Time coding vs 99215

[khacker]

If the provider completes their documentation and states that they spend 40 min, counseling the pt. is that enough to jusitfy coding a 99215 ov visit when the pt doesn't have a followup appt. for 3 months? I am confused on how the time allotment is used. Would this pose as a red flag to medicare when there are about 8 out 20 these done per day?

[RebeccaWoodward*]

Per CPT, when the provider devotes more than 50 percent of his/her face-to-face time with the patient providing counseling or coordinating care, time may be considered the key or controlling factor to qualify for a particular level of E/M service. The documentation should reflect the nature of the counseling or coordination of care the physician provided

Example: A total of 25 minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care.... A brief synopsis of what was discussed (treatment, lifestyle changes, etc) needs to be documented, also.

This would qualify for a 99214.

Curious...what specialty is/are your physician(s)?

[PSloss]

As an auditor for a state agency, I highly recommend if you bill a high level like 99215 that the documentation be VERY detailed on what counseling was done. The CPT requires that the visit is comprehensive in nature and that is where physicians get in trouble with their documentation when audited. In cases of high level billing more is always better.

[cheermom68]

I also want to caution on this issue. Just stating the time (enough to meet level 5) with greater than 50% in counseling and a synopsis of what was counseled even in great detail is not enough for NGS. It still must meet medical necessity according to their auditors. Could be an elderly patient with 10 chronic conditions and multiple meds whom the physician spends 45-60 minutes with great documentation and all requirements to bill a 99215 documented, could still be downcoded by NGS to a 99214 because they say it doesn't meet medical necessity. I have seen it done many times....

[RebeccaWoodward*]

Originally Posted by cheermom68

I also want to caution on this issue. Just stating the time (enough to meet level 5) with greater than 50% in counseling and a synopsis of what was counseled even in great detail is not enough for NGS. It still must meet medical necessity according to their auditors. Could be an elderly patient with 10 chronic conditions and multiple meds whom the physician spends 45-60 minutes with great documentation and all requirements to bill a 99215 documented, could still be downcoded by NGS to a 99214 because they say it doesn't meet medical necessity. I have seen it done many times....

Cheermom does bring up a good point.

Medicare's view:

"Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim."

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

With that being said, I have to rely on my physicians ability to determine what is medically necessary. If the documentation supports 99215, 99205 that's what I have to work with. I'm not going to discredit a piece of documentation because I don't see how it fits into what the doctor is evaluating. I'm not clinical and I'm not present when these services are rendered. E/M codes measure how hard the doctor had to think; how much information needed to be gathered to determine what was wrong with the patient and how to treat the problem If, for some reason, the carrier doesn't feel the services were not medically necessary, then my provider and I are certainly ready to appeal.

I was curious as to what specialty the original poster worked for to get a "feeling" for what type of documentation scenarios she might encounter. We have several specialties within our practice and some of those specialties are certainly more difficult/higher risk than others.

[cheermom68]

I agree Rebecca. Even though I am an RN, I was not in the room when the service was rendered and when the documentation supports the 99215 I don't know how I can say it wasn't medically necessary, I am not really sure how the NGS auditors can either, but that is another story. I have seen these denied on appeal also.

[Love Coding!]

There was an article that clearly states, some coders are clinical and some are not. A coder CANNOT make medical necessity determinations! That is outside our scope of practice. Some coders may agree with me and some may not when I say this, all I can do is stress the importance to the physician that the note be focused on medical necessity. If they choose to beef up their dictation that is between them and the outside auditor (Medicare, commercial payers). The important point here is keep track of what you teach, what you instructed the physician to do, etc. from there it is in the physicians hands. That's my two cents worth :0)

[khacker]

The providers speciality are internal medicine and family practice.

[cheermom68]

I definitely believe that 8 of 20 or 40% per day 99215's would be an outlier and a big target for audit in internal medicine and family practice.
LeeAnn

[RebeccaWoodward*]

I agree with you LeeAnn. That is a high percentage. It would be interesting to see an example of one of these records.