Billing and Coding in Sports Medicine
Medical billing and coding are like taxes: not a favorite subject, everyone wants to pay the exact amount they owe, and no one wants to get audited. Coding guidelines for evaluation and management (E&M) in the outpatient setting have not fundamentally changed since 1997. This commentary will highlight the 21st century changes that have affected the coding of our sports medicine practices. First, we introduce meaningful use (MU) requirements by the federal government, and second, we discuss the subsequent change in our documentation, with coding examples.
Meaningful use is a concept put forth by the Centers for Medicare and Medicaid Services (CMS) to improve health care in the Unites States by collecting and sharing data, advancing clinical processes, and improving outcomes (1). In 2011, stage 1 required core measures such as an electronic medical record (EMR) with a medication list, allergy list, computerized physician order entry (CPOE), interaction checks, electronic prescriptions (eRx), vital signs, up-to-date problem list, smoking status, demographics, visit summaries, and protection of patient health information (2). In 2014, stage 2 added more laboratory results, family health history, medical reconciliation, health information exchange, and patient specific education to name a few. Initially through incentives, the federal government (or our hospitals) convinced us to document this data (3). Adding to the information overload, we received the International Classification of Disease (ICD)-10 in 2015. Now, a single body part may have multiple applicable diagnoses.
Birth of the Electronic Chart
The government suggested that transferring handwritten charts to an electronic format would improve quality of care. Paper charts favored shorthand and efficiency — we wrote the bare necessities. You may remember a physical examination that looked like this: “Gen: NAD, AAOx3. HEENT: NCAT, PERRLA, EOMI. CV: RRR, normal S1/S2, no g/r/m. Lungs: CTAB, no r/r/w. Abd: soft, NTTP, ND, BSx4. Rest: WNL.” Abbreviations are no longer welcome since patients are supposed to understand the clinical notes. Nostalgia aside, we now document electronically.
Medicine teaches a systematic approach based on the current evidence. Should we use a template for documentation? If we teach students a systemic approach to a physical examination and the examination is reproduced the same way each time, why not have a template that can document the information in the note? The EMR favors templates and dot phrases, the modern-day shorthand. While some of the art of medicine and doctor handwriting jokes are gone, we have adapted (or retired). Our EMR notes are more easily read by the health care team, patient, and auditor, albeit at an excessive length.
Through MU, we now record significantly more information in our notes. Medical coding is based on the information in our notes and medical necessity. We calculate the E&M code based on three components: history, physical examination, and medical decision making (MDM). Each of these three were affected by MU (4).
History includes chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past medical, family, and social history (PFSH). The type of history is determined by the amount of information from problem focused, to expanded, to detailed, and to comprehensive level. Comprehensive visits require a CC, four or more bullets on the HPI, at least 10 of 14 systems on ROS and two or more from PFSH. Most sports medicine histories will have four HPI points. Thanks to MU stage 2, we now have family and social history in the note. For the history component, a comprehensive level is not difficult to achieve (5).
Physical examination for sports medicine has not changed much in the 21st century, but our documentation has. Previously, it was rare to document every detail. We put pertinent positives and negatives. What took a couple minutes to examine would take many minutes to write or dictate, an inefficient use of our time.
With EMR, we can click the box, put in a dot phase, or set up a template for our standard examination. The physical examination level, like history, goes from problem focused to comprehensive. The 1995 guidelines are organ system-based and vague on details. The 1997 guidelines have specific bullets. Physicians are free to choose which guideline to use. The exact elements of the 1995 and 1997 examination are available on the CMS web site. For this commentary, I will use the 1997 guidelines because they are easiest to explain and defend.
For physical examination level, expanded requires six or more elements, detailed requires ≥12 elements, and comprehensive requires all elements. This includes vitals, constitutional, cardiovascular, lymph, skin, neuroanatomy, psychological, and musculoskeletal examination of four of six areas (head and neck; spine, ribs, and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity). A comprehensive level is difficult to achieve. If someone presents with acute right knee pain, there is no medical necessity to examine four of the six areas required. However, since orthopedic examinations generally have 12 elements and vital signs are required by MU, a detailed level examination is achievable (5).
Medical Decision Making
The last component is medical decision making. This is divided into three sections: A is diagnoses, B is the amount or complexity of data reviewed, and C is the risk of complications from the presenting problem, diagnostic procedure, or management option (Table 1).
Part A: The number of diagnoses refers to either the new problem with or without further workup (four and three points, respectively) or established problems that are worsening or stable (two points or one point, respectively). Four points is the maximum. Given the complexity of modern medicine, the updated problem lists, and the increased diagnoses through ICD-10, the number in part A is likely higher than that in the past.
Part B: The data section gives one point max for reviewing or ordering laboratory tests, review, or ordering imaging tests, requesting old records, or obtaining the history from someone other than the patient. Two points for reviewing and summarizing old records, discussion of the case with another health care provider, and independent visualization of imaging or tracing. The details and medical necessity must be documented in the clinical note. In sports medicine, we may obtain history from a coach or athletic trainer, independently visualize and review an x-ray or magnetic resonance imaging or discuss the case with another physician. The EMR allows access to other records to review. It also documents the orders, laboratories, imaging results, and referrals that give us data points (four points maximum).
Part C: The level of risk of complications objectively categorizes patient complexity (Table 2). There are three risk parts: the problem(s), diagnostic tests used, and management. The highest level of risk from either determines if it is minimal, low, moderate, or high risk. An acute uncomplicated injury or a stable chronic illness is considered a low-risk problem. An acute complicated injury, chronic injury with mild exacerbation, or more than two stable chronic injuries are moderate risk. Severe exacerbation of a chronic injury, illness that poses a threat to life, or an abrupt change in neurologic status are high risk. Laboratories and x-rays are minimal risk diagnostic tests. Low-risk management options are over-the-counter (OTC) medications or referral to physical therapy. Moderate-risk options are closed fracture care, in-office injections, managing prescription medication, minor surgery with risk factors, or major surgery without risk factors. High-risk options are elective major surgery with risk factors, emergency major surgery, drug therapy requiring intensive monitoring for toxicity or change in resuscitation status.
The level of risk table (part C) has striking similarity to the MDM table — which can be misleading. The language used in the table by CMS also can be misinterpreted. As an example, someone specialized in sports medicine may consider a high ankle sprain as an uncomplicated injury because of their comfort level and experience. The risk refers to the patient’s risk of complications and should not be underestimated because it is routine for your office. A diagnosis that includes extensive downtime, specialized durable medical equipment, advanced imaging, follow-up, and possible surgery would count as complicated or moderate risk. Stopping a prescription of naproxen may seem simple, but as we maintain an updated medication list, discontinuing a prescription constitutes a moderate risk. The laws enacted to combat the ongoing opioid addiction crisis have moved opioids to high risk due to the intensive monitoring required for overdose or abuse. An arthritic patient presenting acutely in a wheelchair because of their severe knee pain is an example of a chronic injury with a severe exacerbation, high-level risk.
Bringing It All Together
Medical decision-making complexity is determined from the two highest from A, B, or C. The E&M visit codes in new patients is the lowest level component from history, physical examination, or MDM. In established patients, we use the middle-level component. Therefore, a 99204 is uncommon in sports medicine given the requirements of a comprehensive physical examination; however, in an established patient, only a detailed physical examination is required. Additionally, for established patients, we can choose two of the three (history, examination, or MDM) components, and many established patients are 99214 level visits (Tables 3 and 4).
Time is the other method to document and determine an E&M code — spending ≥50% of the service on face-to-face discussion and directly coordinating care. Examples are long discussions on return to play or speaking with the hospital to arrange for a treatment. Electronic medical records can accurately time the visit and make it easy to document the time spent.
Ultrasound Procedure Codes
In January 2015, CMS decided to bundle ultrasound guidance procedures for an arthrocentesis. A 20610 for a knee injection is now a 20611 for a knee injection with ultrasound guidance. Injections for nonjoint areas still use a separate 76942 code for ultrasound guidance. All procedures require a 25 modifier to the E&M service if they are done on the same day.
Prolonged E&M Services
In January 2017, a non-face-to-face service was allowed under “Prolonged E&M Services.” Any physician who spends ≥31 min on a patient for medically necessary reasons that relate directly to a service can code a 99358 and bill for that encounter — even if the patient was not in the office that day. A note must be written that documents the start and end time along with the substance of what was done.
Coding properly for medically necessary work is not overcoding. Undercoding is considered just as unacceptable as overcoding. Centers for Medicare and Medicaid Services wants accurate ICD-10, E&M, and procedures codes to determine the needs of our health care system. The implementation of MU has made certain core measures mandatory. The EMR allows physicians unique opportunities to improve their documentation and code appropriately.
CMS Proposed Changes for 2019 Medicare Physician Fee Schedule
Radical changes are under discussion that would change much of what was mentioned above. Physicians have asked CMS for help with burdensome documentation. CMS has several proposals in their 1400 page document including: E&M CPT codes 99212-99215 and 99202-99205 will have a single payment rate (US $93/1.22 wRVU and US $135/1.9 wRVU, respectively), instead of 1995 or 1997 guidelines physicians could use only medical decision making or visit time to determine coding level, 50% reduction in reimbursement of a same-day procedure(s) through the 25 modifier, and adding new CPT codes for telemedicine (6,7). No specifics about changes to quality measures or MU. Physicians and medical societies are currently reviewing the document and submitting comments to CMS. Please keep informed of the modification as they become finalized.