Focus on depth, not detailed list of services, leads to undercoding

LETTER — Posted Jan. 24, 2005

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Regarding "Do you tend to undercode? You're not alone" (Article, Nov. 22/29, 2004): Yes, many of us do undercode. The article implies that we would be better served by fastidiously listing every bit of service we provide a patient.

But the CPT system, coupled with the arbitrary rules imposed by Medicare and many insurers, does not pay based on the number of problems dealt with during any given office encounter. Instead, practitioners are obliged to code based on the depth of the visit (problem focused, expanded problem focused, etc.).

One can spend a half hour discussing five minor problems, none of which requires an in-depth family history or review of systems, and still use one overarching code. Even if all of the diagnoses are documented, one is aware that an audit would show the lack of other elements of the history -- so one codes low to avoid problems.

Similarly, a physician might encounter a coding problem after taking a detailed and comprehensive history but without a comprehensive examination to go with that comprehensive history. (This is not a rare circumstance. In terms of my own specialty of otolaryngology, think about the careful evaluation of many hearing losses, allergies or epistaxis; there is little need for examining the abdomen, pelvis, limbs, etc.)

Although I am looking at this from my specialty's point of view, primary care physicians must encounter the same problems. We can code all the diagnoses we want, and document every word of the encounter, but if we don't comfortably fit the CPT definitions for certain levels of examination and complexity of management, we are reluctant to use higher codes.

We all know Medicare is unlikely to pay for even two items on the same day, no matter how reasonably indicated and appropriately coded these separate items may be.

Shawn Shianna, MD, Freeport, Ill.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2005/01/24/edlt0124.htm.

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