Question "Automatic" level 3

tamale79

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Hello,
My boss wants us to charge a 99213 any time a pt gets a med rx or rx to therapy. She said those are automatically level 3s. I told her that MDM is the main driver of the e/m levels, and just b/c a dr writes an rx (or more accurately, the MA enters an order into the computer) does not "automatically" equal a level 3.
Am I wrong??
If I'm correct, does anyone have any documentation specific to rxs that you can point me to?
Thanks
 

mitchellde

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you are not wrong. The only automatic here is, an order for a prescription will give you moderate risk. However MDM is based on two out of three and risk is only one element if the other two elements are minimal then the MDM will come out as straightforward. so you can have I minor diagnosis with no labs ordered or reviewed with a prescription for antibiotics and still have a level 2 visit. your documentation you seek is the 95 or 97 guidelines. These are what we follow for visit levels.
 

Pathos

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Anyone who claims that they have to bill a specific E/M level every time, is not only setting themselves up for failure; they are coding incorrectly (under or over coding). As a coder you promise to code the encounter based upon documentation, and not by some arbitrary internal office policy that the office needs to churn out a specific code. Not only is this practice unethical, your office is in danger of getting several False Claims thrown at them.

I would be very cautious to follow such a policy, as the office will jeopardize themselves greatly and put themselves at risk for serious allegations. Perhaps a few audits might pass, but this chronic down/overcoding is scary at best. If your boss is still enforcing this practice, I would start updating your resume...

Sources:
OIG
CMS E/M guidelines
 
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you are not wrong. The only automatic here is, an order for a prescription will give you moderate risk. However MDM is based on two out of three and risk is only one element if the other two elements are minimal then the MDM will come out as straightforward. so you can have I minor diagnosis with no labs ordered or reviewed with a prescription for antibiotics and still have a level 2 visit. your documentation you seek is the 95 or 97 guidelines. These are what we follow for visit levels.
Agreed. You could also check Appendix C of your CPT manual. One of the examples for 99211 is a patient who lost their prescription and came in for a new one.

It's my opinion (just mine) that if someone says there's a rule for coding they should be able to produce official guidance to that effect. At the very least it will mean the practice will be protected if it is audited and the auditor challenges the claims.

Finally - what if some of those automatic 3s are really 4s?
 

tamale79

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Thank you both for your help. I've been debating this with her for 5 years, and now she wants to have a meeting to get the providers' input...gee I wonder who they'll agree with??
 
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