Wiki BCBS Outlier Downcodes

[Lindsey.White@nghs.com]

I need help! We have multiple primary care providers that have been hit as outliers from BCBS. BCBS is down coding our charge of 99214 to 99213. We have been sending medical notes left and right and have had great success in getting many of the edit overturned, however, still running into denials for LOS and our auditors are adamant that our coding is correct. I have an example below of an exam that we billed 99214 that BCBS denied stating" the overall level of MDM is not supported in the documentation". Would anyone mind taking a look and giving some feedback? What level of service would you bill? I would greatly appreciate it!

Assessment & Plan (Diagnostic & Therapeutic):
Mixed anxiety and depressive disorder (Primary)
Assessment & Plan:
Stable
Well-controlled off medications
Continue to monitor


Attention deficit hyperactivity disorder (ADHD), combined type
Assessment & Plan:
Stable
PDMP website reviewed
Collaborated with Dr. XXXX
Refill Adderall XR 20 mg p.o. daily
Follow-up 2 months

Orders:
- Discontinue: amphetamine-dextroamphetamine XR (ADDERALL XR) 20 mg 24 hr capsule; Take 1 capsule (20 mg total) by mouth daily.
- amphetamine-dextroamphetamine XR (ADDERALL XR) 20 mg 24 hr capsule; Take 1 capsule (20 mg total) by mouth daily.

Psoriatic arthritis (CMS/HCC)
Assessment & Plan:
Stable
Continue methotrexate 10 mg subcu weekly injection
Recommend patient follow-up with rheumatology,

Chief Complaint:
XXXXX is a 33 y.o. here for ADHD


History of Present Illness and Interval History:
33-year-old presents office today to follow-up on ADHD and psoriatic arthritis. Patient doing well on current medications.


Review of Systems:
Review of Systems
Constitutional: Negative.
HENT: Negative.
Dry eyes
Eyes: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Musculoskeletal: Negative.
Skin: Negative.
Neurological: Negative.
Psychiatric/Behavioral: Negative.
ADHD


Physical Exam:


Vitals
Vitals:
05/24/21 1627
BP: 122/80
Pulse: 88
Resp: 18
SpO2: 98%
Weight: 70.3 kg (155 lb)
Height: 1.676 m (5' 6")


Body mass index is 25.02 kg/m².
Body surface area is 1.81 meters squared.

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
Appearance: She is well-developed and well-nourished.
HENT:
Right Ear: Tympanic membrane, ear canal and external ear normal.
Left Ear: Tympanic membrane, ear canal and external ear normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.

Eyes:
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: S1 normal and S2 normal.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Abdominal:

General: Bowel sounds are normal.
Skin:
General: Skin is dry.
Capillary Refill: Capillary refill takes less than 2 seconds.
Neurological:
Mental Status: She is alert and alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood and affect normal.


Return in about 2 months (around 7/24/2021).
After Visit Summary (Printed 5/24/2021)

 

[mdekthomp01@gmail.com]

Hello, Based upon your note if the issue is stale and they are still prescribed the same medication is would be considered a 99213.
This is based upon the New E/M 2021 Guideline Scoring Sheet. I hope this helps you.

 

[Lindsey.White@nghs.com]

Thank you! May I ask where you determined this information so that I can reference to my Auditors. They state they are using the Marshfield tool and that it should be a 99214.

 

[carlystur]

Thank you! May I ask where you determined this information so that I can reference to my Auditors. They state they are using the Marshfield tool and that it should be a 99214.

This is what I use to help determine the level. Hopefully, it'll help you as well.

 

[kwatson0]

Good Morning, I am a little confused why it would be coded 99213, there's 2 chronic conditions with Moderate decision making. Please see Medicare Q/A to what constitutes as Rx Management

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered "prescription drug management."
"Prescription drug management" does differ from "drug therapy requiring intensive monitoring for toxicity".
Per the CPT definitions, "drug therapy requiring intensive monitoring for toxicity" is for a drug requiring intensive monitoring which is a therapeutic agent with the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis.
Examples of monitoring that does not qualify includes monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.