Over the past few months, YO Info has taken a look at the documentation requirements for the history, exam and medical decision-making. Now it’s time to select the appropriate level of service. While billers, coders and allied health personnel may assist with this, physicians are ultimately responsible for code selection.
Test Your Knowledge — Case #1
A new patient is referred for evaluation due to recent diagnosis of type 2 diabetes. She currently has no visual complaints.
Review of systems (ROS): 10 systems were reviewed in detail — all were negative, except bruising easily.
Past history (PH): History of appendectomy
Family history: Mother with type 2 diabetes
Social history: Patient denies drinking and smoking.
Exam: 13 elements
Diagnosis: Type 2 diabetes, no retinopathy
Plan: Letter to primary care physician, discussion of good diabetic control and return in one year for follow-up
History: Problem expanded
Medical decision-making: Low
Instructions: If a column has three circles, draw a line down that column to the bottom. Otherwise, find the column with the circle(s) farthest to the left, draw a line down that column to the bottom and circle the E&M code.
Explanation: New patients require all three components when selecting the E&M code. For established patients, the recommendation is two out of three. However, medical decision-making carries the greatest weight.
Test Your Knowledge — Case #2
An established patient presents with progressive, decreased vision in the right eye since last visit six months ago. Any work at near is difficult to accomplish.
PH: Uneventful cataract surgery in right eye three years ago
Exam: 12 elements were documented through dilated pupils. Refraction was performed without improvement in the right eye, and there was no change in the left eye.
Diagnosis: Secondary cataract in the right eye
Plan: Perform YAG capsulotomy today
History: Problem expanded
Medical decision-making: Moderate
Instructions: If a column has two or three circles in it, draw a line down that column to the bottom and circle the E&M code.
Note: Based on the plan you should append modifier –57 to the exam, indicating this is the office visit to determine the need for a major surgery.
Other E&M Considerations
Evaluation and management codes are nationally recognized by all payers, and documentation is standardized. The codes use an official audit form based on the 1997 documentation guidelines that were created for a single organ system. There are no frequency edits as to how often a level of service can be billed, and there is unrestricted diagnosis coverage.
* * *
About the author: Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and Ophthalmic Coding series. Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She oversees the Academy’s Chart Auditing Service and is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Codingseries.