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Problem Focused Exam; Scribe Services


Our coding expert discusses coding for unspecified diagnosis at the time of encounter; a problem-focused exam; and scribe services.


Q: When a patient presents to our provider to have a lesion removed, the coder codes from the pathology report for the lesion removal (benign vs. malignant). Would it be appropriate to diagnose from the pathology report too? Or, should the diagnosis code remain as unspecified or unknown at the time of the encounter?

A: Medicare ruled on that question many years ago. Report the diagnosis or condition after any studies or diagnostics are performed and after you rule in or rule out what you are looking for. This allows you to report what you found.

In the case of lesions, you can then report either benign or malignant. Once upon a time payers wanted to know what was "known" at the time the test was ordered, rather than what you found out.


Q: Can we do a psychiatric-focused exam and not do any "constitutional" findings? For instance, can we do a quick check for tremor and rigidity and eye movement and balance instead?

A: When you say "focused," any coder will immediately think of the problem-focused exam described in the CPT which is consistent with a 99201 or 99212 outpatient code. These require only one organ system or one to six elements if using the 1997 E&M guidelines.

An expanded problem-focused exam (codes 99202, 99213 outpatient), needs reference to two organ systems in general - maybe psych or musculoskeletal/neuro, or six elements from one system (likely psych). What you are describing above is largely neuro, but you could make a case for musculoskeletal as well. But no, you don't have to have "constitutional" unless you are doing a comprehensive exam.


Q: Several of our providers are utilizing scribe services and I am now starting to see the time statement reflecting the scribe performing the counseling. For example, a patient was seen by Dr. X, but when the scribe completed the documentation to submit the charge the documentation includes the scribe's name. I have asked that this be corrected but want to verify that an audit would not allow the time statement and base the level on the key E&M components instead.

A: You are basically correct. A payer is not interested in "scribe counseling time." Depending on whom the scribe is, his personal services could have no value.

But the real question is, why is the scribe counseling? Is this person a nurse, PA, NP, or a nonlicensed medical professional? If the scribe has credentials, include them in the note. Still, payers aren't going to be interested in the scribe's counseling time unless the service is billed in the scribe's name, which would require the scribe to be a qualified healthcare professional with billing credentials.


Q: For CMS, can a medical student (not a resident in a GME program) perform and document a 99024 (routine) post-op visit on her own or as part of a visit with a physician or advanced practitioner? For students, the E&M rules are clear: ROS and PFSH are the only components of E&M that students are allowed to perform and document. Since, I cannot locate anything in regard to student/post-op scenarios, and the E&M guidelines don't apply to 99024 because it is in the medicine section of CPT, I think that any documentation and services performed by a student would need to be re-documented and re-performed by the physician or advanced practitioner. Although CPT 99024 has a zero-dollar amount attached to it, the reimbursement is part of the global package that the post-op visit is part of.

A: Your reasoning is mostly correct. I'd steer clear of having students document anything. Since they are not licensed medical professionals, their work has no actual value.

I will, however, note that although a 99024 may be in the medicine section of the CPT that does not mean that the services associated with it are not E&M services. If you look at the definition of the global package in CPT, you'll see that it includes certain "E&M" services, more the pre-op services than post-op services. Although not defined by code 99024 this way due to the circumstances, these are evaluation and management services.

You may wish to establish a rule at your organization that says:

"When there is student involvement with a 99024 post-op visit, the CMS student E&M documentation rules (i.e. student contribution limited to ROS and PFSH) should be followed. Any other documentation and/or examination by the student must be re-documented and reexamined by the provider (physician or advanced practitioner)."


Q: Will you please clarify for me questions I have regarding new patients and what defines "further workup"? I was told that unless I order something that is scheduled, like an MRI, CT, or echo, I can't bill for a "further workup" in the A column of the decision-making tables.

This means that even if a new patient comes in with four different new problems to address and I'm ordering labs, X-rays, reviewing their chart, and prescribing meds, I will not achieve a Level 5. Is there a reference I can review to understand better why labs and X-rays don't count as further workup? The CMS E&M service guide and the CMS 1995 E&M guidelines do not provide clear guidance.

A: Any guidance here is carrier specific and I haven't seen anything written on this in years. Since you are focusing on Table A, do recognize that in the case above with four problems, you can get to six points or more by breadth of problems in that table. You may only get one "three pointer," but if there are other problems, they can certainly count as either stable or worsening established problems. You aren't "capped" at one problem, payers will just only count one problem as three points. If that doesn't resonate, focus on the language in the table. "Further" (further than what you did today) and "planned" (not something done today).

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 2015 issue of Physicians Practice.

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