Learn rules, code properly for more efficient practice

August 1, 2005

Chicago — It is to the physician's benefit to understand the rules regarding evaluation and management codes, says a physician here.

Chicago - It is to the physician's benefit to understand the rules regarding evaluation and management codes, says a physician here.

Speaking at the American Academy of Dermatology's Academy '05, Dr. Dirk Elston, a staff dermatologist with the Geisinger Health System in Danville, Pa., says it is an advantage to physicians to learn the codes.

"The rules are well established, and they aren't going away," Dr. Elston says. "It's really to the benefit of physicians to learn the rules and code properly. It ensures that they actually get appropriate compensation for the work that they do, as well as avoiding potential problems, such as allegations of misconduct or fraud.

It should also be noted that a physician can code by time if more than 50 percent of the encounter was spent face-to-face in direct counseling with the patient. This should be documented in the medical record.

Compliance plan

Dr. Elston emphasized that physicians should have a compliance plan in place to avoid systematic upcoding or downcoding. The program should include education as well as audits of coded visits not yet billed to carriers.

"Mistakes should be corrected, and over-collections promptly repaid. A mistake is simply a mistake. Fraud is a willful act on the part of the provider, evidenced by systematic patterns of upcoding," Dr. Elston says.

Two sets of guidelines currently exist. They differ in the requirements for documentation of the physical exam. Dr. Elston recommends that physicians should use 1995 rather than 1997 guidelines in evaluation and management coding and documentation.

"The 1995 guidelines are simpler," Dr. Elston says. "The burden of documentation on the physician is much greater with the 1997 guidelines."

For a new patient, or consultation, physicians need to detail three key areas before completing an evaluation and management code for a new patient: patient history, clinical exam of the patient and the level of risk of the patient. For an established patient, two of those three areas need to be detailed.

While a new patient is defined as not receiving any professional services in the last three years from the physician or a physician of the same specialty who belongs to the same practice, an established patient has received professional services within the last three years from the physician or another physician from the same specialty belonging to the same practice.

Physicians need to highlight that one component of the review of systems related to the skin. For a level three new visit, a review of a second system must also be documented.

CMS requirements

The Center for Medicare Services requires that the chief complaint be stated, although it may be included in the history of present illness. Dr. Elston advises to list separately the review of systems, and past, family, and/or social history. The history of present illness (HPI) should take into account location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms. Dr. Elston recommends listing these in a bullet fashion to make it easy to determine the number of HPI elements reviewed with the patient.

One common error is to overlook the review of systems in completing the record, Dr. Elston explains. Another common error is to forget that a review of allergies counts as a component of the review of systems for an established patient visit.