Wiki 99214 dilemma

amexnikki23

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Carolina Beach, NC
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SCENARIO?

Provider charged a 99214 in July and dx?d pt w/osteoarthritis of knee after some work-up.
Patient comes in two months later, still in pain, now wants a joint injection.
Provider now charges another 99214-25, and does not mention the knee or any other musculoskeletal area in his exam, yet he meets his exam quantity because of the other exam components (ie. psych, constitutional, cardio).
Performs the joint injection and charges a 20610 and charges for that along with the EM, using the 25 modifier.

MY THOUGHTS?
I believe this to be a level 3 even though the provider technically meets the criteria for 2/3 key components (Hx and Exam) due to the fact that he examined 2-7 ba/os HOWEVER, none of those exam components include anything related to musculoskeletal or the knee. And I thought 95 DGs stated "extended exam of affected OS/BA"- so what would be the overarching criterion here?
 
From CMS - Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

That being said, if the knee was already worked up, a diagnosis established and nothing has changed, where is the medical necessity for an E/M at all? if the MS system is not included in his physical exam then he didn't even re-evaluate the knee. so he is obviously not performing a problem-focused exam.

If I were to bill an E/M it would be a level 2, but I would hesitate to bill an E/M at all considering that payment for a standard pre-porcedure evaluation is already included in the payment for the procedure performed.
 
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I agree completely with emcee101. I am faced with pretty much this same scenario on a daily basis. I do code them down. In this scenario, I definitely would not code this as a level four! And as emcee101 states, I would have a hard time even coding a level two. Since it has been two months though and not two weeks, I could live with a level two with the injection code.
 
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