Wiki 99214 vs 99215

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jhendrix08

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Hi everyone..

My provider asked me to run a report of E/M's billed (99213-99215) over the past two months; mostly out of curiosity. Our 99215 visits are very low and he's thinking that some of his level 4's could have been level 5's based on the complexity of his patients. I've read over the requirements in the CPT book and skimmed over the lengthy E/M guidelines from CMS, however, I'm wondering if any of you can provide me with a link to a document/table that I can show him to make it easier to reference to. I've been looking and haven't had great luck. I may make my own but was hoping someone might have a good starting point for me. (I'm a fairly new biller) Main interest is comparison between 99214 vs 99215.

Also, when does time come into play? I know 99215 states 40min; need some guidance on whether or not that needs to be documented in the note if he bills based on MDM vs time.

I appreciate your time very much!!!
 
To use time vs. MDM, the provider must document the total time of the visit, the amount of time spent on counseling/coordination of care (which must be greater than 50% of the total visit time), and some sort of statement as to why the patient had to be counseled/coordinated

I've had one provider who knew how to document this very well; all other providers I've ever known have difficulties here. Make sure you tell your providers exactly what you need, and also let them know that just because they have 11 diagnoses and spent 90 minutes with the patient and ordered 26 labs and 14 xrays that this does not automatically translate to a 99215
 
This is correct. The ONLY time I can see a 99215 in PCP office is when the quoting this part and also let them know that just because they have 11 diagnoses and spent 90 minutes with the patient and ordered 26 labs and 14 xrays that this does not automatically translate to a 99215 is worsening. IF all 11 dx are stable and the patient is coming in for medication refills then a 99215 is not justified. However, if their COPD is worsening and suddenly they need O2 and maybe a PFTs, and a referral to a specialist and a change in medication is prescribed I can see ticking up to 99215 or if their CHF is in flare and has gone from Chronic to acute on chronic then yes I can see ticking up to a 99215 in this case along w/ the other 10 dx.

Hope that makes sense.

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Don't forget that medical necessity trumps over anything else. Was it really medically necessary for the provider to spend more than 20 minutes face-to-face with the patient to counsel and care coordinate (this excludes time spent on History and Exam)?

Since you are already familiar with the CMS E/M guidelines, I won't post that here. However you might like AAPC's E/M audit tool instead?

AAPC E/M Audit tool

Novitas has some E/M score sheets as well.


For 99214 vs. 99215, there are a number of ways you can go about it. As you know, with Established Visits only 2 of the 3 E/M components are required when looking at History, Exam and MDM. Some payers differ on whether MDM is one of those two (CMS doesn't specify, although recent E/M revisions suggest MDM is important), so you might collaborate with your Compliance Officer/Medical Director on this one. Once this is squared away, two of the following three is required for each level:

99214 (2 of these):
History: Detailed (4 HPI, 2+ ROS, 1 PFSH)
Exam: Detailed (12+ exam elements ['97 version])
MDM: Moderate (3 points in two of the three MDM components [Dx/Mx, Data, Risk])

or if time is documented correctly, "Greater than 50% of 25 minutes was spent on...".

99215 (2 of these):
History: Complete (4 HPI, 10+ ROS, 2 PFSH)
Exam: Comprehensive (9 organ systems with at least 2 exam elements in each ['97 version, can't remember '95])
MDM: High (4 points in two of the three MDM components [Dx/Mx, Data, Risk])

or if time is documented correctly, "Greater than 50% of 40 minutes was spent on...".

Hope this helps, if not ask further!
 
TIME - can be used as an alternative to the 3 elements (hx, exam, MDM) only if >50% of the time was spent counseling and/or coordination of care. The note must specify this.
ie - 25 of 40 minutes spent discussing management of HTN and DM with medication in addition to diet and exercise.
Total face to face time with patient was 40 minutes, of which >50% was spent discussing management of HTN and DM with medication in addition to diet and exercise.
My personal opinion about time based billing is that in 95% of situations, you can reach a higher level billing by elements vs time. You can perform and document hx, exam & MDM of 99215 in far less than 35 minutes of face to face time. However, it is very helpful those circumstances a fairly straightforward patient needs some handholding.

E&M table
There are a ton of good resources out there. I personally took the AAPC link https://www.aapc.com/localchaptereventagendas/fbf94b7c-8efe-477c-89c7-54c7b40acd03.pdf and information I received at a local seminar & then created my personal listing. Every office (sometimes based on type of specialty, or provider preference) has a slightly different way of documenting, and 1995 or 1997 guidelines might work better for you. I personally prefer 1995 count the organ systems, but if I was working for a retina subspecialist, 1997 might be better. I suggest you take a reference like above, and create your own personal listing. Of the 46 page pdf, the relevant data for you is on maybe 4-5 pages.

Word of advice - especially with EHRs and pre-populated/carried over data. It is pretty easy to document a level 5 hx and exam on a patient that is only a level 3 MDM. While the guidelines simply state for established patients, 2 of 3 elements, most auditors and consultants will advise you to use MDM as 1 of the elements. CMS has advised to use medical necessity as an overarching criteria. Just because the provider documented a comprehensive hx and comprehensive exam on a HTN follow up you saw 2 weeks ago, doesn't mean the patient needed a level 5.
 
I can't thank all of you enough for taking the time to help me with this....your responses are SO helpful!!!

Thank you!!! You've given me a great starting point for a discussion with my provider.
 
When a provider refers a patient for physical medicine/therapy/occupational therapy would it be correct to give them credit under "data" for Medicine section ordered and or reviewed?
 
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