Key takeaways from this episode

• Two or more stable chronic illnesses (BPH, ED, elevated PSA, OAB, atrophic vaginitis) put the problem element at level four, but the visit only reaches 99214 if the risk or data element gets there too. Diagnosis codes do not determine the count; it is the number of problems managed, and two, three or ten stable chronic problems all score the same.
• "Refill given" or a medication list such as tamsulosin 0.4 mg PO QD or sildenafil 50 mg PO PRN is not prescription drug management. To support level-four risk the note needs the discussion: how the drug is working, side effects, risks and benefits, alternatives, and the shared decision to continue, and the same applies when you stop a medication such as prophylactic antibiotics.
• Typical BPH/ED follow-up data (a PSA, a UA and a PVR) can independently support level four, but only if it is documented and referenced in the decision-making. A PSA ordered for the next visit counts as one data point; with nothing documented, data scores zero.
• Payers are auto-downcoding 99214/99215 and 99204/99205 and dismissing addendums added after a denial or records request. Get the documentation right the first time, appeal only when the record truly supports the billed level (aim for a roughly 70 percent overturn rate), and take the downcode when you missed.
• A "history of" Z code will not carry a claim, so put it in the right pointer position and lead with the active diagnosis. Z08 works in the primary spot, most other "history of" codes do not; for a hematuria workup cystoscopy, code gross hematuria rather than history of gross hematuria, then switch on later visits if there is no recurrence.
• Decide whether OAB plus atrophic vaginitis on Myrbetriq and estrogen cream is two problems or one. Treated separately it is two stable chronic problems; consolidated as genitourinary syndrome of menopause or treated with systemic hormone therapy it is one problem with prescription drug management, and the note should make the approach clear.
• "History of constipation" and "work on constipation" need detail before they count as a second chronic problem. Say what you are managing and how (hydration, MiraLax, Colace, psyllium, GI referral), and whether it is chronic or episodic, because that judgment call is what auditors and AI review tools will contest.
• Use telehealth for results-review follow-ups and dictation or ambient AI instead of typing. CMS pays telehealth 9921x/9920x visits the same as in person through the end of 2027, and speaking at 140 to 160 words a minute captures the risk-benefit discussion that typing at 75 words a minute tends to drop.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 278, recorded February 2026, with Scott Painter and Mark Painter of PRS Network, and guest Dr. John Lin.

Introducing Dr. John Lin and the Thriving Urology Practice group

[00:00] Scott Painter: On this episode: E/M leveling, it's as clear as mud. Stay tuned. Welcome to episode 278 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, and welcome back to special guest Dr. John Lin. He is a solo practitioner in Gilbert, Arizona, for those of you who do not know him, and he's also the founder of the Thriving Urology Practice Facebook group. John, for those who are not members of the Thriving Urology Practice Facebook group, please share how they can join and why they should.

[01:00] Dr. John Lin: It's a free Facebook group for US-based urology folks: APPs, physicians, billers, coders, office managers. We talk about a variety of topics germane to everyday practice so that you can excel and thrive in this complex healthcare system we deal with. We talk about anything and everything under the sun, whether it's employment, coding, billing, figuring out which cystoscopy table to get in the operating room, the WISeR program. And among those questions we have the E/M questions we're going to discuss today.

Scott: Very good. Thanks, John, for joining us and for bringing these questions to us. We really appreciate it. Let's dive right in. John, you brought us a number of questions. We'll see how many we can get through today. E/M questions.

Scenario one: a one-year BPH and ED follow-up with refills

[02:00] John: This came from an anonymous member from the South, and it goes like this, along the lines of evaluation and management coding: "I'm going to ask some common scenarios," and these are great scenarios, by the way, "and what level visit will that qualify? I know we all have attended several coding seminars, et cetera, but this will be a practical aspect." I love practical questions where we can dig into the weeds, tactical ones. And his assumption that we have all attended several coding seminars, well, I'm not sure about that. But anyway, question number one: one-year follow-up for BPH and ED. Symptoms stable. Recommended to continue ED and BPH medications, refill given. And then there are several other ones. Do you want to just start with the first one?

Mark Painter: Yeah, let's go with the first one.

John: Okay.

[03:00] Mark: All right. And unfortunately, this is where the clear-as-mud comes in with all this stuff. The first part of the answer is, it depends. Ultimately, what you've got is BPH and ED, and he or she, I don't know, as an anonymous member, states that it's recommended to continue ED and BPH medications. So based on those two pieces of information, we can assume that two chronic conditions were managed. And they say symptoms stable, so from the problem perspective that would qualify as two stable chronic illnesses, level four. We don't know if there was any data that was looked at, based on what we're given. A lot of these visits, if somebody's being followed for BPH and ED, a lot of times we see a PSA, a UA and a PVR in a standard follow-up like this. That would be three points of data that would also hit a level four. So based on those two, you could have a level four. But we don't have that information. So that's the first "depends": what data did you look at, and how did you use it to make your decision?

Then the next piece of this is "recommend to continue ED and BPH meds, refill given." As we've talked about multiple times in the seminars that were referenced there, the level-four risk is, as stated, prescription drug management. We're going to assume "refill given" means it was a prescription drug. There are definitely over-the-counter things that get given to patients all the time, but realistically, most urologists are going to be giving prescription drugs. So a refill given is not necessarily qualifying for prescription drug management. It was recommended to continue ED and BPH meds and refills were given, so we could assume there was some discussion about which drugs, what dose, and was there any discussion about long-term use and shared medical decision-making. That would all qualify for prescription drug management and support a level four.

So in general, this could be a level four, but it is going to depend on the documentation. The two pieces that really need to be considered are, number one, was there data, was it documented, and is it referenced? And number two, with the refills that were given, were all of the steps followed to meet the definition, with that overall discussion: what's my drug, what's my timing, what's my dosage, did you talk to the patient about risks and benefits, and at that point in time, as the physician-patient entity, decide to continue the drugs? That would be prescription drug management and qualify for a four. So it could be a four, maybe even should be a four, but it depends on the documentation.

[07:00] John: That's a perfect summary right there. It could be a four. It is most likely a four, but it depends on the documentation. The way this urologist is painting it, if you just read it at a very surface level, without fully understanding all the nuances of evaluation and management: when it comes to E/M services, you're billing based on time or medical decision-making. In all five of these scenarios, these are all based on medical decision-making, which you and I agree is a much more efficient way to do this type of billing.

Evaluation and management scenario one: a one-year follow-up. So this is an established patient with two stable chronic problems. It literally says symptoms stable, BPH and ED. So these are stable, chronic. And a lot of people need to understand that even if it's a first-time patient seeing you, and I get this all the time, an older gentleman will come in and tell me, "Oh, my BPH symptoms just started last week." And my diagnosis is BPH with urinary obstruction. I'll tell the guy, unfortunately, this is an insidious problem that's been going on for a long time. So the patient doesn't have to say that the problem has been ongoing for over a year to qualify for chronic, number one. And number two, at that first visit, even though he's complaining that symptom onset was only a week ago, based on your impression of the symptom history, DRE, uroflow and PVR, this could qualify as a chronic problem.

That said, BPH and ED are both chronic problems. Now we have to figure out, is it chronic stable, or chronic with exacerbation, or chronic not at treatment goal? In this situation, the urologist says the symptoms are stable. So we can assume these are chronic, stable problems. Like Mark said, we don't know anything about data, so I'm going to give a big fat zero for data. And when it comes to the risk section, it says "recommend to continue ED and BPH meds." That's an important word right there: recommended to continue. That means the urologist is assuming the risk of making that recommendation to continue the medication, and that alone nudges the risk section toward level four.

And like Mark said, it is not just, quote, "refill given." For instance, if I'm auditing the chart and I see only tamsulosin 0.4 milligrams PO QD, or sildenafil 50 milligrams PO QD PRN, if that's all that's listed without any discussion of what Mark mentioned, how the medication is working, are there any side effects, have you talked about other treatment options, and did you both agree to continue with this medication, at least some components of those things mentioned in the chart, if that's not there, that is not prescription drug management. You do not get level-four risk if you simply list the name of the medication and how it's taken. So that's the nuance. I get what this urologist is trying to say, but it is never as simple as what is stated. We have to know all the other details and what's actually written to give you the 99214.

Scott: Very true. So that was one question, and look how long we discussed it. Clear as mud, for sure. Anything else to add for that one, or should we move on to the next?

Mark: I think we can move on.

Scenario two: BPH, ED and elevated PSA, and managing multiple problems

John: Question number two: six-month follow-up for BPH, ED and elevated PSA. On this visit, the PSA is stable, and BPH symptoms and ED symptoms are stable. Plan is to follow up in a year with PSA, continue both BPH and ED meds. So similar to the first one.

[11:00] Mark: Very similar to the first one. Now we've got three different conditions, and I think it's important to mention here that diagnosis codes don't determine the number of problems. It's management of problems, not management of ICD codes, because that BPH may have multiple other diagnoses for the symptoms the patient has with his BPH. But we can say, again, we've got stable. So we have three stable chronic illnesses, and in this case that would be a level four because it's two or more. It doesn't matter if it's three or ten or two. It's the same level for presenting problem.

Again, we have no mention of anything but the PSA, and we don't know if that was ordered previously. We do know, however, that it was ordered for the next visit. So we would at least know there is one PSA and it was used in management. We've got one data point in this scenario that we know of, and one data point would be a level two in its support. Now we look at the other part: follow-up in one year with the PSA, which ultimately we count as a data point, and we know the patient's coming back. Then we continue both BPH and ED meds, which I'll shorten a little and say, refer to the previous conversation relative to prescription drug management. So, again, probably a four. Depends on documentation.

Scott: John, what do you think?

[13:00] John: Whenever I see management of multiple problems, I always think, okay, to take care of the patient, yes, you want to manage as many problems as you can in a single visit. But when it comes to evaluation and management, if you have two chronic stables and one prescription drug management, two chronic stables is a level-four problem section, and prescription drug management is level-four risk. You already have a problem at four, risk at four, you already have a 99214. What is the incentive to cover multiple problems during the same visit? But that's from a purely evaluation and management coding perspective. When it comes to taking care of patients, I'm going to try to manage as many problems as I can, within reason. I know a lot of practices and a lot of physicians will take care of the two most pressing issues first and then deal with the lifestyle issues later. For instance, erectile dysfunction. When a guy is coming in with a very high PSA and urinary retention, I'm going to take care of the PSA and retention first and then deal with the ED later, typically, if it's a brand-new patient to me. But in this scenario, it looks like we have three stable problems, and as long as there's documentation to support prescription drug management, then a 99214, since it's a follow-up, will be warranted.

[15:00] Mark: John, this might be a good time to mention the other side of this. In the general practice of urology, across the board, we all know there's a manpower shortage, a QHP shortage. When we look at these little things, I definitely have a lot of docs I talk to about stringing it out from a money standpoint. Now, you mentioned you're going to do things from the clinical perspective of trying to settle down one problem and then deal with the next one. Where medical necessity is there, you should, and that's what we all need to remember: even though we're incentivized to do a lot of this, the base of this is clinical care. But I also say, from a financial standpoint, we have got to handle as many things as we can and juggle as many as we can in urology. You have to consider that part of it. What is the best use of your time, the value of your time, in managing those folks? As I wander around the country, I still see very few urologists twiddling their thumbs waiting for the next patient. So, as John says, routinely treat and street. Juggle your schedule so that you can provide quality care to as many people as you can. The revenue stream, yeah, it's not fair. It's a ballpark across the board as to what goes up and down, but you're going to do better over time practicing well, practicing efficiently, and documenting well so that you get paid for all that you do.

Documentation tools and the case for telemedicine follow-ups

[16:00] John: And when it comes to documentation, I highly encourage everyone to look at either ambient AI or, what I use, I'm still using Dragon voice recognition. I've used it for so long and I've gotten so fast at dictating into it. I can type around 75 words a minute, but I can speak at around 140 to 160 words a minute, and Dragon, or the voice recognition system, will pick up that cadence very quickly, and there's almost no training involved. So I highly encourage you, to avoid burnout and to make it easier for your coders and billers to understand what you are thinking. The adage is: if you think it, ink it; if you did it, ink it. When you do that, it's going to be easier for you to get paid for what you do.

I'll also give another push for telemedicine. A lot of these follow-ups, you do not need to have the patient in front of you physically. Having the patient virtually works really well for telemedicine visits, especially follow-ups. I pretty much exclusively see my follow-ups via telemedicine, because usually I'm going over results and then what to do with those results. For instance, a gentleman I'll be seeing today, in his seventies, with prostate cancer, simply following up his PSA and BPH symptoms. I don't need to see him. I've dealt with him before. I know he's on medication. I know we're just doing active surveillance. We can simply monitor the PSA, and if there are any changes, if I need to do an exam, a biopsy or a prostate MRI, I can do the ordering via telemedicine, and on the back end my staff will take care of all that while I sit literally right here, in this position. The way I'm sitting right now is how I do telemedicine visits, so the setup is already there. I'm in the office. It is super efficient, the no-show rate is low, and patient compliance is super high. Almost everybody runs on time, and usually ahead of time. So if you're not using telemedicine, please look into it.

Mark: And I'll add that patient satisfaction is high with telemed visits, so that's the other one to consider, because they don't have to jump in the car, drive, park. All that stuff makes it a lot easier. So I'm with you, John. Let's go telehealth.

[19:00] John: Yeah. And right now CMS is still covering it as an in-person visit. You bill it with the same 9921x or 9920x as if you're seeing the patient in the office. The billing codes are the same, and the payment is the same as an in-person visit for CMS until the end of 2027. So take advantage of it while you can. And I don't think this is going away. I think one of the fortunate benefits of the COVID pandemic is that telemedicine is now widespread and widely adopted.

Scott: So true. All right, question number three.

Scenario three: OAB and atrophic vaginitis on Myrbetriq and estrogen cream

John: Question number three: female with overactive bladder symptoms and atrophic vaginitis, one-year follow-up. Symptoms are stable on Myrbetriq and estrogen cream. Planned follow-up in a year.

[20:00] Mark: All right. This is one where, in essence, we're almost talking about the same visit for a female as we just talked about a couple of times for a male. Now, OAB, which is interesting. I've been dealing with all the WISeR program stuff recently, and there's a new policy that goes into effect on Sunday relative to Botox and OAB. One of the things that's clearly mentioned, which everybody needs to understand, is that OAB is not an actual diagnosis. OAB is a collection of symptoms, but it is a problem that you manage. So in the end, we've got a diagnosis code, it is a collection of symptoms, but it is a management issue. I'm assuming, and that's why I appreciate that they listed OAB symptoms here, that this is being managed as a problem separate from the atrophic vaginitis, which would make sense. Both of these are longer-term issues. We're expecting these to last at least a year, or until the death of the patient. So we've once again got two chronic illnesses. The symptoms are stable, so two stable chronic illnesses, level four.

She's there for a one-year follow-up. The patient is on two prescription drugs, Myrbetriq and estrogen cream. She's going to be followed in a year. So the same discussion we just had with BPH meds: it has to be prescription drug management, not just a refill. We also don't have a list of data, so we can't make a judgment on that. We'd give the fat zero for that. But this looks like a four. Again, it requires that the risk side of the equation is clearly documented in the prescription drug management, including risks and benefits in the decision to continue those medications moving forward. Alternatives would be another one.

Downcoding, addendums and when to appeal

[22:00] Scott: Are you seeing denials based on the lack of documentation for the prescription drug refills? If they just say "refill" and there's not a lot of risk discussion behind it, are you seeing denials?

Mark: The downcoding game is where this is going. Yes. Whether it's a request for medical records, and that's what happened for a long time, to then the move to an automatic denial, with ultimately a requirement that you submit your records to qualify for the visit that was downcoded. We're seeing this miss.

Scott: And not being able to defend it because of the documentation.

[23:00] Mark: That is an issue, and that is one they look at very carefully: just a refill doesn't count as prescription drug management. That other discussion needs to be there, and that's one of the big fails that's out there. So the answer is, once again, indirectly yes, but they have to look at the documentation to see it, and they can do that and are doing that with automatic downcodes and medical record requests.

Scott: John, any comments?

[24:00] John: I know we talked about this before, the automatic downcoding by payers that's been happening for a while now, meaning the payers are automatically downcoding your 214s and 215s and 204s and 205s without looking at your documentation. But the problem is, when you submit the documentation to justify, "Hey, I need to be paid appropriately for a 214," is the documentation complete? Are you having that discussion of the risks, benefits, alternatives and prognosis without treatment for a particular medication for a particular disease process? If that documentation is not there for true prescription drug management, then it's an easy way for the insurance companies to say, "We looked at your documentation this time, and you did not qualify for level four, so we're going to knock it down." So when you appeal these automatic downcodes, you need to make sure your documentation supports the level you actually billed, or else it encourages them to continue to downcode you until you can prove, and improve, your documentation to support the level you are coding and billing.

[25:00] Mark: John, I'm going to add two more things we're starting to see in all this. Number one, there are some loose guidelines about when an addendum can be added to a medical record and what counts as true medical documentation. One of the things recently where we've seen these payers hang their hats is that any addendum after a request for medical records, or after a review, is considered not relevant to the actual visit. I didn't say that as eloquently as I should have, but essentially they will dismiss addendums that were added after there is a denial or after there is a request for medical records. So you need to have it in there before you get that automatic denial or the medical records request. Get it right the first time. It is one of those areas where you really need to spend the time up front. As John mentioned, it's not a lot of time. With ambient listening, you may need to figure out how to add that into your discussion, or make sure there are templates behind it to actually reflect all that you do. Or hopefully it is your habit to actually discuss risks and benefits with the patient, and they can go ahead and add that in, because that's really what should have occurred. But pay attention to that.

The second thing we're finding is that if you get a downcode, and you look at that medical record and it does not support the level of service you originally billed, so the downcode was correct, don't appeal that. That's a wasted shot. You're really trying to shoot for a 70 percent overturn rate, so if you're constantly putting in information that is upheld, that's not going to help your cause. There are times when you miss. If you miss, you miss. Take the downcode and move on. The best thing you can do is make sure the documentation is up front and accurate the first time, grab the documentation, and appeal.

John: Yeah. If you want to appeal, you have to make sure you are in the right, that you are correct in the appeal. Otherwise, they're just going to keep doing it over and over again. Relative to question three, with OAB symptoms and atrophic vaginitis, the only thought I have is, could this be consolidated into one diagnosis, genitourinary syndrome of menopause? Then you have one overarching problem, one chronic stable problem, with presumptive prescription drug management. That's the only comment I have when it comes to question three.

[28:00] Mark: The one thing I would say, and I'd ask you, John, is the estrogen and Myrbetriq combination: are you really managing two separate issues, regardless of the diagnosis? That's the one I lean into as we teach the auditing team here. I'm essentially treating the overactive bladder symptoms with Myrbetriq, and I'm treating the atrophic vaginitis separately with the estrogen cream, so I've always looked at those as two separate problems. Now, ultimately, yes, you're right. If I went with systemic hormone therapy to try to treat both, then I'm managing it as a single problem. So this might be an area where you think about whether you want to more clearly delineate: are these two separate problems you're dealing with, or is this combination therapy for a single problem? Those are all things that make a difference, because again, it's about the problems, not the diagnoses. It could be one diagnosis with two separate problems, but it does need to be two separate problems, and what is your approach to both of them? Certainly, if the atrophic vaginitis got to the point where you didn't need to provide the estrogen cream and you continued with the OAB symptoms on Myrbetriq, that would be a separate problem. I don't know if that happens, but I'm throwing it out there theoretically.

John: Typically, and again we're making a set of assumptions based on reading this, this is an older female who is postmenopausal or perimenopausal with symptomatic atrophic vaginitis. You start the topical estradiol and you would continue that indefinitely. That's what I tell my patients when I put them on this medication.

Scott: All right. Do we have time for one more?

John: Yes.

Scott: Last one.

Scenario four: recurrent UTI, constipation and stopping prophylactic antibiotics

[30:00] John: Number four: recurrent urinary tract infection follow-up, female with history of constipation symptoms. No new UTI since starting prophylactic antibiotic and estrogen cream. The plan is to stop antibiotics, increase hydration, work on constipation, continue estrogen, and follow up in one year.

[31:00] Mark: All right. Interesting. On this one, the recurrent UTIs: would we consider that a stable chronic illness at this time? I would say basically that's what we're looking at. We're actively managing this patient's propensity for UTIs by changing how we're approaching the antibiotics. We've done prophylactics, now we're going to try to wean her off the prophylactics and see how she's doing, and we're still increasing the hydration, assuming that's part of the UTI treatment and not just for the constipation. So the next one is the constipation, because that would potentially be our second problem. We know we've got at least one stable chronic illness. She's got a history of constipation. Now, does that fit into that same chronic illness category? In everything they're doing, we are managing that symptom. Is there something else underlying it? Is another physician treating the constipation, or whatever is underlying it? We're certainly encouraging this woman to look at diet changes and probably some other things with "work on constipation," we're assuming. So ultimately we could look at this as two stable chronic problems, but we probably need to expand a little here on the constipation, on what's happening relative to it. That would be the only way to get the problems up to a level four. So it would depend, again, on how it's documented.

Now, the estrogen cream is something we know is prescription drug management. So we've got that potential there, with the discussion across the board as to why we're using the estrogen cream and the risks and benefits of it. We'd need that discussion to get to a level four. The stopping of the antibiotics: was that a plan you previously went through with that particular patient? Is this another prescription drug management, or is this the final step in the execution of a plan that was already there, and you're just following through, and we don't really have antibiotic management there? So that one may or may not count in the prescription drug management. The other things we have are diet, exercise, those types of things, which are low to minimal risk. So the constipation management doesn't, at least from what I see, really hit that level four, and most likely wouldn't in most of what I see as far as treatment of constipation. But if it's a prescription, that's a potential. So it would really depend on how the documentation surrounded the circumstances of the plan relative to the antibiotics and the estrogen cream. That would give a level four, and then again, a zero on the data. We don't know.

Scott: John, comments?

[35:00] John: Recurrent UTI: this appears to be a stable chronic problem. It's definitely a chronic problem, and I'm assuming the patient was started on prophylactic antibiotics. I don't quite understand what that means, prophylactic: is it post-coital antibiotic, or is it a suppressive course of antibiotics? But in this case it doesn't really matter. The urologist has decided to stop antibiotics. Any time you start, stop or continue a medication, or give a sample of a prescription medication, you get to count that, if appropriate counseling documentation is there to support prescription drug management. So there's prescription drug management in stopping a prescription. Level four risk, provided the documentation is there. And when it comes to a single problem of recurrent UTI that is stable, because it says no new UTI since starting prophylactic antibiotic, this is a stable chronic problem with prescription drug management. So a three and a four. Currently you get a level three overall visit.

Then there is the constipation. Yes, you could think of it as a chronic problem, but I don't know if it's chronic stable. Is it chronic, not at treatment goal? There's no mention of how bad the constipation is, and what does "work on constipation" mean? Are you telling the patient a specific regimen to follow, more roughage, more hydration? I see the "more hydration" there; it could serve a dual purpose for recurrent UTI prevention and possibly help with the constipation. Are you recommending MiraLax? Are you recommending Colace, psyllium? What does "work on constipation" mean? Does that mean seeing a gastroenterologist? So we need a lot more clarity to give additional credit if you are managing this chronic stable problem. If you are truly managing chronic constipation, I would need a lot more detail, and if you truly are managing it, it could be construed as a chronic stable problem. That would give you two chronic stables, recurrent UTI and chronic constipation, and then you have prescription drug management, and that gives you a 99214.

[37:00] Mark: And John, the other one we always have trouble with, as I'm working with my auditors, and ultimately as we're starting to teach AI back and forth, regardless of who has it on and is doing a lot of these computer-assisted coding situations: "history of constipation." Does that mean this woman has intermittent constipation issues? Is it really a problem we would consider chronic, or is this episodic? This is the other one that is a judgment call. It's going to be based on the documentation. Is this a chronic problem? Yeah, it recurs every once in a while. That's a really tough one to teach anyone, a person or AI, as to where it should be. Ultimately, as you and I have argued with our friends at UnitedHealthcare relative to other issues, it is going to be one of those interpretations that is more difficult. So as much as you can put in that really demonstrates this truly is a chronic problem, that's going to make a difference in how it's interpreted when you get an automatic downcode or a medical records request. So I think this one, in the end, we can make a four, but it has to be medically appropriate as a four. Don't just manufacture it. This is one where there are plenty of ways to shoot at it if they don't want it to be a four, and granted, we know the payers don't want it to be a four.

Z codes, "history of" diagnoses and the semantics game

[39:00] Scott: Would you risk the denial being upheld on this? Let's say you got downcoded and you wanted to defend this. Would you risk one of your denial possibilities on this particular E/M scenario?

Mark: It would depend on my documentation.

John: Yep.

Mark: There we go.

John: Yep. And on the other hand, if it's an intermittent constipation issue, you may want to just use constipation, because the "history of" Z code in ICD-10 is often denied. It's not counted.

[40:00] Mark: It's interesting on the Z codes, and we've definitely dealt with this a lot. I would not use the Z code in a primary position for this. Z08 is one that's great in a primary position, but a lot of the other "history of" codes don't work. So order is important. It's not that it can't go on the claim; it's where it goes, as far as the pointers you use. If history of constipation is something that happens, it could be on there, but you're right, John, putting that as the primary diagnosis or the only diagnosis is probably going to lead to some problems. So make sure you use it in the right spot, and make sure you've got your other diagnoses in the right spot.

[41:00] John: Yeah. On the other hand, when it comes to instillation of immunotherapy for bladder cancer, you want to use the Z code first. But anyway. Also, say a gross hematuria workup: the patient comes in after the CT urogram, and I'm performing the cystoscopy today. I don't want to use history of gross hematuria. I want to use gross hematuria. Otherwise, the claim may not be paid for the cystoscopy. Well, the patient comes in today saying that the hematuria has resolved, and when I look in the bladder there's nothing going on. Everything is normal. So is it gross hematuria or history of gross hematuria? Anyway, list it as gross hematuria so that the claim goes through, and then on a subsequent visit change that diagnosis to history of gross hematuria if there's no recurrence. It's just crazy, the games you have to play. Semantics, if you will.

Sponsor and final thoughts

Scott: So true. All right, let's wrap this episode up and get some final thoughts. We first want to thank ModMed for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. All right, final thoughts, John?

[42:00] John: Well, I'm going to quote Jerry Maguire: documentation, documentation, documentation. Help me help you. From a coder's perspective, help them so they can help you, by writing down what you think and what you actually do. If you simply complete those tasks, it'll make life a lot easier. We gave you a couple of tips on how to document a little easier. Typing is for the birds. I got tired of typing over a decade ago, so if you're still typing, consider an alternative: a scribe, AI ambient listening, or voice recognition. The concepts in evaluation and management are relatively simple, but there's a lot of gray interpretation. If you understand these rules and what is required to reach a certain level, it'll make it easier for you to know what to document. You can be really efficient with your documentation. You don't have to have a lot of logorrhea, I call it diarrhea of the mouth or diarrhea of the words. You can be very succinct and cogent with your documentation to support your level of visit, so that these downcodes, once you support enough and win enough of these appeals, they'll stop doing it to you.

Scott: Mark, final thoughts?

[44:00] Mark: I'll echo John. It's documentation, it's documentation, it's documentation. It really is. And we've got several different options to review documentation these days, so you need to make it clear. It would be nice to be able to answer all of these questions with a nice black-and-white "here you go," but we can't, because it's all based on documentation. It's all based on what you're actually doing in that visit and how well you record what you did. We know now that with patients, discussions need to occur. So make sure you cover all of this. It's the easiest way to make sure you're getting paid for all that you do. And understand that the method by which you're recording that documentation, now that we have options of ambient AI, scribes, clicks, templates, all those things: make sure they match what you're actually doing. If your ambient AI is listening to you and you're not going through that full spiel while the patient's in the room, ambient AI's not going to pick it up. So you want to make sure you've got everything turned on and recording if you're using ambient AI, and that your dictation on Dragon fully recaptures what you did. And of course, if you're using clicks to do those things with templates, make sure you click them. It has to be there in order for the visit to be truly reflective of what you did. And again, I'll remind everyone, as we looped back on in all this: don't chase pennies when ultimately you're looking for efficiency going forward. Look at the bigger picture and make sure your efficiencies are there, from your patient scheduling and how you treat your patients to how you get your documentation done. It's all part of the program we have to live with.

[46:00] Scott: I'll wind this episode up by saying that Mark and John have spent the time and learned the rules. They understand what it takes for an E/M, what level, and the documentation for that E/M level. You have to know the rules and how to apply them to get that documentation where it needs to be. Your clinical documentation is separate from the documentation for reimbursement, and to get the documentation for reimbursement at the right level, you need to understand the rules well. As you heard, we threw those four scenarios at Mark and John, and they attacked them all very specifically and methodically, in the very same way. They looked at the rules, applied them, dissected it, and said, okay, in this section "it depends" was a lot of the answer, because of the way the scenario was presented. Then they took it apart section by section, problem, data, risk, and it's because they knew the rules. So learn the rules and make sure you apply them to your documentation. There's clinical documentation, and then you have to sprinkle in the documentation for reimbursement. That's all we have for today. Take us out, John.

[47:00] John: As always, thank you so much for the privilege of your time. Please take care of yourself and each other. Until next time, happy coding.

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