We're taught how to write notes in medical school, but more as a way to communicate to other providers. This post is mainly about how to write outpatient clinic notes to justify how you're billing. In the last post, we talked about E&M Codes for outpatient problem-based clinic visits (this does not apply to preventive visits or physicals discussed more below), and as a reminder, there are 5 levels, 1-5 for both new patients and established patients, with level 1 being the simplest visit, and level 5 being the most complicated. So how do you determine if you should put something as a level 3 or 4, or a level 4 or 5? Just a gut instinct on how complicated a patient is? Or as a resident, do you just randomly click/write one down and hope the attending or someone catches it later?
In general, in order to determine what level visit is appropriate, visit notes are evaluated on three components: 1) History, 2) Exam, and 3) Medical decision making. How much you document on each of these three components will justify the level of billing. If you go to the AAFP website, you can pull up a table that describes the different documentation requirements for each level... but it categorizes it into categories such as: "Problem-focused", "Expanded Problem-focused", "Detailed", and "Comprehensive", but what does all this actually mean in practice? What is a "detailed" history vs. a "comprehensive" history, or a "detailed" physical exam vs. a "comprehensive" physical exam? It actually is quite algorithmic, and so I created a cheat sheet outlining the exact requirements below, but let me try and paint a broader picture first.
Let's talk about the history as an example. It's probably intuitive that the difference between a detailed history and a comprehensive history is based on how much information you gather, so how much do you need to gather? Histories themselves are further evaluated based on three components: 1) History of Present Illness (HPI), 2) Review of Systems (ROS), and 3) Past Medical, Family, and Social History (PFSH). I put in quotations how each level is named. For a "detailed" history, you need to have an "extended" HPI, which means 4+ elements out of: 1) location, 2) quality, 3) severity, 4) duration, 5) timing, 6) context, 7) modifying factors, or 8) associated signs and symptoms, OR the status of 3 chronic systems. On top of that, for a "detailed" history, you need an "extended" review of systems, which means an additional 2-9 systems, and "pertinent" past medical, family, or social history, which means at least one item in 1 of the 3 (the three being medical, family or social). In contrast, if you want to say you've done a "comprehensive" history, which would be required to bill new patient visits in level 4 or 5, or to bill an establish patient as a level 5, then you need to do a "comprehensive" history. A "comprehensive" history still has an "extended" HPI just like above, but the difference is that for the review of systems, instead of doing 2-9 addition systems, you now need to do at least 10 out of 14 possible systems for a "complete" ROS (which is where the numbers 10 and 14-point ROS comes from. All 14 possible ROS are listed in the cheat cheat), and address one item in 2 out of 3 areas for a "complete" PFSH. The details for each level are listed in the cheat sheet here.
Just to cycle back to the opening of this blog post, so what's wrong with documenting a cardiovascular exam such as "CV: RRR, nl S1/S2, no m/r/g"? If you look at the cheat sheet, for a "detailed" exam, which you need for a level 3 new patient, and a level 4 established patient, you need at least 2 elements in at least 6 systems of your physical exam. The systems for a physical exam and elements that count are listed on page 3 of the cheat sheet, which if you look, the description above only handles one element: auscultation. Personally, I've now added, "no thrills on palpation" to my exam to satisfy the second element.
So why is there a difference between new patients and established patients? The assumption is that new patients will take more time, and therefore they are billed at a higher rate. Similarly, your documentation has to be more detailed. In a new patient, all three of history, exam, and medical decision making need to be satisfied to bill at a certain level, but for an established patient, you just need to satisfy the requirement for 2 out of 3 to bill a certain level. For example, for a 99215, or established patient level 5, you need to do a comprehensive history, a comprehensive exam, and/or a high level of medical decision making. If you only did a comprehensive history, and a comprehensive exam, and the level of medical decision making was low, that would still count as a 99215 because you satisfied 2 out of the 3, and any combination of 2 components would work.
The final caveat is that you can actual bill for time as well. You'll notice that for every level it says "Or" followed by a time period. If >50% of the time you spent with a patient had to do with counseling, then technically you don't need to document a history, exam, or your medical decision making, just what you counseled the patient about and the amount of time spent.
On the second page of the cheat sheet are some other codes that might be useful:
- E&M codes for preventive visit or physical exams, at which point you don't use a problem based code as I have been talking about above. Instead, a preventive visit or physical technically would have no problems in the HPI, therefore you bill them differently, and do it by age as listed on the second page. However, let's say you also addressed some problems, then you can bill for both a preventive visit AND a problem-based visit, and you can do that by adding the modifier 25 to one of the codes to signal that you did more than one thing during that visit.
- Other modifiers that you will probably use a lot in billing is "GC" for when an attending comes in to see a patient with you, and "GE" for when you just precept a patient without the attending seeing them. I have some other modifiers that might be useful on the bottom of page 2.
- On page 2, there are also the preventive visit codes for Medicare as well, since Medicare is now allowing us to bill for preventive visits. The elements that Medicare requires for a preventive visit is included.
- Finally, there's some non-intuitive ICD-9 codes you might want to use when billing for vaccinations, however you should check with your state medicaid rules since different states have different requirements.
Author: Raymond Tsai, MD, MS is a Family Medicine resident at UCLA. MD from Stanford University School of Medicine and MS in Health Policy and Management from Harvard School of Public Health. Follow him on Twitter (@RayCTsai) or see his personal blog about health living.