Medical Documentation and Coding for the Colorectal Surgeon

Introduction

One of the most essential and least understood issues affecting colorectal surgeons is accurate medical documentation and coding via the current procedural terminology (CPT) coding system. This coding system encompasses a broad framework for capturing the components of physician work and requires use of specific descriptors of the work performed to ensure transformation of the encounter into reimbursement via the various physician payment systems. In addition, the specificity of the required documentation should produce accurate coding to support more rapid reimbursement and decreases in payment denials, thus optimizing the revenue cycle. Many surgeons do not fully understand the power of accurate coding to produce granular analysis of code patterns, individual volumes, and resource consumption within a practice. These data, in turn, should be routinely assessed within a robust practice management system to define areas for process improvement for revenue, along with practice patterns to reduce waste and cost. It is essential that all physicians take the time and expend the effort to master the components of a code and the documentation required in the medical record to achieve the financial rewards and avoid the risk of Medicare fraud prosecution.

Process of CPT Code Development

CPT codes are developed under the direction of the American Medical Association (AMA) in conjunction with representatives from virtually all medical specialties. The steps in the process are: (1) identification of a new procedure/encounter and the unique and specific components of that activity by a specialty; (2) presentation of the procedural description to the CPT committee of the AMA by a specialty society and approval of a unique CPT code (Category 1 or Category 3, described later); (3) evaluation of the code using an elaborate survey of practitioners of the service to develop suggested relative value units (RVUs) to define physician work, practice expense, and professional liability values; (4) presentation of the suggested RVU value to the Relative Value Update Committee of the AMA for final code valuation and recommendation of this RVU value to the Centers for Medicare and Medicaid Services for acceptance or refinement; and (5) transformation of the code into approved reimbursement (defined by multiplying the existing $/RVU conversion factor multiplied by the accepted total RVU value). Although surgeons often complain about specific valuations, the system has generally provided sufficient “relativity” between procedures and services to be reasonably fair across specialties.

CPT Coding for Evaluation and Management Services

Coding for evaluation and management (E&M) encounters requires a lengthy discussion and will not be reviewed here. Suffice it to say that the components are the basic components of the history and physical examination coupled with a description of the plan of care. It is essential to record all the activities performed during that encounter, tempered by the medical necessity, to be correctly compensated. Time can be used as a surrogate for task performance when the majority of the visit entails counseling. The Centers for Medicare and Medicaid Services and most commercial insurers no longer reimburse for consultation codes (9924X and 9925X), and thus providers should assess their local environment regarding the applicability of those two code families. The available categories for E&M coding are:

9920X- New patient, office setting
9921X- Existing patient, office setting
9922X- New patient, inpatient setting
9923X- Subsequent hospital day

Office Evaluation and Management Coding

The process of accurate coding for office visits begins with precise registration of the patient. The patient should be encouraged to bring his or her insurance card, and a copy should be retained in the file so that all of the patient’s demographic and insurance plan information is accurate and up to date. The patient also should be asked about the existence of any secondary coverage, which is typical for patients using Medicare products, among other products. A script also should be in place for co-pays, because many commercial plans mandate collection at time of service as part of the contract, and the co-pay may be restricted from subsequent billing.

The patient is now ready to be seen by the doctor. It is important to understand that accurate documentation based on medical necessity of the chief complaint(s) will be required to support an appropriate level of code for services rendered. From a practice management perspective, remember that significant costs are associated with each visit, and it will be the total margin on the visits that will determine the financial viability of the practice. Lower level visits (e.g., 99212) have very similar costs to higher level visits (e.g., 99214), and therefore it is total performance that will be required to schedule the office and receive sufficient reimbursement to support the practice.

The E&M visit should include chief complaint; history of present illness; medications/allergies; social history; family history; review of symptoms; physical examination; impression; and plan. The latter two elements support the concept of medical decision making, which is an important issue supporting the code level. Rarely, in a surgical practice the majority of the visit will be focused on either counseling or coordination of care. These latter two categories are best captured by time allotted, and that alone can support the coding level. Table 93-1 shows the specifics of the history components for scoring as modified from the 2014 CPT Current Procedural Terminology—Standard Edition .

TABLE 93-1

Categories and Scoring for History Elements

Category	Criteria	Scoring
History of present illness	Location Quality Duration Timing Context Modifying factors Associated symptoms	Brief: 1-3 elements Extended: >3 elements or status of 3 chronic problems
Medications/allergies	Recorded	Recorded
Past history/social history/family history	Recorded	Pertinent: 1 from any element associated with HPI Complete (new patient): 1 from each category Complete (established): 1 item from 2 categories
Review of systems	Constitutional Eyes Ear, nose, throat Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Endocrine Hematologic Neurologic Skin/breast Psychiatric Allergic	Problem pertinent: specific to HPI Expanded: 2-9 systems recorded with pertinent positives/negatives Complete: All 10 recorded with positives and negatives, or at least 3 recorded and remainder mentioned as negative

HPI, History of present illness.

Scoring the physical examination is supported by reported bullet items in each organ system that are considered essential and common diagnostic maneuvers; however, it is often not recognized that routine vital signs are included for scoring and should be recorded for all patients at each visit. The list of physical examination components is extensive, and the reader is referred to the CPT Current Procedural Terminology—Standard Edition (see Suggested Reading ) for the suggested elements. Scoring of the physical examination portion of the encounter is based on the following categories: Problem Focused (one to five elements in one or more systems); Expanded (six bulleted items in one or more systems); Detailed (at least six organ systems with two bulleted items or at least 12 bulleted items in two or more systems); and Comprehensive (all bulleted items in eight or more systems). Although the rules seem arcane at a functional level, one can use a fairly pragmatic approach, and additionally, it is important to remember that a patient admitted for surgery will require a full history and physical examination for admission anyway. An example of a three-level office visit for a patient requiring colorectal surgery would include vital signs (weight, temperature, blood pressure, pulse, and respiratory rate); an abdominal examination (gastrointestinal: masses/tenderness; liver/spleen; hernia; perianal, hemorrhoids, sphincter tone, masses); and a genitourinary examination (prostate/rectum for male patients and vagina/rectum for female patients).

Decision making includes both the number/severity of the differential diagnoses that may apply, as well as the available imaging and laboratory data (or testing ordered to be subsequently reviewed as a result of the encounter). The medical record should include a list of impressions and/or documented current status (such as improved or worse), a listed differential diagnosis, comorbid diseases, documented initiation of treatment changes, and documented referral. It is important to list tests ordered or pending, review any recently completed diagnostic studies, and review of a referral letter (and associated medical records). Finally, the surgeon should include a summary of comorbidities, scheduling of an invasive procedure, documentation of the informed consent process, urgency of the decision to perform surgery, and the seriousness of the natural history of the disease ( Table 93-2 ). The strategy for selecting a final code level is demonstrated in Table 93-3 . For a new patient, the code selection is based on the lowest level of one of the components, whereas for existing patients, only two of the three components must be addressed (again with the lowest level defining the code); see Tables 93-4 and 93-5 .

TABLE 93-2

Scoring of the Decision-Making Component of an Evaluation and Management Visit Modified from the CPT Current Procedural Terminology—Standard Edition , 2014 edition