine Fischer, reimbursement policy adviser for the group. As part of that process, Marshfield Clinic staff helped their regional Medicare carrier to develop an audit worksheet that included score sheets for the decision making portion of the documentation guidelines. The carrier medical director continued developing the worksheet after taking a post at HCFA, and a version was eventually distributed to carriers for use by auditors.

Fischer says it was Bart McCann, MD, former executive medical officer at HCFA, who offered the definition of a new problem that you mention. “His explanation makes complete sense,” Fischer says. “The decision making guidelines were designed to give physicians credit for the complexity of their thought processes. Giving a physician more credit for handling a problem he or she is seeing in a particular patient for the first time, even when that problem has been previously identified or diagnosed, is within the spirit of the guidelines.”

But that definition never made it into the documentation guidelines, because the score sheets didn't. The score sheets that define a new problem as new to the examining physician are part of the Marshfield Clinic's audit worksheet, which is now used by physicians, professional coders, Medicare carrier staff and the Office of Inspector General to evaluate documentation, Fischer says. The worksheet is sold by the Medical Group Management Association (303-397-7888).

Before you decide to follow your colleagues' lead, there are a couple more facts you should consider:

  • A score sheet obtained from a carrier by FPM and used as a source for the FPM Pocket Guide to the Documentation Guidelines1 defines a new problem as a previously unidentified or undiagnosed problem.

  • HCFA acknowledges that its reviewers use score sheets but says their use is neither encouraged nor prohibited.

We suggest you ask your regional Medicare carrier's medical director how reviewers evaluate the complexity of decision making. If they use score sheets, ask how a new problem is defined for the purposes of scoring diagnosis or management options. If they don't use score sheets, make sure they're including diagnosis and management options and data reviewed in their assessments. The table included in the guidelines makes risk the most concrete of the three decision making components, but all three must be carefully evaluated to fairly approximate the physician thought process.

Routine venipuncture


If a patient presents for a blood draw for lab work, can I code 36415* for the venipuncture and 99211?


When a starred procedure such as 36415* is the major service provided at an established patient follow- up visit and that procedure is the main reason for the visit, an E/M service is usually not coded in addition to the procedure. If a lab test were then performed in your office lab, a code for the test could also be submitted.

Intrathecal anesthesia


What is the code for intrathecal anesthesia? Is this part of the global OB service?


The appropriate code is either 00946 (vaginal delivery) or 00850 (C-section). The anesthesia is not part of the global OB service and should be coded separately. Note that if you perform the delivery, you should submit modifier -47 with the anesthesia code.

Prolonged labor and a C-section


One of my obstetric patients, whom I'd seen monthly during her second and third trimesters, recently experienced prolonged labor with abnormalities in the fetal heart rate that required my continued presence at the hospital. After attending for six hours, I determined that a C-section was needed. I called an obstetric surgeon and assisted at the C-section. How should I code these services?


The codes for your services should be 59425 for antepartum care of four to six visits; 99223 for initial hospital care, including the admission history and physical; 59514 with modifier -80 for assisting at the C-section; and 59430 for postpartum care. The initial hospital care code would account for just 70 minutes of the time you spent managing the complicated labor, so you should submit the prolonged service codes to account for the balance of your six hours: 99356 (for the first hour of prolonged service) and 99357 (for each additional 30 minutes). The obstetric surgeon should bill 59514 for the C-section.

Lab panel codes


If I don't do a particular test on a lab panel, can I still use the panel code?


No. CPT indicates that all tests in a panel must be performed to submit the panel code. In the case you described, you would need to separately code each test you performed. And, of course, your documentation should include a diagnosis code and supporting documentation that clearly establishes the medical necessity for each test performed, whether the panel code is used or the tests are coded separately.


1. Henry LA. Three documentation tools that work. Fam Pract Manage. 1998;5(1):29–41.

Kent Moore is the AAFP's reimbursement issues manager and a contributing editor to Family Practice Management.

Leigh Ann Henry is an associate editor for Family Practice Managment.

Editor's note: While this department represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will accept the coding recommended. For more detailed information about the codes mentioned, refer to the current CPT manual.


Copyright © 1998 by the American Academy of Family Physicians.
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