Coding and Documentation: A Brief Guide

Dipesh Navsaria, MPH, PA-C


September 12, 2001

In This Article

Coding the Treatment

CPT Coding

CPT stands for Current Procedural Terminology, although for some it means Continually Painful Torture. These codes, published by American Medical Association, identify the exact set of services provided to a patient. On the face of it, it's fairly simple.

Let's say an asthmatic 4-year-old girl presents with cough, shortness of breath and wheeze. A nebulizer treatment is started and she clears up, is breathing easier, and is evidently better. How is this visit described in terms of CPT coding?

CPT coding is fairly easy in terms of supplies or procedures. For example the nebulizer treatment is coded as 94640. However, coding is a lot trickier when it comes down to evaluation and management decisions -- how are these quantified?

CPT uses a set of visit codes. These codes are divided into 2 groups, E&M (evaluation and management) codes and preventative services. Preventative services are fairly straightforward to code -- eg, annual physicals or well-child checkups fall into this category, and they're generally defined by the patient's age. So a checkup for a 6-month-old would be coded as 99391, with any appropriate CPT codes for the immunizations and any screening tests you might routinely order at that age.

E&M visits are "problem-oriented" visits -- generally, the patient is ill or has a problem that needs evaluation and/or management. This can range from ringworm to moderately serious conditions, such as cardiac arrest. Naturally, a provider should be paid a small amount for evaluating and managing a simple case of bacterial conjunctivitis and a higher amount for a serious condition such as a heart attack.

To describe the full set of criteria utilized is beyond the scope of this article. However, it's a multifactorial decision, involving assigned "points" based on how much work was involved in each stage of the visit ( Table 1 ).

These factors all play into deciding which of the 5 E&M visit levels to use. These are called Levels I-V or, alternatively, Minimal, Brief, Limited, Extended, and Comprehensive. Realistically, no one after writing their patient note spends 5 minutes adding up "points", although preprinted documentation forms can greatly speed the process, and some electronic medical record programs will automatically calculate it for you. The reality is that most providers will develop a sense of what category a particular type of visit falls into, although periodically checking one's notes against the full criteria is not a bad idea.

For the most part, the distribution of visits to a primary care provider are generally expected to follow a bell curve. The majority of visits will be level III, with fewer falling into levels II and IV, and very few into level I and V. A specialist, on the other hand, may be skewed upward somewhat due to the inherently more complex nature of the patients seen.

There are a couple of wrinkles in this system, for example, the codes are divided by "new" and "established" patients. Naturally, a new patient requires more work than does an established patient. By coding, a 99202 (brief visit, new patient) rather than a 99212 (brief visit, established patient), you are generally paid more for the extra work involved in reviewing their history. (Likewise there are codes for "new patient physicals" and "established patient physicals.") Incidentally, it is not necessary to write down every small item of past history a patient provides. The patient can fill out a form and annotate the form as needed, and the physician can then sign the form to acknowledge that it's been reviewed. Items must be written down to count toward the criteria for coding.

Finally, what do you do about those extra long visits during which the patient has a lot of questions? One easy way to handle such a visit is to document the visit based on time. If the visit is a certain length, and more than 50% of the time was spent "counseling or coordinating care," the visit level can be determined by the provider based on the time spent. A level III visit is defined as 30 minutes. If an hour is spent taking a history on a child with behavioral difficulties and then discussing a diagnosis of attention-deficit disorder along with treatment options, a level-V visit is easily justifiable, as long as the total time spent and more than half the time was spent counseling is documented. Only face-to-face time you spend with your patient, not time spent talking with the consulting specialist or the time spent by the nurse, medical assistant, or student.

A word of caution: while one could, in theory, get away with writing a brief note documenting time for a long involved visit, recall that these are criteria for billing purposes. A paltry note stating time spent with a patient with severe asthma may get you paid, but it will kill you in a court of law if you are sued for malpractice. Quality assurance guidelines may require other items. And, of course, consider what you need in a note to assure that you can provide high-quality care at that patient's next visit. Always practice good record keeping.