E/M Coding Focus: Geriatric Patients & Dementia
Posted on 15. Jun, 2009 by Editor in Hot Coding Topics
Determine HPI or ROS during assessment for geriatric patients.
Your internist is a pro at assessing and treating medical issues, but you’re the pro at getting him paid for his work. Helping him brush up on how he reports E/M services for geriatric dementia can improve the accuracy of your claims, and therefore reduce denials.
Expect Combination Problems to Yield Higher-Level E/M
Many geriatric patients have health problems like vascular disease, diabetes, hypertension, or a history of stroke or heart attack. Your internist must consider these health issues when assessing patients for dementia.
Your internist should document signs, symptoms, and reasons for the workup using the appropriate office/outpatient E/M code. The level you select depends on what the patient’s problems are. If the patient’s only health problem is forgetfulness, you will likely use a lower-level code.
When a patient has multiple problems, your doctor will typically spend additional time completing the assessment. The visit’s complexity may substantiate billing the highest-level E/M for an office visit (99205 for new patients or 99215 for established patients), says John E. Morley, MD, director of the Division of Geriatric Medicine at Saint Louis University School of Medicine.
At this initial visit, the doctor performs a battery of tests such as a mini-mental status exam and a gait and balance assessment, in addition to the history, physical, and family interview, Morley says. Because these tests do not have their own CPT codes, “we roll all of that into the E/M,” he says.
Recognize that a review of systems (ROS) will be more in-depth at initial visits. Your provider, or in some cases a patient’s caretaker, must complete the...
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