Coding & Billing - E/M Ob/Gyn Crash Course

drcomfydelivers
Feb 10, 2023
6 min read

Okay. Billing.

There are so many people that want to ignore it, but unfortunately it is a necessary evil. I feel as though if we can optimize our billing, we can generate more revenue that rightfully should go to our department, clinical practice, etc. Hopefully, that will help support resources to provide ancillary staff and that should in turn support exceptional patient care.

However, there are *no* resources to understand billing. The AMA does a pretty thorough job of explaining it (link here: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf) but in classic medicine form it is legitimately over 30 pages.

ACOG, also very typically, provides good information but is too vague about how to actually bill most visits. (https://www.acog.org/practice-management/coding/coding-library/evaluation-and-management-changes-for-2021)

Therefore, I put together a little guide to break down the E/M billing codes, how to get paid for the services you actually provide, and how to actually understand coding and billing. Please message me for feedback/details.

*Disclaimer: I am a practicing Ob/Gyn learning this as I go, so please do not take anything I say as the end-all, be-all. This is meant to be a framework for understanding billing and coding. I am not accountable for any false billing or weird billing things you have undertaken.

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THE FRAMEWORK

In order to code, you need to know if it is NEW or EST patient (new = never seen anyone in your subspecialty at your affiliate place of work in the prior 36 months)

You also need to document at least 2 out of the 3 categories:

Number and Complexity of Problems Addressed
Amount and/or Complexity of Data
Risk of complications and/or Morbidity or Mortality of Patient Management

Whether you bill a Level 4 or Level 5 just depends on how complex the problem and treatment decision making was.

A Level 4 is defined as 'moderate' and Level 5 as 'high'.

So, to understand each category let us briefly review the criteria

Number and Complexity of Problems Addressed

TL;DR - Level 4: one new problem with uncertain prognosis counts as Level 4, such as vaginal pain and discharge, pelvic pain, AUB. Shall I go on?
TL;DR - Level 4: One acute illness with systemic symptoms counts as Level 4, such as AUB with systemic symptoms counts, such as signs of anemia
TL;DR - Level 5: Acute or chronic illness that poses a threat to life or bodily function, such as AUB requiring a blood transfusion or fibroids requiring multiple ER visits for pain exacerbations

Level 4 / Number and Complexity of Problems Addressed

[ ] One unstable chronic illness (for coding purposes -unstable- includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal)

[ ] Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

[ ] One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia)

[ ] One acute complicated injury (e.g., concussion)

[ ] One new problem with uncertain prognosis (e.g., breast lump).

Level 5 / Number and Complexity of Problems Addressed

[ ] 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

[ ] 1 acute or chronic illness or injury that poses a threat to life or bodily function

Amount and/or Complexity of Data

TL;DR. Level 4: Moderate (Must meet the requirements of at least 1 out of 3 categories)
TL;DR - Level 5: High (Must meet the requirements of at least 2 out of 3 categories)
If you review prior external notes from another source (primary care physician, hematologist), review the labs, and order a CBC that meets criteria for Category 1 (level 4)
If you also review the ultrasound imaging and decide it is a submucosal fibroid, that counts as Category 1 and Category 2 (level 5)

Category 1: Tests, documents, or independent historian(s)

Any combination of 3 from the following: Review of prior external note(s) from each unique source, Review of the result(s) of each unique test, Ordering of each unique test, Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

You provide an independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

Category 3: Discussion of management or test interpretation

Discussion or management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)

Risk of complications and/or Morbidity or Mortality of Patient Management

TL;DR - Level 4: If this problem requires prescription drug management, then it is level 4. Even if that means stopping a prior medication or refilling a medication
TL;DR - Level 4: No prescriptions but spend time discussing SDOH that impact the treatment for the PCOS? That is Level 4
TL;DR - Level 4: Any surgical decision ever is Level 4. Unless it is a super high risk patient. Then Level 5.

Level 4 / Moderate risk of morbidity from additional diagnostic testing or treatment

[ ] Prescription drug management, which includes ordering, changing, stopping, refilling, or deciding to continue a prescription medication (as long as the physician documents an evaluation of the condition for which the medication is being managed),

[ ] The presence of social determinants of health (lack of money, food, or housing) that significantly limit a patient's diagnosis or treatment,

[ ] Decision about major elective surgery without identified risk factors for patient or procedure

[ ] Decision about minor surgery with identified risk factors for patient or procedure

Level 5 / High risk of morbidity from additional diagnostic testing or treatment

[ ] Drug therapy requiring intensive monitoring for toxicity

[ ] Decision regarding elective major surgery with identified patient or procedure risk factors

[ ] Decision regarding emergency major surgery

[ ] Decision regarding hospitalization

[ ] Decision not to resuscitate or to de-escalate care because of poor prognosis

THE SUMMARY

If you meet Level 4 in 2/3 of your categories, it is level 4

If you meet Level 5 in 2/3 of your categories, it is level 5.

What do you think? Does it make sense? PS: Check out this smartphrase template to add to the end of your notes. Just put your "x" where you need to and it is a fail-proof way to help coders!

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Medical Decision Making Guidelines - requires 2/3 of ### categories

### Number and Complexity of Problems Addressed ###

Level 4 / Number and Complexity of Problems Addressed

[ ] One unstable chronic illness (for coding purposes -unstable- includes hypertension in patients whose blood pressure is not at goal or diabetes in patients whose A1C is not at goal)

[ ] Two stable chronic illnesses (e.g., controlled hypertension, diabetes, chronic kidney disease, or heart disease),

[ ] One acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia)

[ ] One acute complicated injury (e.g., concussion)

[ ] One new problem with uncertain prognosis (e.g., breast lump).

Level 5 / Number and Complexity of Problems Addressed

[ ] 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

[ ] 1 acute or chronic illness or injury that poses a threat to life or bodily function

### Amount and/or Complexity of Data ###

Moderate (Must meet the requirements of at least 1 out of 3 categories)

High (Must meet the requirements of at least 2 out of 3 categories)

[ ] Category 1: Tests, documents, or independent historian(s) ||| Any combination of 3 from the following: Review of prior external note(s) from each unique source, Review of the result(s) of each unique test, Ordering of each unique test, Assessment requiring an independent historian(s)

[ ] Category 2: Independent interpretation of tests ||| Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)

[ ] Category 3: Discussion of management or test interpretation ||| Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)

### Risk of complications and/or Morbidity or Mortality of Patient Management ###