Coding: Solving Your Top Coding Concerns

October 1, 2006
Bill Dacey

Expert Bill Dacey answers your toughest coding questions.


As a specialist in primary care and E&M, I’ll focus on those issues. Feel free to e-mail Physicians Practice your own coding questions; perhaps they’ll be addressed in an upcoming column.

Q Can my physician write “history updated,” “past, family, social history reviewed,” “see intake form,” or any of the other general references to more comprehensive documentation in other parts of a patient’s chart? I thought each note had to stand alone.

A Although CMS does state that each note has to stand alone, there has always been a willingness among payers to consider documentation that resides in other parts of the chart - if appropriately referenced. In the first example above, “history updated,” there’s the suggestion that the original history sheet, a problem list, or other place in the chart has been changed in some fashion. In that case, payers would expect to see some notations in the relevant documents accordingly dated.

It’s really a question of linkage - that is, if you accurately point toward something else in a chart. First, ask yourself if an auditor could locate the reference. If that’s possible, then ask yourself if there is any indication that the physician did incorporate the prior information referenced into that patient visit. Initialing or dating are some ways a physician can indicate that he or she reviewed prior work.

The best practice is to write: “See updated history form of 08/01/05,” or “PFSH of 11/16/03 reviewed and updated.” This points directly to the additional documentation. To make the best case, initial and date those original forms when completing them. This eliminates any question about the physician reviewing those notes.

Both the 1995 and 1997 Federal Documentation Guidelines state: “A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: describing any new ROS and/or PFSH information or noting there has been no change in the information; and noting the date and location of the earlier ROS and/or PFSH.”

QHow does a physician report reassessment visits to patients in a nursing home?
A Often a state will require periodic reviews of plans of care more frequently than once a year for nursing home patients. Until 2006, the AMA’s CPT manual contained codes specifically for these services. These codes, 99301 and 99302, were deleted this year. Respectively, they indicated an “annual nursing facilty assessment” and a “nursing facility assessment.” Code 99302 did not have a time period associated with it; it was used to cover those interim visits that are dictated by state, local, or facility regulations and bylaws.

In 2006, we were given a new code, 99318, that covers annual nursing facility assessments, but there is no code that replaces the “other” assessments of no assigned interval. Since the original codes did have history, exam, and decision-making requirements, the supposition is that a provider now needs to use the follow-up nursing facility care codes 99307-99310 at the level commensurate with a patient’s acuity and/or breadth of management. Note that this approach may not address the medical necessity concerns of third-party payers regarding the purpose of the visit.

The loss of code 99302 does present a bit of a problem, but the provider community must use the reporting tools the AMA makes available.

QWhy can’t I use a 99211 code for injections?
A Code 99211 is for nurse visits, and the nurse is the one providing the service. The service is the administration of some therapeutic, prophylactic, diagnostic, or other agent - not an E&M service. For the most part in these cases, the only items that should be billed are the administration codes and the supply of the material or drug.

There has always been a considerable amount of abuse associated with code 99211. Be certain that there is a documented amount of physician work associated with any use of this code. Although commonly referred to as a “nurse visit,” this code only states that the presence of a physician “may not” be required.

This code is reported with the physician’s provider number, so the suggestion is that there is physician work involved. Although there are no written documentation requirements or specific performance standards for 99211, common sense dictates that the physician should make a note - albeit a brief one - concerning his or her involvement.

These codes are primarily used to report visits in which some clinically significant information is obtained, often by a nurse, such as weight, blood pressure, or even a blood draw for periodic surveillance of a specific problem (e.g., lipids). That information is then recorded in the chart for physician review, and when it is reviewed by a physician a notation should be made indicating the disposition - i.e., leave meds as they are, call the patient, etc. This code should never be used in the absence of a patient visit.

QDoesn’t the “incident-to” concept allow me to bill for my nurse practitioner’s services when I’m not there?
A That’s a loaded question. How are you billing for your NP’s services - under his or her own provider ID number or your own? This concept requires that you be especially aware of presence and supervision requirements. Avoid billing for services under a physician’s name and number if that physician was either not present or failed to denote his or her supervision. Mistakes here often appear to be fraudulent billing, but most often they result from coverage and scheduling problems.

The first step you need to take is to look up the relevant Medicare guidance for the type of services in question. Then determine what range your private payers require in terms of representing the services of extenders. Remember that “incident-to” is a billing methodology created by CMS; there is great variance among private payers.


In many states, Medicare and Medicaid differ in their requirements for the proximity of supervising physicians or the degree of supervision. Many commercial payers don’t articulate presence or supervision requirements in their payment policy manuals. For the most part, here again you have the Medicare standard that a physician be “physically present on the premises and available,” and another standard for commercial payers that a physician be simply “available.”

QI’ve been told that I shouldn’t use templates or dictation macros because they are viewed unfavorably by Medicare auditors. Is this true?
A There is nothing inherently wrong with using a template, macro, or electronic note-taking method. A template is a tool - neither good nor bad in and of itself. However, like any tool, it should be used appropriately. Templates in any form, preprinted or electronic, guide or assist providers in detailing their documentation.

Abuse occurs when someone checks boxes simply because they are there. All payers will tell you that all work performed needs a clinical basis. Filling in the history and exam portions of a template to “achieve” a specific CPT code is an abuse of the tool.

The nature of the clinical encounter determines medical necessity. Medical necessity determines the work that is to be done. The work is done, and the template just makes it easier to record the documentation of the work. Then the documentation determines the code selection.

Medicare and commercial payers often send letters to providers informing them that their individual coding “profile” does not match that of their peers, and that they are an “outlier.” Often this is followed by language that suggests the provider “correct” his or her profile to more resemble that of their colleagues.

Pattern profiling is a way for payers (and providers) to obtain an overview of how a specific provider codes within a given range of codes. The distribution of codes across the spectrum of a code range is a quick measure of a provider’s coding habits.

Since most of the work in primary care involves office visit codes 99201-99205 for new patients, and 99211-99215 for established patients, these two ranges are often carefully monitored.

The problem with such monitoring is that payers often assume that the aggregate of codes reported in a given specialty - a specific specialty’s “curve,” if you will - is the baseline from which they should measure individual providers. Sometimes the aggregate data is simply wrong. By nature, it includes all physicians, even those who under-code, over-code, and don’t know how to code. Also, it makes no allowance for differences in patient demographics, age profiles, acuity, and the like.

Federal and private entities use these profiles to determine outliers and potential over-coders, but the benchmark is skewed and frequently reflects physician under-coding.

Medicare publishes specialty-specific coding profile data annually. The recent data for primary-care physicians indicates to this reviewer that many physicians under-code for their services. Perhaps these conservative profiles reflect coding by physicians who are either afraid to code for what they do, or who don’t understand what the codes mean. Profiles don’t always represent the work actually being done.

So don’t be too quick to follow the suggestion of those letters from your payers, should you receive one. There is some likelihood that your coding practices don’t resemble your peers because you are coding more accurately than they are. As always, be certain your documentation supports your codes, and welcome any payer review.

Bill Dacey, MHA/MBA, CPC is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for over 18 years. He can be reached at billdacey@msn.com or via editor@physicianspractice.com.

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

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