I received several variations of the following question after my last newsletter:
It was clear to me that when coding a 99214, only 2 of the 3 elements, history, exam, or decision making needed to be sufficiently documented. Usually the history would not be necessary. I was dismayed to read the most recent newsletter. Are you now saying "Nevermind, you now need to document all 3 elements"?
Sorry if I've caused some dismay. First off, it is true that you only need to document 2 out of 3 of the elements to code for a 99214. The point we will be making in this year's conferences has to do with history. Let's look again at last week's example:
Patient is here for follow-up of mild intermittent asthma. Over the past 3 weeks has had increased albuterol usage which does improve his peak flows back above the 80% range. Lots of coughing. Currently he is taking Flovent 110mcg 2 puffs bid, Singulair 10mg q HS, and Albuterol MDI 2 puffs prn. No side effects reported. No other respiratory or ENT symptoms.
In this example, this is a typical type of history one would obtain. If your documentation only focuses on physical exam and decision making, then you may have an adequate note for coding, but it may be totally inadequate from a medical or medico-legal point of view. Of course you did a history on the patient. And the above history is what I would consider an average history for this type of patient.
What we will focus on in part of the new Coding Growth Strategies is how can we take the history that we've obtained and write it in such a way as to protect ourselves from audits? For example, let's say that you replace the "No side effects reported. No other respiratory or ENT symptoms" with the much more common line "No other complaints". This would satisfy the 'associated signs/symptoms' element of HPI but would not have any ROS significance.
This is one change I have been making in my practice extensively on my 99214 patients. You know I'm a fan of writing the minimal amount you need to in order to do good medicine and coding and documentation. But if I can train myself to list these two negative ROS, which I've done the work for already, then that is a little bit more 'audit protection.' Is it necessary? Probably not. But I did the work and asked the questions so I need to document it as well.
Think of it as if you have dual insurance coverage. You feel comfortable that your insurance will cover everything you have this year. But if unexpectedly you find that something was not a covered service, then you have the added peace of mind of secondary coverage. Same here. If you've done the work, then you absolutely want to document all the History, Exam, and Decision-Making you've done. That way if you get audited and for some reason your auditor feels that one of the 3 elements wasn't done properly, then you still get credit for the other two.