Part B Insider (Multispecialty) Coding Alert

Published on Mon Nov 20, 2006 PDF

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

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

A recent article in Part B Insider incorrectly stated that you need a physical exam of five to seven organ systems or body areas to bill 99214. (See PBI Vol.7, No. 39, -Coding Coach.-) In fact, the 1995 E/M guidelines as interpreted by the Centers for Medicare & Medicaid Services  (CMS) only call for two to seven organ systems or body areas.

Watch out: This misconception appears to be widespread. At least one Blue Cross/Blue Shield plan has said you need at least five systems or areas for a 99214. And this guidance also appears on the Web sites for the American College of Emergency Physicians and the American Academy of Family Physicians. 

This is a -gross error,- says Mary Falbo, president of Millennium Consulting in Lansdale, PA. She blames big public accounting firms, which have been intimidated by a wave of audits of 99214s, for spreading this overly conservative guidance. -The large CPA firms decided to adopt that [rule] at one point,- she says.

-Just because specialty societies or CPA firms may state that- you need five systems, doesn't mean it will hold up in a Medicare or payor audit, adds Falbo.

Most carriers say you only need two to seven body areas or systems for a 99214, including Empire, Trailblazer and HGSAdministrators, says Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ.

Check with your carrier: Some Part B carriers may actually have different E/M documentation requirements, notes Cobuzzi. CMS recently said that carriers are allowed to come up with their own interpretations of E/M guidelines and scoresheets. Already, Trailblazer has developed its own scoresheet, with different rules for medical decision-making.

Plus: For some specialties, such as ophthalmology or orthopedics, there may be no medical necessity to look at five or more body areas or organ systems, notes Stephanie Jones, chief auditing officer and VP of operations with Parses Inc. in Tampa, FL.

Editor's Note: For more information on correctly reporting 99214, turn to -How To Make Sure Your 99214s Measure Up,- on page 379.