Reaching 99214 without time addendum

[vbrownlee]

I work in a pediatric office and took over coding from an outsourced billing office who was not giving any feedback on levels of service. Now that I am doing so, I'm finding our providers have been billing 99214s on many encounters that don't qualify. They are becoming discouraged and don't like my answer that if they spent the time and documented that, we could bill the level 4. They are hoping for other tips on how to reach this level of MDM and I'm not sure how to help them.

For example, a concussion without loss of consciousness. Does the PECARN exam count as a piece of data, and even if it does, I'm not sure where they get the other two (besides a historian, but then still need one more). I think the thing we are divided on is the risk category. From my coding perspective, the risk of treatment is what this criteria is based on, and not the risk of the problem, which I feel is how my providers think of it. Sure, the risk of a concussion could be severe, but strictly "taking it easy and not participating in sports for week, and returning with concerning symptoms" is not moderate level.

Does anyone have any tips or suggestions for me?

 

[jkyles]

It sounds like the issue is that not as many of their visits meet the requirements for a level 4 when coded with MDM as they want or expect. If so, it's unfortunate that the outside coder got them in that habit. For education purposes I recommend training them with documentation that does meet the requirements for a 4 and comparing it with documenation that does not.

I also recommend taking a look at your practice's bell curve compared to the local norm. Being an outlier doesn't automatically mean they've done anything wrong but it can be a reality check for providers. The other thing the practice should do is determine whether it needs to refund any overpayments.

 

[NRaizman]

For the example above, Column 1 you get to Moderate for condition risk (undiagnosed new condition with uncertain prognosis).
For Column 2, if you don't order any tests, all you get is independent historian, so you're still at Low. PECARN is an algorithm, not a test, and most people go through it and never need a CT. If there are any external tests that are independently interpreted, you can get to Medium here, but that's likely the only way... Could discuss with a neurologist to get you there.
For Column 3, the treatment for concussion in pediatric patients is rarely prescription meds, and rarely gets you to medium.

I think you're largely stuck with Total Time to get to a 4 without other justification, but that's only 30 min for any established patient, and that's total time, not just face-to-face, so as long as your docs understand what they can count towards that and document it, they can often get there. Concussion eval often involves a good bit of counseling, and that takes time....

 

[vbrownlee]

It sounds like the issue is that not as many of their visits meet the requirements for a level 4 when coded with MDM as they want or expect. If so, it's unfortunate that the outside coder got them in that habit. For education purposes I recommend training them with documentation that does meet the requirements for a 4 and comparing it with documenation that does not.

I also recommend taking a look at your practice's bell curve compared to the local norm. Being an outlier doesn't automatically mean they've done anything wrong but it can be a reality check for providers. The other thing the practice should do is determine whether it needs to refund any overpayments.

Thank you! I really appreciate the feedback.