Particularly in our current climate of health care reform and ICD-10 transition, cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever. Starting this issue, the ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze. Look for a new coding and reimbursement tip next month!

Fact #1: The History Component

Q: If I miss a few review of systems (ROS) elements, what’s the big deal? Can’t I leave this to the coders?

A: Remember, you must both perform and satisfactorily document a service to get paid for it. Many practices would agree that the most common documentation omissions are in the history. Elements of the HPI, ROS, and PFSH must be documented consistent with the level of medical decision making/medical necessity. Although physicians often ask the questions and perform the service, they commonly forget to document the required history elements consistent with the services they provide. For example, just forgetting to document required history elements on 10 percent of your highest level patients (99285) could result in a $10,000 loss in charges/RVU’s. Thus, the “$10,000 mistake” can cost you and your practice significant revenue.

A common reason charts get downcoded from a Level 5 (99285) to a Level 4 (99284) is inadequate ROS. Medicare guidelines require that for Level 4 (99284), you record a review of two to nine systems, while Level 5 (99285) requires the recording of 10 or more systems. Listing of pertinent positives and/or negatives with the statement “all other systems reviewed and negative” meets Level 5 (99285) requirements for most payers. Also, remember under-documenting your history of present illness (HPI) and past, family, and social history (PFSH) can also result in significant downcoding of your medically necessary services. For the HPI, Level 4 (99284) and Level 5 (99285) require documentation of at least four HPI elements. For the PFSH, Level 4 (99284) requires recording of one of three PFSH elements, whereas Level 5 (99285) requires recording of two of three PFSH elements.

For more information about this or other reimbursement issues, visit ACEP.org.

Brought to you by the ACEP Coding and Nomenclature Committee.

Ms. Edelberg is chief executive officer of Edelberg & Associates in Dacula, Georgia.
Dr. Lempert is vice president and medical director, health care financial services, at TeamHealth, based in Knoxville, Tennessee.