Billling and Coding Series 3/3: How to Write Notes for Billing

When you're documenting a cardiac exam, do you ever write: "CV: RRR, nl S1/S2, no m/r/g"? If so, you may be sad to find out that doesn't count as an adequate cardiac exam for a basic new patient exam or a physical exam.

 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:

1. 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. 
2. 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. 
3. 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. 
4. 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.

Anyways, that's a lot of information already, so I'll leave it there, and that concludes the 3 post series on coding and billing, going through why it is important to learn these skills, the basic definitions of terms for coding, and the documentation requirements in order to satisfy billing/coding requirements to justify what you're doing. 


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.

Billing and Coding Series 1/3: Why It Matters for Students/Residents in Primary Care

For three years before I applied to medical school, I worked in post-Katrina New Orleans helping to rebuild School-Based Health Centers. One of the main challenges however, was how to create a sustainable safety net for at-risk youth to whom we were hoping to provide much needed health services. The key to that sentence was sustainable. All too often, there isn't funding available to carry out our mission in primary care of improving the health of communities and underserved populations. At the time, I was a public health manager, and I remembered I often felt increasingly frustrated at physicians that couldn't optimize their coding and billing because not only were they leaving money on the table for the much needed services they were providing, but they made my job of trying to advocate on their behalf near impossible. One of the avenues we tried to pursue was state funds to support the School-Based Health Centers, but without proper coding, we never had accurate data to show exactly the needs we were addressing. In addition, when we asked state legislators for increased funding, we were easily countered with, "But you don't use the money we're giving you now through Medicaid...". The only thing I could do was stare back looking like a greedy kid who asks for seconds before I finished what was already on my plate.

At the time, I didn't understand why it was so difficult for physicians to code for the services that they were providing. It is part of their job. I remember thinking, "What is wrong with you people?! Don't they teach you how to do your job in medical school or residency?" Now that I've been through medical school and am in residency, I realized... actually no, no one teaches us about how to actually be a functioning physician in the community. We learn about medicine, a necessary part of being a good doctor... but it isn't the only part. We seem to forget that physicians operate in a larger healthcare system that is increasingly being scrutinized for its cost and quality. It is more than just knowing how to diagnose and treat diseases anymore. In our changing healthcare environment, we're going to be expected as physicians to code accurately to prove we've met certain quality measures, justify our billing (let's not forget one of Medicare's major cost-saving strategy is cutting down on fraud, so as a warning coding inaccurately whether it is intentional or not can be considered fraud), and as there's increasing pressure to drive down the cost of healthcare, we can no longer afford to leave money on the table if we want to be sustainable (particularly when working with underserved populations).

It's a deficit in our medical education system that we don't teach basics of practice management to medical students and residents, but then we expect people to graduate from residency with a sudden knowledge of how to do things that will be expected of us as practicing physicians. In this past year I've been promoting the importance of coding and billing, as well as providing some basic information to my fellow residents. I hope by laying a framework, we can continue to learn more throughout our training, and ultimately graduate more prepared to be functional physicians in the community. However, I think this is an important issue for all residents, so I wanted to share some of the things I've developed as a 3 part series so that we can learn together. The second in the series will be an overview of coding if you ever wondered what CPT and ICD-9 (soon to be ICD-10) means, and then the third and last in the series will be how to document clinic notes appropriately for billing.  


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.

Future of Family Medicine Blog Celebrates One Year of Blogging

Kevin Bernstein, MD,MMS
Co-Founder
Future of Family Medicine Blog

Just about one year ago, Sebastian and I decided to start the Future of Family Medicine Blog. During this time, the blog has been featured in local, state, regional, and national presentations as a successful example of social media use by medical students and residents. We were also nominated for best new health weblog for 2010, only 3 months after starting up! We have been cross-posted on KevinMD on numerous occasions and received international attention from the International Conference on Residency Education. Several of our authors have held key positions in the AAFP, STFM, AMA as well as within medical schools, family medicine residency programs, and state chapters of national organizations.

Although the frequency of postings has decreased recently since many of the authors have started internship and application/interviewing for family medicine residencies, we want to thank all of our dedicated readers, followers, and individuals who have shared our message with your communities, medical associations, patients, and most importantly, the future of our great specialty, family medicine.

This past week I released a video that I have worked on for a number of months to promote the Family Medicine Revolution (#FMRevolution).  I did not know when would be a great time to release it publicly and if it would actually make an impact.  Being as this is the first year anniversary of the blog, I figured it would be a great gift to our readers and loyal followers.  I also realized that this is a very interesting time for the future of our specialty:

• Many fourth year medical students are beginning to interview and may still be on the fence in regards to choice of specialty.
• This is the time where many third year medical students are beginning their time on the wards - learning about different specialties and encountering persuasive physicians and residents that either embrace their decision to choose family medicine, or contribute to the myths and misconceptions of our specialty.
• First year medical students are beginning to attend meetings with various interest groups and may be interested in the current hype surrounding family medicine.
• The AAFP is currently putting on a full-court press in regards to SGR, GME funding, the RUC, and medical student interest across the various regions of the country.

So far, the video has received social media attention around the world, including the AFMRD and STFM list-servs, and by the current AAFP President, Dr. Stream.

It really is amazing how much the Family Medicine Revolution has progressed and how much momentum family medicine has gained within the past year.  I am hopeful that this blog has helped in the process and that it will continue to provide fresh perspectives for the future of family medicine - the only true primary care specialty.