Medicare Compliance & Reimbursement

Question: We recently finished our first internal audit and found a potential issue: One of the doctors told me that he only chooses level 99212 when it is a follow-up from a previous visit. He chooses levels 99213 and above for everything else. I do not believe it is that simple because I thought even if it was not a follow-up visit, something like a minor cold might warrant 99212. Can you advise?

Answer: You are correct. Not only can a follow-up problem-oriented visit for an established patient warrant a “low-level” code such as 99211 or 99212, but your coding should never hinge solely on whether a problem is new.

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 rest and 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 two ways — undercoding and overcoding. A “minor cold” 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.