E/M Coding: Don’t Sell Yourself Short on Problem Sports Exams

Posted on 19. Feb, 2010 by Editor in Hot Coding Topics

Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.

Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.

Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.

Watch for Chronic Conditions

“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.

The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.

Be Alert to Counseling Time

When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.

Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused...

Tags: 250.01, 314.01, 401.1, 493.00, 99201, 99213, 99214, 99215, ADHD, asthma, chronic, counseling, diabetes, diagnosis, E/M, HEM, office, outpatient, time-based, visit