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Sports Medicine Practice Economics

Part 1: Coding Basics

Chris Madden, MD; James G. Macintyre, MD, MPE; Elizabeth Joy, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 5 - MAY 2022

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In Brief: Proper understanding of coding, billing, and other practice economics issues in sports medicine is vital for practice success. Lack of accuracy and understanding in these areas may lead to problems that range from lost income to practice audits and potentially steep fines. A basic understanding of current procedural terminology (CPT), awareness of international classification of diseases (ICD-9) and healthcare common procedure coding system (HCPCS) codes, and the knowledge of how to apply them benefit sports medicine physicians.

This is the first article in a three-part series about economics issues encountered in a sports medicine practice. The authors are not certified coding experts, and the articles are not meant to serve as a definitive guide to billing and coding in sports medicine, but rather to provide insight into this poorly understood and complex area of medicine that can make or break a practice.

Sports medicine coding, billing, and practice economics are like a foreign language to many clinicians. Coding and billing education during residency and fellowship training is often limited. Many physicians have never taken the time to learn the basics of coding and billing, and knowledge in these areas is often spotty at best. Some providers become so frustrated that they simply adopt a passive approach and use a few codes when they should use many. Lack of understanding in these areas may lead to problems ranging from significantly lost income (undercoding) to practice audits and potentially steep fines (overcoding).

Historically, the rationale for coding has been to quantify and then, ideally, reimburse physicians for their work. If physicians document work performed and follow appropriate coding guidelines, they will be able to determine the current procedural terminology (CPT) evaluation and management (E/M) code(s) applicable to each patient visit.

The intent of this article series is not to teach physicians how to "game" the system, but rather to educate them about coding guidelines and how to appropriately apply the rules. There is a certain level of ambiguity inherent in the documentation, coding, and billing process, so physicians should consider their ethical responsibility to carry out these tasks honestly. It's not about changing patient treatment; it's about accurately charging and getting paid for services you already provide.

Many physicians lose significant income by undercoding, especially with established patients.1 At the opposite end of the spectrum are physicians who undergo practice audits that may result in steep fines for overcoding or upcoding.2 Overcoding is more common with new patients, but some practitioners, whether deliberately or not, inappropriately overcode minimal- or low-complexity visits.1,3-5 The potential financial gain that results from overcoding is likely cancelled out by losses that result from undercoding in most practices. However, physicians may still face legal ramifications for improper coding, and undercoding may be ignored by auditors.2 Salaried physicians may have less incentive to pay attention to coding, but honest and accurate coding will help them avoid legal consequences as well as calculate productivity bonuses and possibly negotiate future salaries.

The Role of Coders

Some physicians invest minimal participation in coding. They may rely on credentialed coding specialists—or even noncredentialed or poorly trained staff—to determine overall CPT E/M levels for office visits, which can be challenging if physicians are only scribbling final diagnoses on billing sheets. Chart audits and templates may help determine appropriate code levels, but this process takes considerably more time by paid employees than does coding by physicians at the conclusion of each patient visit. Using only office-based or clinical staff to code and report physician services may lead to serious revenue loss in some circumstances.1,6,7

Available data suggest that physicians accurately code for their services only 50% to 60% of the time compared with professional nonphysician coders and auditors.1,3 Accuracy is even less likely during physician coding for new patients.1 To further complicate matters, credentialed coders often have difficulty agreeing on proper CPT E/M codes using current guidelines, and one study3 reports that agreement among credentialed coders for new and established patients occurred in only 58% of visits.

CPT guidelines are complex and subjective, and both physicians and professional nonphysician coders face difficulty in applying them consistently.1,3,4 Yet, by knowing how to code accurately, getting involved with or doing their own coding, and performing independent and self-audits, physicians will improve their coding precision. As a result, many physicians will decrease lost income and minimize the risk of being penalized for inappropriate coding practices. Correct coding is ultimately the responsibility of the physician.8

Definitions of Coding Basics

CPT provides a uniform language that describes medical, surgical, and diagnostic services. It standardizes communication among physicians, patients, and third-party payers.8,9

E/M codes describe services rendered during patient visits.8,9 Outpatient codes used by most sports medicine specialists may include those for established patients, new patients, consultations, confirmatory consultations, fracture care, and other procedures (eg, injections, casting in nonfracture care). Physicians often perform a separately identifiable E/M service on the same day that an initial E/M service is provided, and the separate E/M service may be billed in addition to the visit by using a modifier (eg, a shoulder impingement evaluation that results in a therapeutic injection on the same day).

International classification of diseases, ninth revision (ICD-9) codes are diagnostic codes that support E/M services.10 Comprehensive listings of ICD-9 codes may be found in an ICD manual or an indexed computer program, and many offices have developed billing help sheets that list common ICD-9 codes. When choosing ICD-9 codes, be as specific as possible, especially if a definitive diagnosis is made. Use codes for all pertinent symptoms and signs if a definitive diagnosis cannot be made, and use proper fourth- and fifth-digit codes when appropriate.

Insurance company software may attempt to determine if the ICD-9 codes provided by a physician support the E/M level listed, but it is impossible to establish the validity of an E/M code from listed ICD-9 codes alone, which is why appeals with explanations and office notes are often successful. Inappropriate ICD-9 coding may lead to increased denials and bundling, in which an insurance company inappropriately combines two or more CPT E/M codes and substitutes one overarching code. Overall, ICD-9 codes are simply a list of diagnoses, signs, and symptoms, and they are much less complicated than the E/M codes they support.

Healthcare common procedure coding system (HCPCS) level 2 national codes, or hick-picks codes, describe medical and surgical supplies, durable medical equipment (eg, cervical collars, orthoses, braces), and miscellaneous items.11

Every office should have at least one copy of the current CPT book (which is updated annually), as well as ICD-9 and HCPCS manuals.

CPT E/M Codes and Rules

E/M codes in the sports medicine outpatient setting include those for established patients (99212 to 99215), new patients (99202 to 99205), consultations (99241 to 99245), and confirmatory consultations (99271 to 99275). Specific codes and their requirements are listed in table 1. The code most often used for established patients is 99213, but many visits support 99214. The codes 99201, 99211, and 99212 are rarely used for sports medicine visits, because most patients require a higher level of service.

TABLE 1. Evaluation and Management (E/M) Coding Requirements
Patient or Visit Code    History  Exam   Medical
Decision Making
 
Time (min)
Established99212
99213
99214
99215
PF
EPF
D
C
PF
EPF
D
C
SF
L
M
H
10
15
25
40
New99202
99203
99204
99205
EPF
D
C
C
EPF
D
C
C
SF
L
M
H
20
30
45
60
Consultation99241
99242
99243
99244
99245
PF
EPF
D
C
C
PF
EPF
D
C
C
SF
SF
L
M
H
15
30
45
60
80
Confirmatory
consultation
99271
99272
99273
99274
99275
PF
EPF
D
C
C
PF
EPF
D
C
C
SF
SF
L
M
H
N/A
N/A
N/A
N/A
N/A
PF = problem focused; SF = straightforward; EPF = expanded problem focused; L = low complexity; D = detailed; M = moderate complexity; C = comprehensive; H = high complexity

An E/M service or code may be supported by either documentation or time. Documentation requirements are divided into three areas: history, examination, and medical decision making. Only two areas need to be satisfied for established patients, while all three must be satisfied for new patients.

Time requirements are met when counseling or coordination of care occupies more than 50% of the total visit. This must be face-to-face time between the physician and patient, and specifics about the counseling or coordination of care must be documented.12,13 Coding by time can be useful in sports medicine, especially when the visit includes discussing rehabilitation and return-to-play issues, reviewing the benefits and risks of certain treatments, obtaining curbside consultations from colleagues, and discussing and arranging for specialty imaging, testing, and further evaluation.

E/M Documentation Requirements

The Centers for Medicare and Medicaid Services produced Documentation Guidelines for Evaluation and Management Services in 1995 and published a revised version in 1997. The guidelines clarify differences among levels of service and encourage consistent coding. The following sections on history, examination, and medical decision making briefly review and discuss the guidelines pertinent to coding in sports medicine. Complete guidelines are available online at https://www.cms.hhs.gov/medlearn/emdoc.asp.

History. The history portion of a patient visit is divided into history of present illness; review of systems; and past, family, and/or social history. Components of the history portion and its documentation requirements are reviewed in table 2.

TABLE 2. Evaluation and Management (E/M) History Components and Classification

Chief Complaint*Problem FocusedExpanded Problem FocusedDetailedComprehensive
History of Present Illness ElementsBriefBriefExtendedExtended
Location    
Severity    
Timing    
Modifying factors    
Quality    
Duration    
Context    
Associated signs and symptoms    
Review of SystemsNonePertinent to problemExtendedComplete
Constitutional    
Eyes    
Ears, nose, mouth, throat    
Cardiac and vascular    
Respiratory    
Genitourinary    
Musculoskeletal    
Neurologic    
Endocrinologic    
Allergy/immune    
Integumentary    
Psychiatric    
"All others negative"    
Past Medical, Complete Family,
and Social History Areas
NoneNonePertinentComplete
Past medical history (eg, illnesses,
operations, injuries, treatments)
    
Family history    
Social history    
*A brief exam includes 1-3 elements; an extended exam includes ≥4 elements or ≥3 chronic or inactive conditions.
†Pertinent to problem = 1 organ system; extended = 2-9 organ systems; complete = ≥10 organ systems or some systems with statement "all other systems negative."
‡Pertinent = 1 history area; complete = 2 history areas for established patients and 3 history areas for new patients and consults.

Examination. The exam is divided into systems with elements, and some systems have more elements than others. Specific elements may be reviewed in various coding documents, but a careful exam and good documentation usually eliminate the need to refer to a list of systems and elements.

A detailed exam contributes to codes 99203, 99214, and 99243 (all reimburse well), but it requires 12 elements from at least two organ systems or body areas or two elements from at least six organ systems or body areas. This level of exam may be challenging to achieve with most sports medicine visits. General multisystem exams have different documentation requirements than single-organ system exams. Pertinent organ systems and body areas in sports medicine include the following: constitutional, musculoskeletal, neurologic, skin, cardiovascular, pulmonary, and psychiatric. Areas that may be included in a musculoskeletal exam are the head and neck; spine, ribs, and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity.

Assessment of vital signs combined with examination of an injured area and, if appropriate, examination of the contralateral area for comparison purposes may satisfy requirements for a detailed exam. When warranted, specialized musculoskeletal testing or examination of gait and station, digits and nails, or proximal and distal kinetic chain problems may also contribute to a detailed evaluation. According to the Medicare guidelines, examination of a given musculoskeletal area includes: inspection and palpation with notation of misalignment, asymmetry, crepitation, defect, tenderness, mass, or effusion; assessment of range of motion with notation of pain, crepitation, or contracture; evaluation of stability with notation of dislocation, subluxation, or laxity; and measurement of muscle strength and tone with notation of atrophy or abnormal movement.

Remember that only two of three E/M areas need to be satisfied with established patients, and that history and medical decision-making criteria are easier to meet with sports medicine visits. Exam components and coding requirements are presented in table 3.

TABLE 3. Evaluation and Management (E/M) Exam Components and Classification

General Multisystem Exam Complexity Single-Organ System Exam
1-5 elements identified by •* PF 1-5 elements identified by •
≥6 elements identified by • EPF ≥6 elements identified by •
≥2 elements identified by • from 6 organ systems or body areas OR ≥12 elements identified by • from at least 2 organ systems or body areas D ≥12 elements identified by • EXCEPT ≥9 elements identified by • for eye and psychiatric exams
≥2 elements identified by • from 9 organ systems or body areas C Perform all elements identified by •
Document all elements in shaded boxes
Document ≥1 element in unshaded boxes
*Bullet symbol (•) refers to specific elements of exam for each organ system or body area. A detailed list of these elements is beyond the scope of this article but may be reviewed in The Centers for Medicare and Medicaid Services' Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.hhs.gov/medlearn/emdoc.asp.
PF = problem focused; EPF = expanded problem focused; D = detailed; C = comprehensive

Medical decision making. The level of decision making required for a patient visit essentially determines the code level if a physician is not billing for time.14 It is easy to "fill in the gaps" for the history component. Fulfillment of exam documentation is not needed with established patients, except for quality purposes, because only two of three areas need to be satisfied. Medical decision making is a complex and poorly understood concept, and it may be grossly underused or undercoded as a result.

Further adding to the complication, medical decision making is divided into three additional areas: number of diagnoses or management options; amount and complexity of data to be reviewed; and risk of complications, morbidity, or mortality (table of risk, table 4). Two of three areas need to be satisfied for all patients to meet each of the four levels (straightforward, low complexity, moderate complexity, high complexity) of medical decision making. The table of risk is further divided into three areas: the patient's presenting problem(s), diagnostic procedure(s) ordered, and management options selected. Each of these areas is assigned minimal, low, moderate, or high risk. Essentially, this area incorporates overall risk of a visit into the E/M code. Two of three areas do not need to be satisfied here; instead, the highest area of risk for the visit in any one category determines overall risk.14

TABLE 4. Scoring Guidelines: Risk of Complications, Morbidity, or Mortality

Level of RiskPresenting ProblemsDiagnostic ProceduresManagement Options
Minimal 1 self-limited or minor
problem (eg, cold, insect bite)
Lab tests requiring venipuncture
Chest x-rays
ECG/EEG
Urinalysis
Ultrasound
KOH prep
Rest
Gargles
Elastic bandages
Superficial dressings
Low 2 or more self-limited or
 minor problems
1 stable chronic illness
Acute uncomplicated illness
 or injury
Physiologic tests not under
 stress (eg, PFTs)
Noncardiovascular imaging
 studies with contrast
Superficial needle biopsies
Lab tests requiring arterial puncture
Skin biopsies
Over-the-counter drugs
Minor surgery with no
 identified risk factors
Occupational therapy
IV fluids without additives
Moderate 1 or more chronic illnesses
 with mild exacerbation,
 progression, or side effects
 of treatment (eg, asthma)
2 or more stable chronic
 illnesses
Undiagnosed new problem
 with uncertain prognosis
 (eg, lump in breast)
Acute illness with
 systemic symptoms
 (eg, pyelonephritis,
 pneumonitis, colitis)
Physiologic tests not under stress
 (eg, PFTs)
Noncardiovascular imaging studies
 with contrast (eg, barium enema)
Deep-needle or incisional biopsy
Cardiovascular imaging studies
 with contrast and no identified
 risk factors (eg, arteriogram,
 cardiac catheter)
Obtainment of fluid from body
 cavity (eg, lumbar puncture,
 thoracentesis)
Minor surgery with identifiable
 risk factors
Elective major surgery (open,
 percutaneous, or endoscopic)
 with no additional risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or
 dislocation without manipulation
High 1 or more chronic illnesses
 with severe exacerbation,
 progression, or side effects
 of treatment
Acute or chronic illnesses
 or injuries that may pose
 a threat to life or bodily
 function
Abrupt change in neurologic
 status (eg, seizure, weakness,
 sensory loss)
Cardiovascular imaging with
 contrast with identified risk factors
Cardiac electrophysiologic tests
Diagnostic endoscopies
Diskography
Elective major surgery (open,
 percutaneous, or endoscopic)
 with identified risk factors
Emergency major surgery
 (open, percutaneous, or
 endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive
 monitoring for toxicity
Decision not to resuscitate or to
 de-escalate care because of
 poor prognosis
The orange shaded area represents areas often pertinent to sports medicine visits. The yellow shaded areas represent areas intermittently pertinent to sports medicine visits. Determine overall risk and apply to the final evaluation and management determination (see table 7). Adapted from the Centers for Medicare and Medicaid Services' Documentation Guidelines for Evaluation and Management Services.

ECG = electrocardiogram; EEG = electroencephalogram; KOH = potassium hydroxide; PFT = pulmonary function test; IV = intravenous

Useful Resources

Score sheets or worksheets that use a point system may help clinicians determine the appropriate level of medical decision making to report. Examples of available worksheets include E/M Documentation Auditors' Worksheets developed by the Marshfield Clinic (available through the Medical Group Management Association at 877-275-6462), the Family Practice Management Pocket Guide to the Documentation Guidelines (available at https://secure.aafp.org/catalog), and a variety of articles with score sheets available from the Coding Center (a collaboration of the Maine Medical Association, the New Hampshire Medical Society, and the Vermont Medical Society) at https://www.codingcenter.org. Worksheets are used by many physicians, professional coders, Medicare carrier staff members, and by the US Office of Inspector General.15

It is important to note that worksheets may vary in defining new problems. The Marshfield worksheets give more points to physicians who are seeing a problem for the first time, even if the problem was previously diagnosed by another physician. The scoring system and the definition of "new problem to this examiner" are not included in Medicare's documentation guidelines. The score sheet from the Family Practice Management pocket guide defines a new problem as a previously unidentified or undiagnosed problem. The Massachusetts-based organization Health Care For All acknowledges that its reviewers use score sheets, but it neither encourages nor prohibits their general use.16 Because of obvious ambiguity in this area, individual clinicians should contact their regional Medicare carrier's medical director to learn how Medicare reviewers evaluate the complexity of medical decision making, and specifically how reviewers define a "new problem" for the purpose of scoring diagnosis or management options.15

Scoring guidelines for the level of risk, number of diagnoses and management options, and amount and complexity of data to be reviewed are provided in tables 4, 5, and 6. Note that "moderate complexity" medical decision making criteria that support 99214 with an established patient may be satisfied simply with either a new problem to the examiner (with no additional workup planned) or with prescription drug management (eg, for new rotator cuff tendinopathy requiring treatment with nonsteroidal anti-inflammatory drugs [NSAIDs]).

TABLE 5. Scoring Guidelines: Number of Diagnoses or Treatment Options

ProblemsPoints
Self-limited or minor: stable, improved, or worsening 1 (maximum = 2)
Established problem: stable, improved 1
Established problem: worsening 2
New problem*: no additional workup planned 3 (maximum = 3)
New problem*: additional workup planned 4
*New problem may be defined as "new problem to examiner" or as "previously unidentified or undiagnosed problem."
The yellow shaded area represents areas often pertinent to sports medicine visits. The orange shaded area represents areas occasionally pertinent to sports medicine visits. Points are assigned for problems and treatment options, and the total number of points are applied to the final E/M determination (see table 7).

TABLE 6. Scoring Guidelines: Amount and Complexity of Data to Be Reviewed

DataPoints
Review or order lab tests 1
Review or order radiologic studies 1
Review or order tests in medicine section of CPT 1
Discuss test results with performing physician 1
Obtain old records or history from someone other than patient 1
Review and summarize old records or obtain history from someone
other than patient or discuss case with another healthcare provider
1
Independently visualize image, tracing, or specimen itself
(not simply a review of the report)
1
The yellow shaded areas represent areas often pertinent to sports medicine visits. Points are assigned for data review,
and the total number of points is applied to the final E/M determination (see table 7).
CPT = current procedural terminology

Computerized Assistance for Documentation

Determining a final E/M code can be challenging, but a physician's ability to do so efficiently and accurately will determine his or her overall coding success. Table 7 provides a summary of E/M areas, levels of complexity, and specific coding requirements. Various templates (paper and computerized) are available to assist with this process, but physicians should be careful not to sacrifice documentation quality in an attempt to satisfy coding criteria.

TABLE 7. Summary of Evaluation and Management (E/M) Areas, Levels of Complexity, and Specific Requirements

History and ExamProblem FocusedExpanded Problem
Focused
DetailedComprehensive
History of present
illness
Brief (1-3
elements)
BriefExtended (≥4 elements
or ≥3 chronic or inactive
conditions)
Extended
Review of
systems
NonePertinent to problem
(1 organ system)
Extended (2-9 organ
systems)
Complete (≥10 organ
systems, or some organ
systems with statement
"all others negative")
Personal, family,
and social history
NoneNonePertinent (1 history area)Complete (2 or 3
history areas)
Exam1-5 elements≥6 elements≥2 elements from 6
organ systems or body
areas OR ≥12 elements
from at least 2 organ
systems or body areas
(≥12 elements for single-
organ system exams)
≥2 elements from
9 organ systems or body
areas (all elements for
single-organ system exams)
Medical Decision
Making
StraightforwardLow complexityModerate complexityHigh complexity
A. Number of
diagnoses or
management
options
≤123≥4
B. Amount and
complexity of data
≤123≥4
C. Highest riskMinimalLowModerateHigh
The yellow shaded areas represent a summary of a hypothetical visit in which an established patient with a prior knee injury presents with an acute anterior cruciate ligament rupture that requires x-ray and probably later MRI, treatment with nonsteroidal anti-inflammatory drugs, and other initial conservative measures.

Too often, we have observed generic, computer-generated consultation notes from specialists who produce two to three pages of redundant and poorly worded documentation, with the final diagnosis listed as a single ICD-9 code such as "pain in knee" (719.46), and the treatment plan presented in computer-burdened, nonspecific language. Many consultation letters are created in a similar manner. These documents serve as an example that a poor-quality office note and a consultation letter that provides minimal helpful information to the referrer may easily satisfy coding criteria.

Physicians should not forfeit the artful way of describing a complex history when only non-computer-driven, subjective descriptions can suffice. Thorough descriptions are needed for a detailed exam in which subtle testing variations may contribute significantly to initial or later diagnoses, and especially for an assessment and treatment plan that does not fit categorically into an ICD-9 code. Such documentation may prove particularly valuable in describing physicians' thought processes that led to diagnostic conclusions, and help set the stage for further evaluation and management if initial attempts fail.

Unfortunately, many computer-driven templates force physicians to use neutral and unhelpful language in an attempt to satisfy coding criteria. Computer programs that allow typed or transcribed input of "own-word" text may sidestep these problems if used well. Unfortunately, user skill varies widely.

Computerized templates, paper templates, coding charts, cheat sheets, software programs, and seminars and courses may help physicians code accurately and appropriately.17 The American Academy of Family Physicians posts a comprehensive review of various coding and billing software for PDAs on its Web site at https://www.aafp.org/fpm/20020500/33codi.html. Additionally, it provides various coding resources at https://www.aafp.org/x3309.xml. We have found it helpful to post E/M documentation requirements (see tables 2-7) on a wall in our dictation area, and we refer to the charts while coding and dictating. Frequent references to these resources contribute to a good coding knowledge base that evolves over time.

The visit described in table 7 may be coded as 99214, because two of three areas meet its criteria (detailed history and moderate-complexity medical decision making). Documentation of a comprehensive history of present illness, past injury during history taking (and often social history for activity level, sports participation, smoking status, etc), and review of systems (eg, neurologic, muscular) easily meets the criteria for a detailed exam. The exam may be either expanded problem-focused or detailed, depending on the need for a more comprehensive follow-up that may include evaluation of the contralateral knee for comparison, measurement of vital signs, analysis of gait and station, or examination of other pertinent areas (eg, proximal referral sites of pain such as the hip and back).

The level of medical decision making employed during this visit is moderate or high complexity. Part A is high complexity, because a new problem is presented to the examiner, with additional workup planned (ie, x-ray and magnetic resonance imaging). Part B may be either moderate or high complexity, depending on whether the physician reviews and summarizes records about the patient's prior knee injury and whether the physician independently visualizes the imaging studies ordered. Note that what constitutes "additional workup" in part A is open to interpretation. Individual coders and auditors may disagree on this point, so be conservative. Two of three sections pertaining to medical decision making (A and B) may be high complexity, but an acute anterior cruciate ligament rupture alone will never support a comprehensive history or exam. Thus, the visit should not be coded as 99215, yet it easily meets criteria for 99214. Part C is moderate risk because it involves prescription drug management (for an NSAID).

Get Paid for Your Work

Established patients with new problems make up a large part of most sports medicine practices. Many clinicians use the code 99213 when they should use 99214, and sports medicine office visits by established patients often meet criteria for 99214.14 Clinicians may not give this much thought, but such undercoding is inaccurate. Common reasons for undercoding include lack of knowledge, inappropriate documentation, and fear of an audit.

The two easiest ways to code 99214 are through history and decision-making documentation or time. Tables 8 and 9 provide details on how to meet 99214 code criteria for sports medicine visits. The little "extras" that patients often mention, especially if they require minimal time to address, can be advantageous from a coding and documentation standpoint. However, physicians should be careful not to create patient expectations that a large list of problems is always appropriate. If documentation requirements for 99214 are not met, review the face-to-face time spent during the visit. If the visit lasts at least 25 minutes, and if more than half of the encounter time is spent on counseling (eg, rehabilitation issues, return-to-play issues, teaching) or coordinating care (eg, arranging specialized imaging or follow-up, reviewing the case with a colleague), document the specifics, and code on the basis of time.12

TABLE 8. Evaluation and Management (E/M) Code 99214 Documentation Requirements for Sports Medicine Visits
History (detailed)
  • HPI easy to determine
  • PFSH: History of sports injury, contributing problems, medication use, treatment, smoking status, exercise program, activity history, family history, joint or back problems, etc
  • ROS: Constitutional, musculoskeletal, neurologic, cardiovascular, pulmonary, integumentary, "all others negative"
Exam
  • May support 99214 in sports medicine; easier to use other areas
Medical Decision Making* (moderate complexity)
  • 99214 frequently met with:
    New problem to examiner (with no additional workup planned)
    Prescription drug management
*If medical decision making criteria are not met here, refer to table 9 for other criteria. The yellow shaded areas represent the two areas most often used to meet criteria for 99214. HPI = history of present illness; PFSH = past, family, and social history; ROS = review of systems

TABLE 9. Other Medical Decision Making Criteria That May Help Establish Moderate Complexity and an Evaluation and Management (E/M) Code of 99214
Medical Decision MakingPoints
Number of Diagnoses or Treatment Options
Self-limited or minor (improved, stable, or worsening)
Established problem (to examiner); improved, stable
Established problem (to examiner); worsening
New problem (to examiner); add workup

1
1
2
4
Amount or Complexity of Data to Be Reviewed
Review or order tests in radiology section of CPT
Obtain old records or history from someone other than patient
Independently visualize image, tracing, or specimen itself (not simply a review of the report)   
Review and summarize old records or obtain history from someone other than patient or
  discuss case with another healthcare provider

1
1
2
2
Table of Risk
1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment
  (eg, asthma, back pain)
2 or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis (eg, lump in breast)
Acute illness with systemic symptoms (eg, pyelonephritis, asthma, colitis)
Abrupt change in neurologic status (eg, seizure, weakness, sensory loss)
E/M = evaluation and management; CPT = current procedural terminology

Keys to Coding Success

Sports medicine clinicians should practice honest and accurate coding behavior. Their goal should be to get appropriately reimbursed for work performed and documented, not to "game" the system. A thorough understanding of coding definitions, criteria, and rules will improve coding accuracy. Proper application of this knowledge will help ensure against legal penalties. Many physicians are guilty of scant documentation and undercoding, which does not protect against an audit.

Prerequisites to coding success include an open mind and a positive learning approach. By using tools such as cheat sheets or computer programs, physicians will become better coders and will be reimbursed appropriately for their services.

Disclaimer: This review is for educational uses only. The authors are not coding and billing experts and are not responsible for any consequences resulting from the misuse of this review. THE PHYSICIAN AND SPORTSMEDICINE is not liable for any information found in this material.

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  14. Hill E: How to get all the 99214s you deserve. Fam Pract Manag 2003;10(9):32-36
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  17. Morrison KM: Coding and billing software for palm-top computers. Fam Pract Manag 2002;9(5):33-37

Dr Madden is a sports and family medicine physician at Longs Peak Family Practice in Longmont, Colorado. Dr Macintyre is a family practice physician at Advanced Orthopedics and Sports Medicine in Murray, Utah. Dr Joy is a clinical associate professor and the primary care sports medicine fellowship director at the University of Utah in Salt Lake City. Dr Joy is chair and Drs Madden and Macintyre are members of the American Medical Society for Sports Medicine Economics Committee. Address correspondence to Chris Madden, MD, Longs Peak Family Practice, 1309 Sunset St, Longmont, CO 80501; e-mail correspondence to [email protected].

Disclosure information: Drs Madden, Macintyre, and Joy disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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