Coding and documentation of evaluation and management (E/M) services: This has to be the topic that physicians hate to read about most. As we all know, the “guidelines” for coding and documentation are actually a morass of rules that seem to encourage downcoding by making the rules vague and the penalties harsh. The “new framework” for the documentation guidelines, expected to be released later this year, may make the rules more plain — or it may not. Thus far, at least, revision has not made the system any easier to use.

As if you need convincing on this point, here's an example of the guidelines' user-unfriendliness. My group recently underwent an audit. Four professional coders each spent 40 hours reviewing a total of 100 dictations. That's 1 hour, 36 minutes for each dictation. If it takes a professional coder — with manuals in hand, specific training and years of experience — more than an hour and a half to review a single note, consider the challenge we face in documenting our services and coding accurately in the few minutes we have between patients.

I think it's fair to say that most of us code by a mixture of rote memorization and gut instinct. We develop a coding gestalt (try explaining that to an auditor). But in doing so, most of us tend to play it safe and undervalue the work we do. As I teach coding to residents and attending physicians, the example of this I see most frequently is coding 99213 for a visit that merits a 99214.

For me, it's easy to identify a level-3 visit, and I think most doctors have a sense of what one feels like. I go through cycles, after I've boned up on what's needed for a 99214, when I'm better able to recognize one when I see it, and my level-4 visits increase. But after a few months I forget a few nuances, and I start shying away from the level-4 codes in order to avoid fraudulent billing. What helps me is something that in any other environment I'd call a “cheat sheet” — a

to help me remember what qualifies a visit for a level-4 code.

99214 in a nutshell

According to CPT, 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity.” [For more detailed guidance on when to choose this code, see “99214 Made Easier,” April 1997, page 51.]

Do you find it difficult to remember what that means as you see patient after patient, day after day? For me, it helps to boil down the common indications for 99214 to a few simple rules. (See “Rules of Thumb for 99214.”)

Documentation help

To make our use of level-4 codes more consistent and to reduce the amount of time we spend on coding, I've developed a tool for myself, my partners and our residents — the “

.” On the front, the card lists the major criteria that your documentation must meet to qualify a visit as a 99214 (any two of the following: a detailed history, a detailed exam and decision making of moderate complexity), and it summarizes the elements that must be documented to meet each criterion. It also includes a box listing how the requirements for a level-4 visit with an established patient (99214) differ from those for a level-4 visit with a new patient (99204). On the back, the card lists the systems and body areas that may be included in the general multisystem exam, complete with all those bullets to count. Keep in mind, of course, that the reference card applies to the 1997 version of the documentation guidelines only. [FPM plans to publish an updated version of the reference card once the revised guidelines are finalized.]

You can use the reference card in at least two ways: First, with the card tacked to the wall where you dictate, you can follow along as you record your note, making sure that your dictation includes all the details that indicated your choice of the level-4 code. In addition, you can use the reference card as a guide when you perform internal audits of other doctors' charts.

Internal coding and documentation audits may strike you the way that visits to the dentist strike the general public, but don't underestimate their value. Every doctor in our 22-person group reviews five dictations per month, and each is a better coder for it. In our practice, the standard is that the physicians should be the coding experts. Nothing teaches me more about coding than reviewing the dictations of my partners to see whether their codes are on target and their documentation is complete.

It's also important to do a little quality improvement with your own coding. One trick we've learned is to add the CPT codes to the bottom of all our dictations, in addition to marking them on the superbills. That way, when we get our dictations back, we can perform our own mini-audits to ensure that our documentation supports our coding. If we find that we've undercoded, we generally write off the loss. If we find that we've coded too high, we may submit a corrected claim (and our procedure is to hold all our level-4 and -5 Medicare charges until the dictation has been reviewed). But the real value of this exercise is that it makes all of us better coders.

Level-4 visits with new patients

As I review my colleagues' charts and my own, I find that we also commonly downcode our moderately complex new-patient visits. The rationale goes something like this: “The visit would be a 99214 if this were an established patient, but I can't remember the cut offs for a 99204. So I'll round down to a 99203 and keep from attracting some auditor's attention.”

A 99214 requires a detailed history and physical exam, and a 99204 requires a comprehensive history and physical exam. As far as the documentation is concerned, those differences are manifested in four ways (you'll also find these listed on the “

”):

• For a 99204, all three major criteria (history, physical exam and medical decision making) must be met. A 99214 requires only two of the three major criteria.

• For a 99204, the review of systems must include at least 10 systems or body areas. A 99214 requires a review of only two.

• For a 99204, the past, family and social history must cover all three areas. A 99214 requires only one area.

• For a 99204, the physical exam must cover at least 18 bullets from at least nine systems or body areas. A 99214 requires at least 12 bullets from at least two systems or body areas.

When we don't keep the rules in mind, we may not include information in the progress note that we've obtained during the visit — information that we felt was necessary because of the patient's condition. Either we simply neglect to mention these details, or we summarize them by dictating things like “Complains of cold symptoms.” We ask the patient what he or she means by “cold symptoms,” but we don't record the specifics.

If we did include the details, we'd realize that many of these are level-4 visits. For example, a new patient, a 60-year-old man, complains of having had a fever, a productive cough, slight dyspnea on exertion, nasal discharge and malaise for the past three days (five elements of the HPI). He denies chills, rash, allergies, dysuria, hemoptysis, sore throat, headaches, chest pain, myalgia, nausea, vomiting and diarrhea (10 systems of the ROS). He has a history of exercise-induced asthma and says that his mother and sister have severe asthma; he smokes a half pack of cigarettes per day; and he works as a carpet layer (three elements of the PFSH).

Dictating about five extra lines of history has put you on track for a 99204. Investing the extra 30 seconds in dictation time and 50 cents in transcription costs can earn you the extra $30 you deserve.

The mantra: Document everything

The idea, of course, is not to add irrelevant information to your note in order to increase your reimbursement. The idea is to record everything that you do or talk about that is relevant and to bill the code that the documentation supports.