ACR Coding Specialist Responds to Letter: Of Coding and Perception

Read the letter from our reader first.

Thank you for forwarding this concern; feedback on the “Coding Corners” is greatly appreciated. I would like to discuss each issue line by line.

• The use of time in this example was used to demonstrate how time can be used to support the medical necessity of a level. I understand that using time as a key factor to determine the level of a visit is a delicate issue, but it does happen—not often, but it is an acceptable documentation guideline. According to CPT, “When counseling and/or coordination of care dominates (more the 50%) the physician/patient and/or family encounter (face-to-face time in the office/other outpatient setting or floor/unit time in the hospital or nursing facility), the time shall be considered the key or controlling factor to qualify for a particular level of E/M services.”
• The notes do not state that the X-ray or urinalysis was done at that visit, but they were reviewed, and this is acceptable according to the 1995 and 1997 E/M documentation guidelines. This would support the level of the complexity of the medical decision making.
• Unless the reviewing of the X-ray was discussed with the patient face to face, it would not be included in the 30 minutes.
• As for the review of systems and past family social history, this example was from an actual rheumatologist chart. I do not feel, as a coder and auditor, that it is up to me to question a physician as to what he or she has documented in the chart unless there is clear evidence of fraud. From reviewing this chart alone, evidence of fraud or bringing notes forward from an EHR is not shown.

I understand rheumatologists have many different documenting styles and I try to demonstrate the different styles in “Coding Corner” each month. Again, thank you for your feedback!

Melesia R. Tillman, CPC-I, CRHC, CHA
ACR Coding and Reimbursement Specialist
Atlanta