Go head to head with our review panel in coding six troublesome progress notes.
Fam Pract Manag. 2002;9(2):41-45
Think about the coding and documentation problems you’ve run into in your practice. Do you undercode some visits? Do insurers frequently downcode or reject your claims? Are you sometimes stumped or puzzled when it comes time to code a service you’ve provided? Studies suggest that coding inaccuracy and confusion are everyday occurrences in many family practices. Consider the following:
• A study published in the May/June 2001 issue of the Journal of the American Board of Family Practice found that family physicians overcoded new patient evaluation and management (E/M) visits 82 percent of the time and undercoded established patient E/M visits 33 percent of the time.1
• The Direct Observation of Primary Care Study found that family physicians either overcoded or undercoded 45 percent of visits.2 The authors of the study determined that “family physicians tend to undervalue the time they spend in longer visits that have less focus on treatment … [and] tend to overcode for visits that are focused on prevention or treatment, more social, less complicated or shorter.”3
The coding recommendations presented in this article were given by a panel of family physicians, consultants and certified professional coders. The reviewers were asked to read each progress note and submit recommendations, which were then combined into the responses that appear in the article. The following people participated in the panel: Robert H. Bosl, MD, FAAFP, Starbuck Clinic, Starbuck, Minn.; Thomas A. Felger, MD, ABFP, CMCM, St. Joseph Regional Medical Center, South Bend, Ind.; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic, Omaha, Neb.; Emily Hill, PA-C, Hill & Associates, Wilmington, N.C.; and Joy Newby, LPN, CPC, Joy Newby & Associates Inc., Indianapolis, Ind.
Family physicians’ problems with coding could be traced to any number of causes, such as the complexity of the codes themselves, limited coding training and inadequate documentation. In any case, it’s an area of practice management that could be improved in many practices. This article will enable you to test your own procedural coding and documentation skills.
The following six progress notes were submitted by family physicians who identified these visits as especially difficult to code. Patient names have been removed and a few minor formatting changes have been made; otherwise, these are the actual notes. Read carefully through each one and then fill in the blank following each note with the procedure code or combination of codes you would submit. After you have coded each note, compare your selections to those recommended by our reviewers in the next section of the article.
Progress note 1
Established patient office visit, annual exam and skin-tag removal, chronic condition.
How would you code progress note 1?
Progress note 2
Established patient office visit, cold symptoms, tobacco user.
How would you code progress note 2?
Progress note 3
Established patient office visit, hernia, chronic conditions.
How would you code progress note 3?
Progress note 4
Established patient office visit, annual exam, chronic conditions.
How would you code progress note 4?
Progress note 5
New patient office visit, chest pain.
How would you code progress note 5?
Progress note 6
Established patient office visit, annual exam.
How would you code progress note 6?
Each of our five coding reviewers suggested how best to assign procedure codes to the visits described in the progress notes you just read. In some cases, the reviewers recommended a particular code or combination of codes based on the documentation in the progress note but also explained how another code might have been appropriate if the documentation had been more complete. You’ll also see that in some cases even the review panel was unable to come to an agreement on which codes were most appropriate. In such cases, we present all points of view and leave it to you to decide which approach you’d be most comfortable taking. (For more information about the coding review panel, see "The Reviewers.")
Progress note 1
Reviewers’ recommendations: 9939x-25 + 11200 or 99213-25 + 11200 or 99214-25 + 11200
For this visit, three reviewers recommended one of the preventive medicine services codes 99391-99397 (determined by the patient’s age, which is not included in this note), 11200 for the removal of the skin tags, and modifier -25 attached to the preventive medicine services code since the procedure was performed on the same day as a significant, separately identifiable E/M service. According to one of the reviewers, “the documentation in this note does not clearly support a service above that included in the preventive service.” However, two reviewers coded this as a problem-oriented visit. One recommended 99213-25, pointing out that the review of systems (ROS) and exam documentation do not cover the range you’d expect for a preventive medicine visit. The other reviewer cited the detailed history, detailed exam and moderate complexity decision making of the visit for the selection of 99214-25.
In all cases, the reviewers commented that the note should have included the number of skin tags removed. The first 15 lesions removed are included in 11200, but for each additional 10 lesions removed, code 11201 can be added.
Progress note 2
Reviewers’ recommendation: 99213
Four of our reviewers agreed that the documentation of the history and exam in this note could support 99214. However, several indicated that the nature of the presenting problem and the questionable medical necessity of parts of the exam would make 99214 hard to defend, so they opted for 99213 instead. The fifth reviewer indicated that the history and decision making supported 99213 and no higher.
Progress note 3
Reviewers’ recommendations: 99213 or 99214
Three reviewers agreed that the documentation in this note easily supports 99213 when the guidelines for history, exam and decision making are applied. Two said the note supports 99214. One reviewer pointed out that the decision whether to code 99213 or 99214 may boil down to how the genitourinary and psychiatric reviews are counted. Also, four of the reviewers noted that if the physician had spent a significant amount of time providing counseling to the patient (more than half of a visit that lasted 25 to 39 minutes) and such encounter time had been documented, 99214 would have been the appropriate code. Code 99213 is associated with 15 to 24 minutes, and 99215 with 40+ minutes.
Progress note 4
Reviewers’ recommendations: 99397 + Q0091 + G0101 or 99214 + Q0091 + G0101
Three reviewers coded this as an annual well-woman exam for a Medicare patient, using preventive medicine services code 99397 and HCPCS codes Q0091 (for the collection of the Pap smear) and G0101 (for the clinical breast/pelvic exam). All three indicated that while they had considered the possibility of submitting a problem-oriented visit code to account for the work associated with treating the patient’s chronic problems, they didn’t believe the note adequately supported that strategy. Several chronic conditions are addressed in the assessment and plan portions of the note but are given too little attention in the history and exam documentation to justify using a problem-oriented E/M code, they said. For example, one reviewer pointed out that headache is not mentioned in the history and there is no documentation of a neuro or HEENT exam. Similarly, rhinitis, although addressed in the history of present illness, is not addressed in the exam.
Two reviewers selected 99214 rather than the preventive medicine services code. One characterized this as a “well-documented, well-woman encounter with management of several chronic conditions.” The other cited evidence of a detailed history, detailed exam and moderate complexity decision making and pointed out that the visit focused more on disease-related problems (stress incontinence, chronic rhinitis, etc.) than on preventive care (e.g., no cancer screening or cholesterol screening were done).
Progress note 5
Reviewers’ recommendations: 99386 or 99386 + 99201-25 or 99204
Three reviewers agreed that the primary focus of this note is on preventive services, and they coded the visit accordingly as a 99386. All three felt that clearer and more thorough documentation of the problem-oriented portion of the visit would have helped make a better case for also submitting a problem-oriented code. For example, one reviewer said the physician should have documented his or her assessment of the chest pain and why the tests were ordered. Two of the three reviewers decided the documentation was sufficient to justify submitting 99201 (with modifier -25 attached to indicate this was a significant, separately identifiable service) in addition to the preventive medicine services code.
The other two reviewers saw evidence in the note of a comprehensive history, comprehensive exam and decision making of moderate complexity, and they coded the visit as a 99204. One reviewer pointed out that, although some screening was done, the patient’s presenting complaint of chest pain makes this a problem-oriented visit.
Progress note 6
Reviewers’ recommendation: 99396
Most of the work of this visit is associated with preventive services, and the consensus among our reviewers was that it should be coded accordingly with 99396. One reviewer said that submitting a problem-oriented E/M code would help to account for the additional work associated with diagnosing and treating the patient’s vaginal infection, but it is difficult to justify billing an additional E/M service for a problem such as vaginitis since the necessary exam is included in a typical well-woman exam. In the words of another reviewer, the vaginal infection was an “incidental finding and did not change the overall focus of the encounter from preventive care.”
How did you do?
Since the reviewers could agree on procedure codes for only two of the six notes, it’s reasonable to argue that there’s no correct answer to some of these coding questions – or, more cynically, that the “correct” answer is up to your insurer. The reason may be inadequacies of documentation or some fundamental mismatch between the E/M documentation guidelines and the reality of practice. Whatever the cause, where our reviewers disagreed, the majority took the more conservative course.
If your coding choices followed those of at least some of our reviewers, you probably have a good grasp of E/M coding. On the other hand, if your coding choices weren’t even close to the reviewers’ recommendations, you might want to consult some resources for improving your coding and documentation skills. (See a list of resources available from FPM.) Either way, perhaps this glimpse into the way your progress notes are turned into reimbursable codes can help you as you document and code your next patient visit.
FPM RESOURCES ON CODING AND DOCUMENTATION
This material is not included in the print version of the article.
FPM’s Coding & Documentation department. If you have a specific coding or documentation question, send it to FPM. We can’t always respond directly, but we can publish answers to selected questions in our “Coding & Documentation” department. (See the department in this issue.) The answers are written by the AAFP’s manager for health care financing and delivery systems and reviewed by the FPM Coding & Documentation review panel.
The FPM Toolbox. The FPM Toolbox offers a number of practice management tools, including a compilation of articles on Medicare’s documentation guidelines, ICD-9 reference lists for family physicians and other coding tools.
Editor’s note: We cannot guarantee that third-party payers will accept the coding and documentation recommended in this article. Because CPT and ICD-9 codes change annually, you should refer to the current CPT and ICD-9 manuals and the “Documentation Guidelines for Evaluation and Management Services” for the most detailed and up-to-date information.