Internal Medicine Coding Alert

Published on Mon Nov 01, 1999 PDF

Internal medicine practices should be on the watch for an increase in denials of high-level E/M services in the office setting and be ready to combat the turn downs through documentation.

A number of insurance companies are automatically downcoding E/M levels, 99214s and 99215s, particularly, warns Kathy Palmerton, CPC, coding consultant with Gordon, Odom and Davis, an accounting firm in Sacramento, CA. Anyone billing those levels needs to make sure you have good documentation in your chart, because you may need to appeal it.

CPT requirements stipulate that the presenting problems for 99214 and 99215 are of moderate to high severity. Code 99215 requires a more extensive history and physical than a Level 4 (99214) visit. And, Level 5 visits require medical decision-making of high complexity rather than the moderate complexity required for Level 4. But, both codes are used for visits that indicate a serious clinical problem.

Many payers may be gambling on the unlikelihood of physicians seeing moderate- and high-severity problems in their office setting, Palmerton says. They are downcoding to save money and because they feel that the potential for upcoding in these situations is high.

And, they may not be all wrong.

There are still a lot of physicians out there doing things the wrong way, Palmerton says. They code based on time, instead of going by the documentation guidelines for the type of history, exam and medical decision-making used at each visit. They say, I spent 45 minutes with the patient, its a 99215.

But the carriers arbitrarily downcoding a service is not appropriate either, she adds.

If you have the documentation to support that the physician obtained the appropriate amount of history, performed the physical exam, and had medical decision-making to support the claim, then I would appeal it, Palmerton counsels.

If you have the documentation, you can justify it. If you can justify it, you can get paid.

However, many third-party payers are likely betting that practices wont want the added headache of appealing every denial and will just choose to downcode their services prophylactically and avoid a fight. But you really shouldnt take it lying down, Palmerton counsels.

Lack of History Documentation a Problem

Some physicians are upcoding Level 4 and Level 5 services in the office setting, warns Garnet Dunston, CPC, immediate past president of the American Academy of Professional Coders and an independent coding consultant in Phoenix, AZ.

The difference (between the codes) will most likely be in the history, whether you have a detailed or comprehensive historymostly whether the physician documented a past, family, social history (PFSH), says Dunston. I have seen a lot of charts that were coded at Level 5 that did not have a comprehensive history. Because the patients are established patients, the physician doesnt always document a past history. (See requirements for reporting 99214 and 99215 in the box on page 85.)

Although the established patient E/M codes require that only two of the three components (history, exam, medical decision-making) meet or exceed the level of service reported, it is not wise to rely solely on the documentation of the exam and medical decision-making.

If there is a dispute over the level of exam or decision-making, then a history that meets the level would help ensure reimbursement at the fullest appropriate amount.

Level 5 services are rarer in an office setting. But, they do occur, notes Dunston.

Consider patients presenting with CHF (congestive heart failure), some pulmonary edema patients, the patients with more severe chronic illnesses and exacerbations of those illnesses. For some, determining the exact problem and treating it will warrant a pretty high level.