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 2/3: CPT, E&M, ICD-9... Oh My

My first day of clinic as a resident, I was feeling pretty confident. After all, this was the moment I prepared for during my 4 years of medical school. I did all the things I was trained to do: I went into the room, set an agenda, did a focused history and physical, came up with an assessment and plan, presented to a faculty member, put in the orders, and moved on to the next patient. Since my medical school and residency used the same electronic medical record, I was already familiar with the system, which helped my flow through the day. At the end of the day, I was just finishing up my notes so that I could go home. The last step would just be to click the "Close Encounter" button that would indicate that all my work was officially finished, and everything could be filed in the patient's chart. As I clicked the button, the system indicated: "REQUIRED: NO LEVEL OF SERVICE FOR THIS ENCOUNTER".

Wait, what? What is this "level of service". Nobody talked about "level of service" in medical school... is that like a rare genetic disorder? That seemed unlikely though, since every one of the charts had this flag. What could every one of my patients have... oh wait, maybe "level of service" is another word for "diabetes"... no, that doesn't seem right. I asked a second year resident in the charting room what to do, and they said, "Is it a new patient or old patient? If new, click the new patient level 3, if old, click the old patient level 3." Oh ok then. Problem solved, at least temporarily. I clicked level 3 on everyone, closed out my note, and went home.

This scenario might not be too far off from your own residency experience. With the implementation of electronic medical records into practices, the job of assigning billing codes that was often previously given to a ancillary staff member in the office (who would go through our notes and use that to bill) is now being diverted back to the physician. What that means though, is that residents now are required to assign billing numbers before we can finish our clinic days. If your program doesn't have an electronic medical record, you may be carrying around a piece of paper and required to check or circle things that represent diagnoses, a level of service/E&M code, and any procedures done. Without necessarily realizing it, we're billing and coding through these activities, because each each diagnosis, level of service, and procedure we click, check, or circle is associated to a code. So what's the problem? If we can just click, circle or check it, then we're doing our job right?

The clincher is this, each code is associated with rules. You can only use certain codes in certain instances, otherwise, your claims may be rejected and your practice won't get paid for what you've done, or you may unknowingly be engaging in billing fraud if your note doesn't match the documentation requirements needed to justify a code. So in order of us to do our job correctly, legally, and and get paid for what we do, we need to use the codes in a way that is compliant with insurance company rules... but hard to do when we're not taught about what codes means and the rules associated with each.

If you're getting to this point, and going, "Wait, so what's level 3? What's E&M?" then you're probably where most of us were when we leave medical school. So the purpose of this post is to give a basic definition of the codes you're likely encountering in your practice. The codes that you are seeing every day generally fall into 2 general categories: CPT and ICD-9 codes. I'll go into more detail on each below.

- CPT stands for "Current Procedural Terminology" and is the code for anything that gets done in an office or hospital. These codes are usually 5 digits, so any 5 digit code you see on your billing sheet or electronic medical record system likely represents a CPT code. Luckily the hospitals still have billers that take our in-patient notes and turn them into codes, so I'm going to focus on out-patient CPT codes. In my mind, I further break CPT codes down into E&M codes and procedure codes.

1) E&M stands for "Evaluation and Management" - If I simplify it, it is a fancy way to say office visit where we evaluate and manage a patient. As we know, office visits can either be problem-based, "I stubbed my toe, and have hypertension... which is higher because my toe hurts... and maybe because I don't take my meds", or preventive ("I'm here for my physical", but should not have ANY History of Present Illness, otherwise you're doing BOTH a preventive visit AND a problem focused visit and you actually need to bill for both, but we'll get to that in my next post). If you're doing a problem based visit, the patient will be either a new patient or established patient, which are coded differently with the assumption that new patients would take longer. If you're using an electronic medical record, you can likely click new patient level __, or established patient level __ to indicate this. If you're circling or checking on a sheet of paper, you'll usually see a code like 99201 - 99205 next to new patients and 99211 - 99215 for established patient. The last digit in each category you'll notice run from 1-5 (i.e. 99203), and that last digit represents the level of service, with 1 being the most basic visit, and 5 being the most complicated. However, if it is a preventive care visit, you have to use an entirely different code, often based on the age of the patient coming in. Your system may allow you to click that code, or you have to type it in manually (I'll share those codes in my next post).

2) Procedure code - The other type of CPT code is specifically for procedures that you did with the patient. If you lifted a finger, there's probably a code for it. Even filling out a school form or doing smoking cessation >3 mins count as separate billable "procedures". For family medicine, common codes may be excisional biopsies or joint injections, just as examples. 

- ICD 9: Stands for "International Classification of Diseases" or simply diagnosis code. It is a number attached to diagnoses you're assigning the patient. These codes are the ones that have a decimal place in them. So for instance, obesity has the diagnosis code of: "278.00". All the visit diagnosis that you're putting in are translating into these codes. These codes matter because it tells insurance companies what diseases you're trying to treat. Let's say you have a patient with a BMI of 41.4 that you want to refer to bariatric surgery. You assign "Obesity" as their diagnosis, which corresponds to a ICD-9 code of "278.00". Seems ok right? The problem is, the insurance company comes back and says, "No... you can't do that, sorry, we don't do bariatric surgery for obese people". Wait what? The reason would be, the indication for bariatric surgery for this insurance might be a patient that's morbidly obese, which is a ICD-9 code of "278.01". The numbers after the decimals usually indicate more detail about a diagnosis, and that level of detail is often necessary to justify the treatment you are recommending. Without proper ICD-9 codes, you're not communicating properly what disease you're trying to treat. Even something as benign as a flu shot without being linked to the diagnosis of "needs flu shot" can get denied. In practice, just be sure every treatment you're doing is associated with an appropriate ICD-9 code, and when choosing ICD-9 codes, be as specific as possible. On a side note, we're currently still using ICD-9, but just be aware that the next version (ICD 10) is going live in October 1, 2014, which will be even more complicated because there will be more ways to assign details (including laterality of a lesion, or what trimester a pregnant patient is in), so the general name of the game is, be as detailed as possible and start practicing now.

Alright, so you should have a basic understanding now of the types of codes that exist, what they look like so you can recognize a CPT vs. ICD-9 code generally, and what they mean. This will set the stage for the 3rd and final post (coming in around a week), where I'll go over the documentation requirements that justify each level of service so you know: 1) How to assign the appropriate level for each patient, and 2) What is required in your note to justify your billing. Hope this is helpful!


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.

Motivational Interviewing - a core competency or an elective skill?

This past Thursday, I attended a seminar on motivational interviewing. After 3.5 years of medical school focused primarily on the science of medicine, it was a refreshing change. As I progress through medical school, I've been increasingly frustrated by my inability to influence behavior changes in patients - most, if not all, of my patients know that smoking is bad, that fast foods lead to obesity, that exercise can help prevent cardiac disease... the list goes on. As clinicians, we sound like a droning tape recorder when we ask (once again) if our patients are exercising (they're not), if they're still drinking (they are) and if they're still smoking (they're still doing that too).

I've spent countless hours learning about things like Kreb's cycle, IL-1, APO-B and Fabry's Disease, all of which I am unlikely to ever use in my professional career. But, in my medical school training, I have not had a single hour devoted to behavioral change in patients.

Motivational interviewing is "a collaborative, person-centered form of guiding to elicit and strengthen motivation for change." It is a method of empowering our patients to take responsibility for their health and accompanying them on the journey towards that change. It is a method that views each patient as a person with a story and a background and not as the "diabetic in room 2" or "the non-compliant patient."

OARS is often used as an acronym in approaching motivational interviewing:

• Open-ended questions
• Affirmation
• Reflection
• Summarizing

Science tells us that prevention decreases morbidity, increases quality of life and decreases cost. Motivational interviewing provides a systematic approach to prevention.


To better serve our patients, medical schools and residencies across the country need to focus more on teaching the art of medicine, which includes behavioral change methods. Strategies like motivational interviewing should be listed as core clinical competencies and students need to be evaluated on these skills in addition to their clinical knowledge. Learning medicine is daunting - the continuously increasing body of knowledge requires that schools pick and choose what they can teach. But if schools continue to focus on teaching the science of medicine at the expense of the art of medicine, it can only be to the detriment of those we aim to serve.

Motivational Interviewing Resources:
http://www.motivationalinterview.org/
http://motivationalinterview.net/clinical/interaction.html
"A 'Stages of Change' Approach to Helping Patients Change Behavior." http://www.aafp.org/afp/2000/0301/p1409.html