E&M Mixing and Matching
Q: In our office when auditing an E&M service using 1995 guidelines, we consider the EPF (expanded problem-focused exam) to contain between two and four body areas or organ systems and DET (detailed exam) to contain between five and seven body areas or organ systems. I was taught that you can mix and match body areas and organ systems in order to get the level. However, my colleague at my new job was taught that you cannot mix and match them. What is your take on this?
A: Often when you hear a payer talking about "mixing and matching" they are talking about mingling 1995 guidelines which are based on organ systems and body areas with the 1997 guidelines which are measured by "element" or "bullets." But I've heard the term refer to the body area/organ system that you mention as well. You are actually posing two questions here. One is about differentiating between EPF and DET by splitting the two-to-seven range into two to four areas/systems and five to seven areas/systems respectively. People do that and it makes a certain kind of sense, but there really is no authoritative precedent for it. Many payers will go so far as to say that you need some number of systems in no great detail, and some degree of detail on one or two of them. That has no overriding authoritative source either - you are hearing different payers giving you their different versions.
The best question for you to answer is whether your documentation is defensible, medically necessary, appropriate, and proportional to the patient's problem(s). There are as many reads on how to measure these things as there are payers.
In answer to your second question, specifically, the CPT says that you can count body areas/organ systems, or mix and match if you will, for PF, EPF, and DET exams. It somewhat notably doesn't mention body areas on the comprehensive exam. Some Medicare payers also specify that the comprehensive exam must contain eight organ systems, and any other areas are additional. The online E&M "Service Guide" tells you that as well. So it's pretty safe to say you can count both, such as two organ systems and a body area for an EPF, or even one of each.
Q: When counting points for the data reviewed in E&M, do you count "independent review of image, tracing, or specimen" (two points), for example, when a cardiologist sees a patient, interprets an EKG, and provides an E&M service?
A: This one depends on whether the physician billed the EKG (93000 or 93010) in addition to the E&M. If she billed the interpretation she cannot also count the two points for reading the EKG as part of the MDM calculation - she has already been paid for that in the EKG code. If the physician doesn't bill for the EKG, count the points if she visualizes the tracing.
New Medicare 'G' Codes
Q: Can I use the new Medicare G0438 and G0439 like I use the older preventive medicine codes 99381-99397? I've been told that I have to do more.
A: In some ways you need to do a bit more for annual wellness visits than for the CPT-based preventive codes and in some ways less. The G-codes actually don't include a physical exam, though many providers indicate that they are doing them (Often this is because they are handling problems at the same time as prevention).
The additional work that some providers may not be aware of is related to the personal preventive plan requirement. The two services that require a good bit of work are (according to CMS):
• A written screening schedule for the individual, such as a checklist for the next five to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual's health status, screening history, and age-appropriate preventive services covered by Medicare.
• A list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
I recommend that all providers go to the USPSTF website for the screening elements. This outlines the recommendations by the task force. You may be surprised that these differ somewhat from certain accepted standards. Your best bet is to develop a form to use in your practice to address these two requirements.
Separate or Equal?
Q: I have a physician who saw a patient for a preventive visit and also charged a 99215 for this patient on the same date of service. He used the same documentation for both visits. Yes, the patient had five to six chronic illnesses or conditions. Where can I find documentation that proves the physician must document each visit separately? Also, can he use the same history for both encounters?
Thanks for any help in this situation. I want to be able to show some documentation to this physician besides just telling him that he needs to have separate, identifiable documentation to support each visit.
A: You may want to look at this a little differently. There is no overriding authoritative requirement that says the two "aspects" of the combined preventive/medical management visit need to be documented separately.
They really are two different services being provided in the context of one visit. The "problem list" (assuming the problems are being managed that day) is not part of a preventive service, but should appear in the HPI to give the status of those problems if they are chronic, and some detail on them if they are acute or episodic.
The ROS is somewhat shared between the two services, as is the PFSH.
The exam is also largely shared, except that often you will have some narrative findings related to the "problem" organ systems or body areas. This is the norm for these types of visits.
Maybe the most important part is that the in the A/P, the management of the problems is clear (Dx, status, Tx, and RX per problem) and that there is a separate section that outlines all the preventive aspects of the visit - vaccines, diet, mammogram, DEXA, PAP, etc., or whatever is applicable.
So you are correct in that there needs to be clarity that two services were provided and there was some separation there - but not entirely separate - as if it were one service provided in its entirety that was followed by another. They do kind of "unfold" together, and so the documentation will be mingled a bit.
Just make sure the physician says up front - in the CC - "Here for E&M of HTN, CAD, DM, lipids, and gout as well as periodic preventive medicine services" - or something like that!
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. He can be reached at firstname.lastname@example.org or email@example.com.
This article originally appeared in the May 2011 issue of Physicians Practice.