Wiki 2 out of 3

[KaylaRieken]

My doctor is questioning us coders why they are not getting 99214s for their patients when they have a detailed/comprehensive history and a detailed/comprehensive exam but they have a low decision making. They are saying that it is 2 out of 3 and that's all they need. I need some kind of explanation for this? Does anyone have anything that can help me?

 

[sxcoder1]

The CPT book states that 99214 only needs 2 out of 3 of the key components.

 

[thomas7331]

I agree with the physicians and with the previous post - CPT guidelines are that 2 out of 3 qualifies the level for established patients. If your practice is not following this rule, you must have some kind of internal guidelines or reasoning that you are using to reduce levels based on MDM or medical necessity criteria?

 

[KaylaRieken]

So we are a urology group. This is an example of what we have been seeing from our docs. Patient is being seen for BPH. They are dictating a comprehensive history and exam and for the mdm they are saying come back in six months or a year or refilling a BPH medication. And dictating the same way the next 6 months or a year. Does this constitute a 99214 every time? To me it seems a bit extreme when the patient is stable.

 

[stacil]

Use Medicare Carrier Manual reference

I've been coding for years and have heard this opinion ......millions of times.

In response to the provider, I 've used the CMS or the Medicare Carrier Manual (MCM) reference found in section 15501. Google it and you will find it. Paraphrasing the statement it says that medical necessary should be the overarching criteria for the level of service not the amount of documentation.

It has saved many of the providers I've worked with since they would all document the Hx and Exam as their 2 of 3.

Good luck!!

 

[thomas7331]

So we are a urology group. This is an example of what we have been seeing from our docs. Patient is being seen for BPH. They are dictating a comprehensive history and exam and for the mdm they are saying come back in six months or a year or refilling a BPH medication. And dictating the same way the next 6 months or a year. Does this constitute a 99214 every time? To me it seems a bit extreme when the patient is stable.

Actually the correct coding in this situation would be 99215 if both history and exam are comprehensive. I agree, this is indeed a medical necessity question, and any payer auditor would certainly ask this same question - if the patient is stable and has no new problems, why did this patient require the highest level of E&M service, which is normally reserved for the sickest or most complex patients?

The best way to resolve this, in my opinion and from my experience, is not to change the coding rules to assign a lower code just because it appears that the patient is stable, but to have a discussion with the providers. Did they fail to accurately represent the complexity or severity of the patient's problems in the documentation? Or are they documenting (or performing) more history and exam than was really necessary? Or a third possibility is that is this really a more serious problem than appears to a coder? I've encountered all of the above with my providers, and rather than make an assumption, it's best to talk this out and try to get the providers to understand that the level billed has to be supported not just by history and exam but by the severity of the patient's illness. If they insist that they level is correct, show them the E&M curve for your specialty, and let them know that being an outlier in the coding could put them at higher risk of an audit and that they would need to justify that they are treating sicker patients - this would need to be reflected in their documentation. Let them know that coders and auditors are not physicians and can't make their own interpretation of information the record so it is sometimes necessary for physician to spell out something in writing that might seem obvious them in order to help support medical necessity in an audit. Put a question to the providers - if these claims were audited, would they bill able to write an appeal explaining why a patient presenting with this problem required this level of care? Would their peers in this specialty agree that this problem is expected to require a full history and exam at a follow-up visit? Another suggestion is to have the providers review the clinical examples in Appendix C of the CPT book, which will help them understand in a general sense what the different E&M levels equate to in clinical terms.

The coding rules require that you take 2 of 3 elements to determine your level. If you're going to step outside of that due to medical necessity, you and the provider will need to come to a consensus as to what elements you are going to disqualify in order to reach an appropriate level. Most likely, this is the history - it's unusual that a provider would need to re-do an entire history at a short interval and the provider has pulled it forward from a previous visit, but it could also be an exam that is padded with irrelevant information to inflate the level. But I recommend making a decision like this in collaboration with your providers since it involves a clinical judgment as to what is necessary for the patient which is outside the scope of coding and really requires their participation to make this correct. Sorry for the long-winded answer, but hope this may help some.