Documenting Psychotherapy; Pre-screening Visits; Appropriate Use of 99211

June 2, 2014

Q: I have a provider who documents an E&M service in his note and also states that he performed psychotherapy. How should we document the time component?

Documenting Psychotherapy

Q: I have a provider that documents the elements of an E&M service and also states that he performed psychotherapy in his note. How should we handle the documentation of the time component? What if the provider only documents total face-to-face time and not the time specifically spent rendering the psychotherapy service?

A: The change to the psychotherapy codes in recent years directs providers to report both E&M services and psychotherapy when both are performed. The psychotherapy is a timed code and the provider needs to document the time spent in psychotherapy specifically. The note should indicate that two distinct types of services were performed.

In a perfect world, the provider would basically label one portion of the note as psychotherapy, and write that he spent "X" time doing it. He might then write something like:

"Medical Management - Patient with depression slightly worsening. Family still pressuring him about a job; can't sleep. Has been taking Paxil - will increase Paxil to 'X' mg. F/U up in one month."

The key is that each service should be separately identifiable. If you want to get paid for two things you need to show the payer two things.

Medical History and Chronic Conditions

Q: A team from a large national payer visited our practice yesterday. It stated that our providers shouldn't be documenting current chronic health conditions under past medical history, in addition to the problem list.

They stated that documenting current chronic conditions under past medical history indicates that the condition is "resolved." Our physicians have been documenting things like DM, hypertension, and COPD both under the history and on the current problem list. Is this really a mistake?

A: There is no authoritative coding source that says you should not document current chronic conditions under medical history. I think the payer is telling you how it likes things.

The idea that a problem is resolved if it is listed under past medical history is just an odd perspective. Just because a patient has a problem, and has had a problem, has no real bearing on its status.

You aren't doing anything wrong by any actual documentation standards if you list the problems in both places.

The payer's guidance does, however, underscore the need to give a clear "status" of each problem addressed in the assessment and plan, such as stable, mildly exacerbated, etc. This takes it out of the potential "resolved" column.

Pre-screening Visits

Q: How do you code an E&M if the patient comes to the office to have the physician order a screening colonoscopy? The patient doesn't have any complaints and the assessment portion of the progress note is only documented: "Assessment: Colonoscopy screening." The screening colonoscopy is scheduled in three weeks.

A: There are a couple of answers to this. Medicare has long held that a pre-screening visit is considered part of the procedure if there are no issues beyond routine screening. So for Medicare, if it is a purely screening issue, you should charge no E&M. Most commercial payers do not articulate this.

If this is a new patient, you will typically have difficulty getting a full history of present illness and likely end up with a 99202. For established patients, we frequently see 99212s and 99213s. The decision making is somewhat problematic here, as the nature of the visit is preventive.

Here's what most people do with the different versions of this presentation:

• If the patient presents for clearance for screening colonoscopy and there is no diagnosis or problem, the patient is not on high-risk medications, and the patient doesn't require significant counseling, you should bill no E&M.

• If the patient presents for clearance for screening colonoscopy and there is no diagnosis or problem, but the patient is on high-risk medications and/or requires significant counseling, you should bill commensurate with risk and management of medications.

• If the patient presents for a problem that results in a diagnostic colonoscopy and there is a diagnosis or problem, you should bill at the level of E&M commensurate with the problem.

Appropriate Use of 99211

Q: I am an obesity medical specialist and clinical lipid specialist who works with therapeutic lifestyle change to reduce patient cardio-metabolic risk through dietary intervention and weight loss. I only bill insurance; I do not have cash-pay patients. I feel that my patients would be better served with more hands-on emphasis on exercise, which is a scary prospect for most of my patients.

Can I hire a personal trainer, train the trainer to do vital signs, and have my patients follow up with the trainer who I would consider my medical assistant? The personal trainer would offer 30 minute sessions, would follow up on weight and vital signs, instruct the patients through a variety of exercises, and plan and review workout history at home. I would like to bill that as a 99211 medical assistant office visit.

I understand that for some payers (such as Medicare) this would not work because I would have to be in the building at the time of the patient's visit, but otherwise I am wondering if this would work.

A: It is decent idea, and doubtless beneficial to your patients' overall health, but I have some concerns with this approach.

The 99211 code is not "a medical office assistant visit." Although frequently referred to as a nurse visit, this code is intended to represent physician work. The CPT manual states that this code "may not require the presence of a physician," but it still represents some physician work. Some examples it provides are blood pressure checks and weight checks. Clinically significant information is obtained and passed on to the physician who makes a call as to treatment or disposition.

Depending on your location, there also may be requirements regarding what constitutes a medical assistant. There are scope-of-service considerations; you can't necessarily just consider someone your assistant.

In some cases, you can use the 99211 to represent work performed by employees of the physician or the group, and you can include education services here, but the services you describe are those of a personal trainer and exercise, not necessarily medical treatments or services. The closer you stick to dietary and weight counseling, the closer to mainstream practice you are.

There is a code for work hardening/conditioning (97515) or the unlisted code for physical medicine/rehabilitation (97799), but these are intended more for rehab than prevention or general fitness.

When you use 99211 to describe medically necessary services directly supervised by a physician (present in the office, as you mentioned), you must also have a diagnosis code that supports that service. I'm assuming that you'd be using diagnosis codes related to cardiovascular risk, lipids, etc.

Again, although exercise is certainly recognized and suggested as treatment, it is not the norm that a physician would bill Medicare or a commercial payer for essentially over-seeing a personal trainer. It's not so personal anymore once you introduce the third-party payer. Your idea may be ahead of its time, but I think you'd have difficulty getting paid if anyone really realized what you were doing.

Unexplained Denials

Q: I have been having an issue with a payer. It is reviewing our medical records and denying every visit without giving a reason. It says the records are being reviewed by coders or licensed practical nurses, not physicians. An EHR generated the records in question and all applicable fields are filled in. The doctor is losing $50,000 to $60,000 a year due to this. We are considering dropping out of this payer's plans because of this issue. Its representatives say they have no control over these chart audits. What's the best way to deal with the payer?

A: I'm sorry to hear that. I see reviews all the time conducted by all types of staff - nurses, CPCs, even physicians - and I wonder what charts the reviewers are looking at, since their findings do not seem to correlate at all with my own. Since the payer is not giving a reason for the denials, I would pursue whatever channels of appeal exist within this payer and if necessary, go to your state insurance commissioner. Payers are regulated and can't just override your claims without cause.

Do remember, however, that there is no all-encompassing payment policy that covers all services across all payers. Each payer is entitled to have its own payment policies, but it does have an obligation to tell you specifically what is wrong with any given claim. In the chart review, the medical necessity element is often the trickiest to define, and most payer contracts allow the payer to determine the definition of medical necessity. See what your contract with this payer says about chart reviews. What did you agree to?

Consult for Readmission

Q: If I am asked to see a patient for a consultation who is readmitted to the hospital during the surgery global period, can I bill for the visit? For example, if a patient with hydrocephalus who I recently shunted returns to the hospital after a fall and the CT (as expected) still shows hydrocephalus.

A: You can see the patient again and use a consult code (if it is not a Medicare patient). You need to append modifier 24. That modifier means "unrelated E&M in the post-op period."

You could encounter an issue with the payer if the consult is not entirely unrelated to the first visit, especially if you use the diagnosis of hydrocephalus again. The payer may make the case that any visit related to the surgery in the ensuing 90 days is covered, and although this is likely more related to the initial reason for the surgery, payers will also likely take the harder line.

If there is another code you can use, you will have better separation. If you don't have much choice, the -24 is the best bet.

Degree of MDM

Q: A patient presents for her second appointment to an otologist after her initial visit for dizziness and hearing loss. Just prior to coming to the second appointment, she has an MRI. Later the same day at the office visit the otologist reviews the MRI and diagnoses vestibular schwannoma. He and the patient discuss treatment and agree on surgical resection most likely through the suboccipital approach.

My usual audit algorithm calculates this as "low" MDM due to one established worsening problem (though the patient still has symptoms of dizziness and hearing loss), one radiology test, and high risk. But this seems low for a management option selection of brain surgery. I think that the Table of Risk drives the visit level, and I'd value any comments.

A: Your technical read is correct on the face of it, but you are absolutely right that brain surgery probably isn't fairly represented by low MDM. You could get artful and say that now that you have a diagnosis (based on the MRI) that it's a new problem. Previously you had only signs and symptoms.

Does the history or physical exam support a higher level? Usually we like to see MDM be the solid component of the two or three key components required in an E&M visit, but you can always get technical with the other two. Regulators certainly don't hesitate to get technical on you when it suits them.

At the end of the day I wouldn't worry about it. The audit algorithms are guidelines, not natural laws, and they don't always fairly represent a given situation. Certainly this is at least moderate MDM. If the patient still has the hearing loss that's a problem too. Also, don't forget to consider how long the review of the MRI and the ensuing discussion about surgery took.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, 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 more than 20 years.

This article originally appeared in the June 2014 issue of Physicians Practice.