Well, it's been a month since my last newsletter. I haven't forgotten about you all, but I have been busy completing the editing and production of our two newest products: Practice Growth Strategies and Advanced Coding Strategies 2013. At the bottom I've attached a few excerpts from the first disk of the Practice Strategies seminar as well as a special offer.

But before we get to that let's go over a very good coding question that was submitted last month:

Question:

Under what circumstances is an E/M for a concussion a 99215?

Patient was injured at school and is brought directly to the office with headache, feeling in a fog, and off balance. Abrupt change in neurological status? High risk?
Patient was injured with the above symptoms and comes to the office the next day. The symptoms have resolved.
How about if the patient was seen in the ED last night and comes in for follow the next day?

Discussion:

What an excellent group of questions! Here is our mantra for coding 99215s: (1) Not everything that is High Risk is a 99215, and (2) a 99215 requires 2 out of 3 of Comprehensive History, Comprehensive Exam, and High Complexity Decision Making.

Easy right? Not always. So let's step through them.

We will make the assumption that we are talking about an established patient.

Let's start with our medical decision making. Most auditors would agree that a concussion (altered mental status following head trauma) would classify as high risk due to an abrupt change in neurologic status. That is one part of Medical Decision Making. If we want credit for a high level of decision making, we must also have either a high level of Diagnosis/Management Options or a high level of Data Review.

Depending on the type of auditing scale your auditor uses, you will probably qualify for high level of Diagnosis/Management options. If your auditor counts the number of management options you will easily have 4 by the time you do the work up and instructions involved in #1. If your auditor only counts the number and type of diagnoses, then they will often give you 4 points for working up a new problem as in #1. Examples #2 and #3 probably will not have further workup like a CT and will probably not earn you a high level of decision making.

Most of us would do at least 4 elements of HPI and 2 elements of review of systems on all three of the above cases. Let's assume we would do a past medical history (at least problem list, med list, or allergies) and a social history (smoking status). That still only gives us enough history for a Detailed History. If we want credit for a Comprehensive History, then you need to include a review of 10 systems. That would not be hard to do in a concussion case. I would recommend strongly, however, that you do not just put "all other systems reviewed and are negative." It's not safe if you get audited. Instead, list each specific system you review and specifically write it down. Say something like "Eyes: Negative" or "Eyes: No blurry vision".

For physical exam, we probably would do a good neuro exam but probably not comprehensive. So that means we would need to examine 8 organ systems to get credit. There's a good chance you may have done that. But if not, then you do not have enough for a Comprehensive Exam.

Here's what I've found in my own practice: In case #1, about 75% of the time I do enough work for a 99215, and about 25% it is 99214. In case #2, it is probably 50% 99214 and 50% 99213. In case #3, it depends on if the symptoms are resolved (then it's like #2) or if the symptoms are persisting and they have not had a CT yet (then it's like #1).

So the take-away message is: High Risk means that this visit might/can/could be a 99215, but it totally depends on how much History, Exam, and Decision Making you perform with that particular patient.