General Surgery Coding Alert

Question: We recently finished our first internal audit and found a potential issue: One of the surgeons told me that he only chose level 99212 when it is a follow-up from a previous visit. He always chooses levels 99213 and above for everything else. Is that correct?

Washington Subscriber

Answer: No, that is not correct. Not just a follow-up problem-oriented visit for an established patient warrants a “low-level” code such as 99211 or 99212. And all other visits don’t automatically earn a higher E/M level. Your coding should never hinge solely on whether a problem is new.

Do this: The selection of an E/M level should be based on documentation and medical necessity.

If you have documentation that supports a comprehensive history and a comprehensive exam but you are sending the patient home with a plan of symptomatic treatment with mention of over-the-counter medications, that is a low level of medical decision-making, which typically would not warrant billing 99214.

When physicians announce that they will only choose a particular level of service for a certain type of patient, that is typically a learned behavior which can hurt the physician in both ways (undercoding and overcoding). A “minor condition” could warrant a 99212 — but it could also warrant a 99214 depending on the patient’s other coexisting conditions, symptoms, and history. Each case should be coded individually based on the documentation.