Documenting a Level 5 Office Visit

Medicare has stepped up efforts to discover billing errors and recover money already paid to clinicians. Medicare administrative contractors are auditing nurse practitioners and demanding that money already paid be returned. The contractors audit a small sample of charts and extrapolate any overpayments they identify, applying that error rate to all claims filed by the provider. A $3,000 overpayment identified on an audit of 30 medical records can turn into a demand for $185,000.

Nurse practitioners and physicians should be certain that their documentation supports the level of service billed. To be sure that you are paid appropriately and to prepare for audits, review your knowledge of coding and perform regular self-audits.

In this column I review requirements for billing a level 5 Evaluation/Management (E/M) visit in the office. Level 5 office visits—CPT code 99205 for a new patient and 99215 for an established patient—should be relatively rare. Medicare expects that most clinicians will bill on a bell curve, that is, mostly code 99213, with some 99212s and 99214s and few 99211s and 99215s. However, a clinician who has performed all elements of a level 5 visit, and documents what was done, should not be shy about billing at that level.

For CPT 99205 (new patient), the clinician must satisfy the requirements for history, examination, and medical decision making. For CPT 99215 (established patient), the clinician must satisfy the requirements for 2 of those 3 elements, that is, history and examination.

History

History at level 5 is “comprehensive,” composed of an extended history of present illness (HPI), a complete review of systems (ROS), and a complete past family and social history (PFSH). For an extended HPI, the medical record should describe at least 4 elements of the present illness or the status of at least 3 chronic or inactive conditions.

For a complete ROS, at least 10 organ systems must be reviewed. The review includes the systems directly related to the problems identified in the HPI plus all additional body systems. Those systems  with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.

A complete PFSH consists of a review of 3 areas: 

past history: a review of the patient’s past experiences with illnesses, operations, injuries, and treatments 

family history: a review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk

social history: an age-appropriate review of past and current activities

At least one specific item from 2 of these 3 history areas must be documented for a complete PFSH for an established patient office visit. At least one specific item from each of the 3 history areas must be documented for a new patient office visit.

Physical Examination

Physical examination at level 5 also is “comprehensive.” A comprehensive examination may be a general multisystem examination or a complete examination of a single organ system and other symptomatic or related body areas or organ systems.  Specific abnormal and relevant negative findings of the affected or symptomatic body areas or organ systems should be documented; a notation of “abnormal” without elaboration is insufficient. However, a brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected areas or asymptomatic organ systems.

A comprehensive examination should include at least 9 organ systems or body areas. Medicare’s Documentation Guidelines for Evaluation and Management, 1997 version (the current version), lists 11 organ systems: cardiovascular; ear, nose, and throat; eye; genitourinary; hematologic/lymphatic; immunologic; musculoskeletal; neurologic; psychiatric; respiratory; and skin. For each system or area selected, all elements of the examination identified by a bullet (•) in these Medicare guidelines should be performed, unless specific directions limit the content of the examination.

For all areas or systems, examination of at least 2 elements identified by a bullet should be documented. Documentation of every element in each box with a shaded border and of at least one element in each box with an unshaded border is expected.
For a complete examination of a single organ system, it is necessary to examine and document all elements identified by a bullet in Medicare’s Documentation Guidelines, both those in shaded and unshaded boxes.

Medical Decision Making

Medical decision making at level 5 is “high complexity.” Medical decision making refers to the complexity of establishing a diagnosis or selecting a management option as measured by the number of possible diagnoses or management options that must be considered; the amount or complexity of medical records, diagnostic tests, or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, or mortality, as well as comorbidities, associated with the patient’s presenting problems, the diagnostic procedures, and the possible management options.

High-complexity medical decision making is documented by addressing any of the following:

one or more acute or chronic illnesses or problems with severe exacerbations

4 or more stable chronic illnesses or problems requiring evaluation

an acute complicated injury with significant risk of morbidity or mortality

one or more acute or chronic illnesses or problems that pose imminent threat to life or bodily function or an abrupt change in bodily function (such as seizure, cerebrovascular accident, or acute change in mental status)

Below are some guidelines for preparing documentation to support your coding of a level 5 office visit:

For each encounter, document an assessment, clinical impression, or diagnosis. For a presenting problem with an established diagnosis, note whether the problem is improved, well controlled, resolving, or resolved; or, alternatively, whether it is inadequately controlled, worsening, or failing to change as expected. For a presenting problem without an established diagnosis, state the assessment as a differential diagnosis or as a possible, probable, or “rule out” (R/O) diagnosis. Document the initiation of or changes in treatment. Treatment is not limited to therapies and medications; it also includes patient instructions and nursing instructions.

Note referrals made, consultations requested, and advice sought, including the individuals involved.

Document any diagnostic service, test, or procedure ordered, planned, scheduled, or performed at the time of the E/M encounter.

Indicate the review of laboratory, radiology, and other diagnostic tests. A simple notation such as “WBC elevated” or “chest xray unremarkable” is adequate. Another way to document the review is to initial and date a report with test results.

Note a decision to obtain old records or additional history from the family or another source to supplement information obtained from the patient. 

Indicate relevant findings from the review of old records or the receipt of additional history. If there is no additional relevant information, that fact should be documented. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient documentation.

Document discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study.

Document the direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another provider.

Indicate comorbidities and underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, or mortality.

If a surgical or invasive diagnostic procedure is ordered, planned, scheduled, or performed at the E/M encounter, indicate the specific procedure.

Document referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis.

Self-Educate

Don’t stop at this review. Nurse practitioners who know the difference between levels 2, 3, 4, and 5 E/M office visits can be more certain of receiving every dollar they deserve, without worrying about failing an audit and paying money back. Familiarize yourself and use Medicare’s Documentation Guidelines for Evaluation and Management, 1997 version or 1995 version. Auditors will accept documentation that conforms with either version.