Coding: Because You Asked

June 1, 2006

Coding expert Bill Dacey answers some of the questions he hears most.

QDo I always need to have a physical exam for a new-patient visit?

A No. In the American Medical Association’s CPT manual, new-patient visits require all three of the basic E&M components - history, exam, and decision-making. But these three components are not the sole methods of measuring visits or assigning codes.

If counseling or coordination of care is the predominant characteristic of the encounter, the more accurate way to assign the code is by time, rather than by the visit’s key components. It’s true that most encounters are not characterized by counseling, but if a provider or coder tells me there was no exam, one of my first questions is whether discussion constituted a large part of the visit.

And take care not to overlook time spent with patients within inpatient settings as well. While outpatient time is measured by how long you spend face-to-face with a patient (and/or family, per the AMA), inpatient time can include much more of what is regarded as coordination of care.

QFor established patients in which only two of the three E&M components - history, exam, and decision-making - are required, does it matter which two?

A Neither the CPT manual nor any third-party payer of which I am aware specifically delineates a hierarchy among the three components. That said, the medical decision-making component is the one most closely linked to medical necessity - and the payer community certainly has an opinion on that.

But suppose one were to base an E&M code on the history and exam components alone, and these were deemed excessive or beyond the level of decision-making required by the medical necessity apparent in the visit. Some payers may suggest that the provider had overreached and hence overcoded - although technically the code is supported.

Ultimately, this is resolved by whose perception determines the level of medical necessity - the provider or the payer? Most contracts and manuals I’ve reviewed give the payer the right to determine necessity, so it may be best to ensure your thinking is at least close to that of your payer when it comes to determining necessity.

Since medical necessity is so closely linked to decision-making, it makes sense to make a rule for your providers that for established patients, of the two required components of E&M, medical decision-making must be one of them. There is some safety in this approach.

QIs there a rule regarding the sequence in which modifiers must appear on a given code? For example, if you are using modifiers -50 and -52, or -59 and -LT?

A There is no all-encompassing rule to my knowledge. The modifiers are listed in the HCPCS II and CPT manuals for use as needed. However, individual payers may have different requirements regarding sequencing.

In general, one would first sequence the modifier that affects reimbursement, that is, modifier -59 before modifier -58. Or modifier -50 before modifier -76, for the same reason.

These modifiers are most likely processed first by a computer, so you would want the first step in a calculation involving payment to make the more definitive impact. Common sense should prevail here in the absense of specific guidance. Remember that the purpose of modifiers is to impart information - some particular circumstance surrounding the use of the code or codes in in a specific instance. They tell a story.

QShould I use preventive service codes or regular office visit codes for camp physicals and sports physicals required by schools?

A Neither one of those code types is really appropriate for the services described. No insurance policy I’ve ever seen has specifically covered those services. Most policies cover either medically necessary office visits or some periodic health maintenance services, but not something as limited and focused as camp and sports physicals.

These types of services should really be handled outside insurance plans. Simply charge a fee commensurate with their value and request cash for the service. Make this practice policy known and post it in your office.

You don’t want to waste a real preventive service code on a less comprehensive service like those above. Most people only get one full preventive visit a year. A service of this type coded as an office visit could be viewed as a false claim.

QI don’t always get paid when I use modifier -25 on an E&M code. Some insurance companies also make me submit specific documentation. What can I do about this?

A Modifier -25 is added to an E&M code when there is a “separate, significant, and identifiable service provided on the same day as a procedure or other service.” When you use one with your E&M code, first be certain that you are actually providing two “separate” and “significant” services. Second, be certain that your documentation clearly supports these claims.

Your specific payment issues may have several causes. First of all, remember that what any given payer reimburses for services rendered is not only based solely on your coding of those services, but also on the payer’s reimbursement policies regarding that code or codes. Over the years, some providers have added an E&M visit to every office procedure performed. This has certainly made payers somewhat wary.

Most payer claim adjudication involves computer edits that may compare both the CPT codes and the ICD-9 codes for the services rendered. If the services are “related” on that level, the systems tend to cut one. Some systems may simply require that all such “combination” services have supporting documentation sent in for review. Some providers have alleged that this is simply an added burden to discourage follow-up on a denial, but whatever the reason, it is a reality.

To help with this aspect of claims follow-up, ensure that your documentation really does indicate “separate and significant.” When two services are provided - for example, a “visit and procedure” or “medical visit and health maintenance” - break the chart into two sections. Label these sections “procedure” and “maintenance” or “medical management.” If you have performed two services, document those two services. Determine which each of your payers require for reimbursement.

QMy doctor only writes “here for FU” (follow-up) in the History of Present Illness (HPI) area. When I audit her charts she always scores low on the history section as a result. She says it’s because there aren’t any problems that day to report. Is that acceptable?

A You both have some legitimate concerns. First, if your physician just writes “f/u” on all her established visits, she is essentially giving up the history component as supporting documentation for the visit - so the exam and decision-making better be clear.

In part the issue has to do with the way the HPI is defined. The original 1995 guidelines listed only the attributes likely associated with an acute visit - descriptors such as “duration, location, severity” etc. If a patient is presenting for follow-up of something - such as chronic disease processes - then these descriptors don’t fit.

It could well be that a patient is presenting for follow-up of something like an ankle sprain, in which case the provider really should provide some detail. For example, “follow-up of ankle sprain last Thursday, seems to have responded to ice, elevation, and air cast over weekend, swelling down, less pain w/ ambulation.” That tells the story and should likely be part of the patient’s record.

However, in the case of a patient who presents for follow-up of hypertension, hyperlipidemia, and diabetes, we really have a different concern. Truly that patient is there that day because the provider told him to come back. He has no complaints - this is probably what the physician in the question is referring to.

So how do we handle that in the HPI? The 1997 federal guidelines gave us a provision for that very instance, at least when you have three chronic problems to deal with. If the provider gives a brief status of the patient’s chronic problems, that is considered an extended HPI.

Many providers fall a bit short here, but are on the right path. They’ll say “here for f/u of HTN, lipids, and DM.” This is a list of problems, not the status of the problems. The HPI they should be aiming for looks something like this:

“Here for 3 months’ f/u. Pressures running in the 130s at home, checks regularly. No palpitations, muscle aches - watching diet and execising to HR 135 in hopes of lowering statins. Sugars down to 90 in the AM, good job monitoring, no polydipsia, polyuria - continues on meds - see current list.”

Although sizable and quite subjective, you can’t “can” this or even make a macro out of it; this is likely the conversation you had with the patient who visited you for “f/u” and this is what his record should state. It also has the advantage of meeting the criteria for a detailed history - the one most likely associated with this type of presentation for an established patient.

Many practices follow a protocol in which the nursing staff fills in the chief complaint or the beginning of the HPI. This can often set the practice off on the wrong foot if it is not done well. We often see CC/HPI that consist solely of “f/u,” “med refills,” or “f/u labs.”

What is really behind each of these statements is a chronic disease follow-up visit. Give such visits appropriate detail. Perhaps your providers can work with their nursing staff to provide some of this detail based on their initial evaluation of the patient.

To summarize, for acute problems do try to address the four elements of the HPI. Be sure the HPI contains the adjectives relevant to the patient’s problem such as where, when, how long, how bad, and what makes it better. To develop good documentation habits, record four of these decriptors if possible. This will meet the highest level of any HPI and will not allow the HPI to limit your code selection. For patients with chronic problems, writing a brief status of each encounter is the best way to go.

QCan the nurse do the HPI?

A Although not in the form of an actual guideline, CMS has responded to queries of this sort by stating that it is their expectation that the HPI be taken by the provider.

Federal guidelines have always suggested this, in that they state ancillary staff may obtain a review of systems and a patient’s family and social history. However, they do not include the HPI in these guidelines. For commercial payers, the answer is variable, as many of these companies and plans do not always provide this type of detail regarding documentation requirements.

To be on the safe side, be certain the provider addresses the HPI. If the language in the note does not indicate that the provider actually obtained the HPI data personally, then the provider should indicate specific knowledge of the HPI. If an entire HPI is not repeated when taken by other staff, it is often added. At the very least, the provider should indicate “HPI as above significant for XYZ.” This is borrowed from the teaching guideline methodology, but it should also suffice to meet federal standards. Don’t allow ancillary histories to stand alone without provider commentary and additions.

Bill Dacey is principal in The Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor who has been active in physician training for more than 15 years. He can be reached at or via

This article originally appeared in the June 2006 issue of Physicians Practice.