Making definitive decisions; delving into 'double dipping;' and ICD-10 code assignments

February 24, 2011

Coding questions? We've got the answers.

Making Definitive Decisions

Q: Our physician was recently audited by one of our larger payers and had to pay back a good deal of money. The part she apparently did the worst on was the decision making piece - but all they said was "insufficient documentation for level." What are they looking for on level 5s for the high-level decision making? Even some of the 99214s were down-coded for this.

A: The exact answer to this question depends in part on which payer it is and what guidelines they use to measure medical decision making (MDM) - but most of them use the three table approach. To start, you should ask them for the criteria that your provider was evaluated against.

This is a big question, so here are the core elements of the answer. You need to communicate the complexity and/or severity of the problem(s).

For decision making to qualify for a 99215 on the first table you need to show them either:

• Two worsening chronic problems; or

• One worsening and two stable chronic problems; or

• One new problem with no further workup and one stable problem; or

• One new problem with further workup (diagnostic) planned.

For a 99215 on the third table, which you need to have in addition to the first table, you need to document:

• One chronic problem with severe exacerbation or side effect of treatment; or

• Several problems which are either worsening or stable but when taken together have the effect of creating the high risk situation; or

• Discuss a potential problem with high risk/morbidity/mortality that requires urgent rule out.
The best way to make this documentation visible is to enumerate the problems and make the status or potential threat of the problem clear. For individual problem status on 5s use the words severe, severely worsening or progressing, severe exacerbation, life threatening, seriously ill, gravely ill, significant functional impairment, etc. You can also say deteriorating, significant side effects of treatment, significant complications.

You can also make an overall statement that the patient is at high risk of morbidity or mortality "due to X." Rely on a statement like this only when the management of individual problems doesn't convey the sense of complexity involved with the overall management of the patient.

We don't want totally replicated, cloned comments about risk, but you need to deliver a sense of the overall patient acuity/complexity as necessary. Once any of these statements become too commonplace and prosaic they will lose impact. Only use them on the patients that need them.

Don't just say 'high risk,' specify 'high risk or M/M due to X.'

Remember that you can code either the 4s or the 5s by time if counseling or coordination of care dominates the encounter. We'll give you this same breakdown next month on the 99214s.

Delving Into 'Double Dipping'

Q: I read your recent coding column in which "double dipping" came up. What would be considered "double dipping" between the HPI and ROS?

One thing that I find in psychiatry is that the symptoms for a particular diagnosis can cover a lot of systems - for example, depression symptoms include "loss of appetite" -I assume that this counts as a GI ROS item as well. Am I correct?

A: The following discussion between a provider and a Medicare medical director is the classic example of double dipping:

Physician: "It is my understanding that a single statement may be used in both the HPI and the ROS, negating the need for a physician to repeat himself. For example, in documenting an ER encounter for a patient presenting with abdominal pain, documentation of the patient's nausea could be used as an 'associated sign and symptom' (HPI element) for credit in the HPI section, and also in 'gastrointestinal' for credit in the ROS section."

Medicare medical director: "It is not necessary to mention an item of history twice in order to meet the documentation requirement guidelines required for the ROS."

Do remember that this is subject to carrier/payer interpretation, and that it sure does make it easier to count if HPI and ROS are separate. You don't want to make it hard on a Medicare auditor.

The second part of your question was about your example: appetite is considered part of constitutional, not GI.

ICD-10 Code Assignments

Q: I know that there are going to be significantly more codes with ICD-10, but will the rules change regarding how codes are assigned?

A: Good question, and one that I'm sure a lot of people want to know the answer to. In terms of how codes are assigned, the general guidance, and ICD-10 coding guidelines, the rules are not all that different from ICD-9.You still have the same guidance for assignment of the first-listed (primary) diagnosis code, selection of secondary diagnosis codes, injuries and accidents, late effect codes, and infections.

Many specific areas of coding such as diabetes and HIV have essentially the same rules. They have new codes, but the same governing rules. Your Volume II still has the general alphabetic index, the Neoplasm table, the Table of Drugs and Chemicals, and the Index of External Causes. There is currently no Hypertension Table in I-10, but that doesn't mean there won't be one. You no longer have sections in the back of Volume I (Tabular) for your E-codes and V-codes because these have each now been assigned their own chapters in the Tabular section. Your old E-codes are now in Chapter 20 (V01 – Y99) and the old V-codes are now Chapter 21 (Z00 – Z99).

You will still find familiar instructions and conventions throughout the manual. For example, brackets are still used in the index to indicate secondary codes that should be reported, and the Tabular will contain sequencing instructions such as "code first underlying disease" and "code xx as an additional code."

There are some new concepts such as place holders, but in the main, once you become familiar with the appearance of the codes and their organization, it should not be a difficult transition for a coder.

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 or

This article originally appeared in the March 2011 issue of Physicians Practice.