Part B Insider (Multispecialty) Coding Alert

Published on Fri Oct 15, 2010 PDF

But don't assume you have a 99214 just because you have 5 or more

Are you a victim of "detailed exam" confusion? Don't miscode your evaluation & management visits based on numerical standards that may not apply.

A subscriber wrote to the Insider noting that she recently attended a seminar where she heard that you need a physical exam of five to seven organ systems or body areas to bill 99214, and she asked if this was accurate, noting that a previous E/M code selection tool she owned only called for two to seven organ systems or body areas.

What CMS says: The actual written guidance from CMS is extremely vague. CMS does not specifically publish, in actual numbers, how many organ systems or body areas the doctor needs to examine for a 99214.

But CMS does say you need a "detailed" examination for a 99214, versus an "expanded problem-focused" examination for a 99213. An expanded problem-focused exam is a "limited examination of the affected body area(s) or organ system(s) and any other symptomatic or related" areas or systems.

"Some payers and even some societies will interpret the guidelines differently," says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and documentation compliance with UPMC in Pittsburgh, Penn. "The difference between expanded problem-focused and detailed varies amongst payers," she says.

Here's the source of confusion: "Some payers say the difference is two to seven for each, but with at least one organ being more detailed," Berman says. "Others state (like in the original guidelines) two to four areas for expanded problem-focused and five to seven for detailed," she notes. "Highmark Medicare Services uses two to seven, with four of them having at least four points illustrated."

Check With Your Payers

CMS has said in the past that carriers are allowed to come up with their own interpretations of E/M guidelines and score sheets. Therefore, you should always check with your MAC before you determine how to report a 99214. If you have offices in different states and you therefore deal with different MACs, it's possible that one carrier might lean in one direction and another MAC might be more conservative.

Bottom line: Keep all MAC requirements at your fingertips to avoid any billing problems down the road.