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HBULLOCK

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I believe this is a 99214 but Dr. wants to charge a 99215. What do you think? Thanks :)

mom states no urine x2 days,drinking ok

pt states also vomiting, diarrhea, fever

Vital Signs
AGE 15y8.7m
TEMPERATURE 99.3 F
BLOOD PRESSURE 100/62
WEIGHT 131.8 lb
WEIGHT (%) 73

History of Present Illness
Seen here mutiple times over the past month for multiple illnesses. Vomiting starting two days ago, no diarrhea. Fevers 100-101 at home, more often at night (last fever was 2 nights ago, no fever last night). Cough has improved, less rhinorrhea and congestion. Now mostly complaining of abd pain, mostly right sided pain. Last BM was a couple of days ago, soft nl stool. Had a couple of drops of urine yesterday, maybe a full stream per Mikayla but Mom says only some dribbles. No urine since then per Mom. Today drank a bottle of water, and 1/4 bottle of gatorade. Nothing to eat today, last emesis 11pm last night. Able to keep down the water and gatorade at school today. Some mild pain with urination yesterday, felt like she had some pain at the end of urination. Maybe a little back pain as well. Urine seemed dark yellow yesterday as well. No foul odor.

Allergies
ATOMOXETINE HCL - Headaches, Vomiting : Strattera

Physical Exam
General Appearance

‎WDWN, NAD, well hydrated, alert and communicative

Skin

Clear, no rashes, nl skin turgor, nl cap refill

Head

‎Normocephalic, atraumatic

Eyes

‎Sclera white, conjunctiva pink. No injection or abnormal discharge noted.

Ears

‎NL canals, TMs clear with normal landmarks

Nose

‎NL shape, no discharge

Mouth

MMM

Throat

absent tonsils, no erythema

Lymph Nodes

‎No palpable lymph nodes

Heart

‎RRR, no murmur, S1 & S2

Lungs

‎Clear to auscultation, no rales or wheezes

Abdomen

‎Soft, mild right sided abd tenderness (slight wincing when palpating middle aspect of right side of abd), no guarding, no rebound tenderness, no masses. Liver/spleen not enlarged. NL bowel sounds.

Labs / X-Ray Findings Urine Culture; Urine Dipstick
Assessment and Plan
Assesment

Gastro

Poor UO - likely related to very mild dehydration or viral cystitis

Plan:

Zofran as prescribed. UA nl. Attempted to reassure Mom and patient given nl UA, but Mom was demanding that lab work be done because "we are missing something". Mom was very upset, and started to raise her voice stating that it "isn't normal for a girl to not have a full stream of urine or have belly pain like this". CBC nl, CMP nl. Reassured that limited UO likely related to mild dehydration or ?post-viral cystitis.

Encourage rest and hydration.‎ Advance to regular diet as tolerated.

RTC for persistent vomiting/diarrhea and unable to tolerate PO, vomit that is bright green or bloody, or blood in stool.
 
I agree with you, this is not a 99215. There is nothing in the documetnation that would indicate a "threat to life or bodily function", he's not putting her on toxic drug therapy or proposing any major surgery, and he's not doing a huge work up for the problem.

I'm not a doctor and wouldn't presume to question his decision making, but based on what he's written and the guidance that we've been given for evaluating the documentation, his note as written does not meet the criteria for 99215.
 
I agree it doesn't seem to be a level 5 HOWEVER I'm of the opinion if the dr wants to bill a 5 and WE spend time educating him that what he currently has is a 4 We bill it anyway, let the denial come and then use the denial as a way to educate him about proper documentation and what is required for a 5.

I refuse to downcode. To me that's fraud since I'm not the clinician and I don't have carte blanche to go in and "correct" a chart. My job IMO and how it's written in MY scope of work is to educate, educate, educate and I can't do that without allowing my docs to make mistakes and then taking the time to develop corrective action plans.

It curls my hair to see coder/billers automatically down code an E/M in order to avoid working an appeal. / shudder
 
Gailgordon,

Respectfully, our job is only to confirm documentation and shouldn't try to interpret their clinical judgement. I don't see that either DClark or HBullock were doing anything of the sort. If we bill for a code and the documentation does not support what is reported, this is the epitome of fraud by pure definition as stated by not only the AAPC but also CMS and every carrier out there. The claim will not deny simply because a 99215 was billed. The carriers are trusting that our documentation supports the level that was billed.

DClark and HBullock and are correct, the nature of the presenting problem does not support a Severe Exacerbation as the patient is only mildly dehydrated, rest, rehydration and zophran prescription only puts the MDM at a Moderate level, downcoding to a 99214 is correct coding, not fraud. And we absolutely not only have the authority but the responsibility to bill CORRECTLY when the documentation does or does not support what is reported.
 
Last edited:
OCD_coder said:
Gailgordon,

Respectfully, our job is only to confirm documentation and shouldn't try to interpret their clinical judgement. I don't see that either DClark or HBullock were doing anything of the sort. If we bill for a code and the documentation does not support what is reported, this is the epitome of fraud by pure definition as stated by not only the AAPC but also CMS and every carrier out there. The claim will not deny simply because a 99215 was billed. The carriers are trusting that our documentation supports the level that was billed.

DClark and HBullock and are correct, the nature of the presenting problem does not support a Severe Exacerbation as the patient is only mildly dehydrated, rest, rehydration and zophran prescription only puts the MDM at a Moderate level, downcoding to a 99214 is correct coding, not fraud. And we absolutely not only have the authority but the responsibility to bill CORRECTLY when the documentation does or does not support what is reported.
Click to expand...


Read what I wrote. I never said and shouldn't try to interpret their clinical judgement.

I said WE spend time educating him that what he currently has is a 4 We bill it anyway, let the denial come and then use the denial as a way to educate him about proper documentation and what is required for a 5. Which means I confirm the diagnosis is supported and the note reflects what he says he did. If it doesn't then I bring it to his attention. For example 250.42 and forgetting to add the CKD. I'm not teaching him to document to a 5. I'm teaching him what constitutes a 5 based on the CPT book.

If when reviewing the note I determine that the 5 should be a 4 or even a 3 I go to the doctor and we have a conversation. If he agrees it's changed if he doesn't then it goes out as is.

That's what I said. I am not sure what you read but that's what was said.
I'm not a clinician. I'm a coder. I am going to educate my doc to make him better at documenting. Whether he is doing a 3 or a 5.
 
Thanks for the responses. I do believe it is a 99214 and I will go back to the physician and let her know why I can only bill a 99214. Thanks again :)
 
I can't say I've ever had a denial for an E&M code that didn't meet the documentation guidelines, outside of an audit.

Am I understanding this correctly? If my provider documents a 99214, and wants to bill a 99215, we allow him to do that because the claim will be denied as a 99215? Then we go back and educate them as to the error of their ways and show them the denial? What psychic payers know that the documentation does not support a level 5? We don't send the note---so how does the payer know?

Do other payers outside New England deny claims for level of service relative to documentation issues without even seeing the note? You've got my attention.
 
Hi Pam,

A little bit of a different scenario, but our MAC has started requested records for inpatient claims billed as 99233. We haven't had (or to my knowledge) had carriers request records for claims billed out as 99215. We have several specialist and more often than not, those claims meet the requirements for this particular level.
 
RebeccaCross* said:
Hi Pam,

A little bit of a different scenario, but our MAC has started requested records for inpatient claims billed as 99233. We haven't had (or to my knowledge) had carriers request records for claims billed out as 99215. We have several specialist and more often than not, those claims meet the requirements for this particular level.
Click to expand...

Hi, Rebecca....yes, we've had record requests, particularly if providers are billing outside the bell curve. But I've never seen a first-pass denial due specifically to Level of Service, so I wasn't sure about the comment to educate providers based on this kind of denial. I have seen requests for records for high-level visits, but if we have a provider consistently billing 99214 when a 99212 is warranted, it's unlikely we'll get any payer pushback. Only the coder would know that the billing is inappropriate, which I think was the point made.
 
This is only anecdotal evidence, as I have not seen the acutal denials or remittance statements for them, but I have heard of denials for 99215 when the diagnosis code is "highly unlikely" to require such a level of service, i.e. the only ICD-9 code is 462 for a 99215. I would agree with the payer to further investigate - why a level 5 for a sore throat? - but that would usually prompt a request for records not a straight denial, correct? Again, this is anecdotal, not something I have actually witnessed.
 
gailgordon314 said:
I agree it doesn't seem to be a level 5 HOWEVER I'm of the opinion if the dr wants to bill a 5 and WE spend time educating him that what he currently has is a 4 We bill it anyway, let the denial come and then use the denial as a way to educate him about proper documentation and what is required for a 5.

I refuse to downcode. To me that's fraud since I'm not the clinician and I don't have carte blanche to go in and "correct" a chart. My job IMO and how it's written in MY scope of work is to educate, educate, educate and I can't do that without allowing my docs to make mistakes and then taking the time to develop corrective action plans.

It curls my hair to see coder/billers automatically down code an E/M in order to avoid working an appeal. / shudder
Click to expand...

Could you clarify the beginning of your post, are you saying that if you review a note, and the practitioner wants to bill out a level of service, that does not meet the documentation, that you attempt to educate them, and if they still hold that the higher level of service is correct, although unsupported you bill the higher level (i.e 99215) and then await the denial?

Denial for what, I've never experienced a denial back for an E/M with a 'higher code'. Unless I've gotten a medical records review/request from the payer.

I'm interested to hear your clarification.
 
I've had an experience with level 5 coding for a house doctor, but it was a global pre-payment review, not denials that then required appeal. I would also be very interested to hear more about letting unsupported claims be submitted and waiting for denials. I've only ever seen that in an audit, and if you wait for a audit you are likely to be in bigger trouble because often times the payor wants to extrapolate the error rate.

A couple years ago, Medicare did some sampling and determined that just about every level 5 house doctor visit (99350) was not supported by the documentation, so they began a brutal year long pre-payment review process. What a $750,000 nightmare! Medicare lost a whole bunch of records, then denied for non-response (although we documented they had signed for the packages and after much yelling and screaming somehow the documents were discovered someplace in the monolithic NGS machine, but since they only process claims one by one it was near impossible to get proper attention to each one), payment for supported claims (we had 97% of our claims supported) was delayed by months creating a significant cash flow problem for the provider and it took an incredible amount of staff time to respond, follow up and respond again.
 
OCD_coder said:
Gailgordon,

Respectfully, our job is only to confirm documentation and shouldn't try to interpret their clinical judgement. I don't see that either DClark or HBullock were doing anything of the sort. If we bill for a code and the documentation does not support what is reported, this is the epitome of fraud by pure definition as stated by not only the AAPC but also CMS and every carrier out there. The claim will not deny simply because a 99215 was billed. The carriers are trusting that our documentation supports the level that was billed.

DClark and HBullock and are correct, the nature of the presenting problem does not support a Severe Exacerbation as the patient is only mildly dehydrated, rest, rehydration and zophran prescription only puts the MDM at a Moderate level, downcoding to a 99214 is correct coding, not fraud. And we absolutely not only have the authority but the responsibility to bill CORRECTLY when the documentation does or does not support what is reported.
Click to expand...



I have ask this same question reverently. where our providers are using EHR and they are selecting about 14 bullets and again my question was how do I determine what is the correct level of care ? this is really confusing . Am i supposing to be counting all the elements ?? or am I going off the assessment and chief complaint ?
 
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