Receive Optimum Payment by Avoiding Undercoding
Published on Sat Apr 01, 2000
CPT outlines the three key components for choosing an E/M levelhistory, examination and medical decision-makingof outpatient visits for both new and established patients. But there are many factors that affect each of the three components and can drive a code to a higher or lower level and cause confusion.
Note: Although this article focuses on evaluation and management (E/M) codes for outpatient visits by established patients99211-99215 (office or other outpatient visit for the evaluation and management of an established patient)most of the same considerations apply to new patients. The major difference is that all three key components must be satisfied for new patients while only two of the three are necessary for established ones.
Cindy DeVries, RN, CPC, coding and reimbursement coordinator for Lee Physician Group, a 140-provider, multi-specialty practice in Fort Myers, Fla., says concerns about overcharging patients and confusion about E/M codes cause undercoding. Its the financial impact of a higher code that may cause an FP to choose a lower level of service, she says.
Some FPs undercode because they know the price will suit the patient, but you have to be careful, warns Terry Fletcher, CPC, CCS-P, a healthcare coding consultant with McVey Associates, a national specialty coding seminar company in Novato, Calif., because that is considered fraudulent billing. If Medicare continually sees undercoding, it may send up a red flag. Medicare, however, does not fine for undercoding, DeVries says.
Fletcher also believes that some family doctors dont realize when they have reached key levels of service. If you can document service, you shouldnt be afraid to code at a higher level, she adds.
Factors Affecting the Three Key Components
Follow these four rules when determining the appropriate level of outpatient visits for established patients:
Rule 1: For 99211 and 99212, there is usually a self-limited or minor problem, such as a cold (460, acute nasopharyngitis [common cold]) or insect bite (919.4, insect bite, nonvenomous, without mention of infection or 919.5, insect bite, nonvenomous, infected) that requires a brief history of present illness and a discussion of the chief complaint. The examination is limited to the affected body area or system. The number of diagnoses/manage-ment options (i.e., rest or gargling), number/complexity of data and risk of complicationsall elements of medical decision-makingare minimal, resulting in straightforward medical decision-making.
Code 99211 has no history, examination or medical decision-making associated with it. It simply represents a face-to-face encounter with a patient that may not require the presence of a physician and typically involves minimal presenting problem(s). That is why it is often referred to as a nurse visit.
Example 1: A mother brings in her nine-month-old baby girl with diaper rash. The visit simply requires a brief history, [...]
