99205 - baractric patient

coder21

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A provider wants to bill a 99205 for a baractric patient that's is going to have surgery in 3-6 months. I read an article from aapc saying when picking a level 5 it's saying the patients next stop is the emergency room. So would this really be a 99205? Is there any more documentation ok there?

Thank you
 

CodingKing

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5's should be pretty rare. The provider cannot tell you to bill a 5. the documentation needs to support it. Have you read the E&M guidelines? Does it show a Comprehensive History, Comprehensive Exam, and MDM of High complexity. Or does counseling and/or care coordination dominate (more than 50%) the visit. For level 5 must be at least 30 out of 60 minutes. Must be well documented. What the extent was, how long the whole visit was and how long was the Counseling and/or care coordination.
 
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coder21

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Yes, comp history, comp exam and he doing a major electric surgery with risk factors since he has morbid obesity with identify Rick fast of the co morbidites. Hypertension, dm, extra.
 

thomas7331

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99205 does not require that the patient be on their way to the emergency room. The medical necessity of that level can be met by the complexity or uncertainty of the illness as well as by the severity. Be cautious with your MDM - you've identified the level of risk but to meet high MDM you also to have either extensive number of diagnosis or extensive data. And the way the Marshfield clinic audit tool is structured, the only way the diagnosis points will add up for a new patient is if additional workup is required. Also, some guidelines take 'major surgery with risk factors' to mean identified risk factors above and beyond the normal risks associated with that procedure due to the comorbidities.

99205 does require good documentation, but it can certainly be supported for patient whose illnesses are complex and/or severe.
 

CodingKing

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Out of curiosity I ran claims on some bariatric specialists and the number of level 5 is very low compared to level 4.
 

coder21

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So you are saying they should be 4's? That's what I told him but he says they are 4's. He is finally coming around to agree with the 4's .
 

CodingKing

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I'm not saying they should be 4's just saying 5s are rare, there were many 3s as well. There is no one size fits all for this and if you just pick a code an run with it without making sure the documentation matches that would be fraudulent.
 

coder21

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I understand what I should have said was I got my point across that they where not fives.
 
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