Revenue Cycle Insider

Question: My billing department billed CPT^® code 99214 for an established patient whose encounter lasted 30 minutes. The patient’s insurance carrier is requesting records for a pre-payment review. We submitted the office visit notes. The carrier reviewed the records and denied the evaluation and management (E/M) claim, saying the level of service was not documented in the medical record. We think the 99214 is supported, but carrier does not. Can we reduce the E/M to a lower level of service and submit a corrected claim?

Codify Subscriber

Answer: You describe that the established patient’s encounter lasted 30 minutes (but not whether the visit included patient history/examination and medical decision making (MDM). But if those circumstances were met and recorded, then CPT^® code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) seems appropriate and supported by the documentation.

Billing 99213 (… low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) instead could be construed as downcoding, if the documentation of the encounter supports the initial selection of 99214.

If your code selection is indeed supported by the documentation — and not just the services the clinician provides — then appealing the carrier’s decision makes sense. Make sure you detail the evidence of the problem, data, and risk to fully support the code choice during your appeal.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC