Rheumatology Coding Answer: Deconstructing Evaluation and Management Codes

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Answers:

1. B: No—Only the treating physician can take the HPI. The medical assistant is allowed to take the review of systems. If the documentation indicates the treating physician did not take the HPI, the insurance can deny the claim as not medically necessary.
2. B: No—If the high-risk medication is not assessed and a treatment plan does address it during that visit, then no; it would not be a factor if the patient is at high risk during the date of service. For example, if a patient is on methotrexate and the physician decides to order a lab to monitor for toxicity level during the visit, then the visit would place the patient at a high level of risk.
3. A: M06.09, M17.12—Do not code for any diagnosis codes unless they are being assessed and a treatment plan is made for the patient during that visit.
4. B: Established patient—Even though the new partners have never seen the new partner’s established patients, they would be considered as established to all the providers in the practice. A patient is considered to be an established patient if the providers are in the same practice, are of the same specialty and see a patient within three years.
5. B: No—If a midlevel provider sees a patient with a new problem and the supervising physician does not assess the problem and participate in the treatment plan, then the visit does not meet the guidelines of billing incident-to according to Medicare guidelines.

For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.