Careful and correct documentation and coding are vital skills for every family physician. They enable us to record the high-quality care we provide for our patients and help ensure that we don't undercode or overcode the services we provide.

My previous article, “Coding Level-IV Visits Without Fear” (FPM, February 2006), focused on ensuring that you're coding all the level-IV visits you're entitled to. This article will focus on the slight differences in the requirements for established patient level-II (99212) and level-III (99213) visits – differences that can have a surprisingly significant effect on your bottom line if you don't understand them well. For example, the 2007 Medicare allowance (not adjusted for geographic differentials) for a 99212 is $37.14, while the allowance for a 99213 is $59.50. Consequently, each time you code a 99212 when you should have coded a 99213, you leave $22.36 on the table. If you undercode 10 of these visits a week, you've failed to capture $223.60 per week, or more than $10,700 over 48 weeks.

Of course, learning when a 99213 is really a 99212 is also important. Thorough documentation of the work you perform, along with careful attention to medical necessity, will help you audit-proof your practice.

History and exam

Medicare's Documentation Guidelines for Evaluation and Management Services, which most private payers also rely on to a great degree, divides documentation into three key components: history, exam and medical decision making. For established patient visits (99211-99215), two of the three key components must meet or exceed criteria to qualify for a specific level of evaluation and management (E/M) services. (This does not apply to new patient visits, 99201-99205, which require not only all three key components but also more detail for certain key components.)

The documentation guidelines are available in 1995 and 1997 versions, and we are allowed to use either one. Of note, the only significant difference between the two versions is the exam section. I prefer to use the 1995 guidelines, and I have used them in this article, because I believe the exam requirements are easier to follow. Here are the criteria to keep in mind when conducting a patient history and exam:

History. The history requirements for level-II and level-III visits are comparable. They both require that you note a chief complaint (CC) and one to three elements (location, quality, severity, duration, timing, context, modifying factors, or associated signs and symptoms) that describe the history of present illness (HPI). A past medical, family and social history (PFSH) is not required for either level-II or level-III visits.

The only difference between the history requirements for a level-II and a level-III visit is the review of systems (ROS). A level-II visit does not require an ROS, while a level-III visit requires a problem-pertinent ROS, which is a description of one system that is directly associated with the problem. This additional component raises the level of history from problem-focused to expanded problem-focused.

Exam. The exam requirements are slightly different for level-II and level-III visits. Under the 1995 guidelines, a level-II exam must be problem-focused, which requires the description of one component of the affected body area or organ system. A level-III exam is expanded problem-focused, which requires the description of one component of the affected body area or organ system and at least one other affected body area or organ system. The body areas include the following: head/face, neck, chest/breasts/axillae, abdomen/genitals/groin/buttocks, back/spine and each extremity. The organ systems include the following: constitutional (general appearance or vital signs); eyes/ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric and hematologic/lymphatic/immunologic.

The 1997 guidelines require documentation of one to five specific exam “bullets” for level II and six to 11 bullets for level III. You can find a complete list of exam bullets, as well as the 1995 and 1997 guidelines in their entirety, on the Centers for Medicare & Medicaid Services' Web site at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp.

Medical decision making

The medical decision making component represents the most significant difference between a level-II and a level-III visit. “Straightforward” decision making is sufficient for level II, while “low complexity” decision making is required for level III. Three parameters (diagnosis, data and risk) combine to determine the level of decision making. When two of the three parameters meet or exceed the specified requirements, then the overall level of decision making is determined.

You can use a simple point system to evaluate the number of possible diagnoses or management options and the amount of data to be evaluated. While the point system is not part of the documentation guidelines, it is widely used by Medicare carriers, coders and physicians to assess documentation and aid in code selection.

Diagnosis. The number of diagnoses or management options needed for a level-II visit is considered minimal; only one point is required. You can earn one point if the patient has a self-limited or minor problem (e.g., cold, insect bite, tinea corporis) or an established problem that is stable or improved.

The number of diagnoses or management options for a level-III visit is considered limited, with two points required. Two self-limited problems, two stable established problems or one established problem with mild exacerbation would each yield two points.

Data. In the data section, points are earned according to the amount and complexity of data to be ordered or reviewed. You should document your review of lab, radiology or other diagnostic tests. If you order, plan, schedule or perform a diagnostic service at the time of the encounter, you should document this as well.

For a level-II visit, you need one point to meet the data requirement, which is considered minimal. You can earn one point by ordering or reviewing lab, radiology or procedure reports, or simply by obtaining old records about the patient or obtaining history from someone other than the patient (e.g., a family member or caregiver).

The data for a level-III visit is considered limited and requires a total of two points. You can earn two points by reviewing or ordering two different types of tests (e.g., a complete blood count and a chest X-ray). You can also earn two points by summarizing old records or discussing the case with another health care provider.

Risk. The risk associated with an E/M visit is based on the chance that significant complications, morbidity or mortality occur during the current encounter/procedure or between the present encounter and the next one. The guidelines characterize these in the context of the presenting problems, diagnostic procedures and management options. The highest level of risk in any one of the three categories determines the overall risk.

The risk associated with a level-II visit is considered minimal. Examples include a presenting problem that is self-limited or minor; diagnostic procedures such as labs with venous puncture, chest X-rays, ECGs, EEGs, urinalysis, ultrasound and KOH preparation; or management options such as prescribing rest, gargles, elastic bandages and superficial dressings.

Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable chronic illness or an acute uncomplicated illness would qualify. Diagnostic procedures with low risk include physiologic tests not under stress, non-cardiovascular imaging studies with contrast, superficial needle biopsies, labs requiring arterial puncture and skin biopsies. Low-risk management options include prescribing over-the-counter drugs, minor surgery with no identified risk factors, physical therapy, occupational therapy and IV fluids without additives.

Time-based billing

Another option for coding level-II and level-III encounters is to use time as your guide. According to CPT, a typical level-II visit lasts 10 minutes, while a typical level-III visit lasts 15 minutes. If counseling or coordination of care account for more than 50 percent of the visit, then you can select your E/M code based on the length of the visit. In general, the time spent face-to-face with the patient (and the time spent in counseling) should meet or exceed the listed typical visit times. Remember, the coders who audit your charts do so by counting required components as well as noting recorded visit times. If you decide to use time-based billing, make sure to include in your note that at least half of the face-to-face time was spent counseling or coordinating care (e.g., “total visit time was 15 minutes, half of which was counseling”). Your documentation should also describe the nature of the counseling or care coordination.

Coding with confidence

Although E/M coding is not always instinctive, understanding the differences between level-II and level-III visits will help you choose the appropriate code for your patient encounters and receive the proper reimbursement for your work. Every day you provide your patients with the best possible care. Document it accurately and code with confidence.