Wiki Coder review 99212/Provider insist on 99213


Perryville, MO
Best answers
I need feedback from Auditors and fellow coders. Let me start off by stating this provider does handwritten notes, which in itself is an issue. It is not at all helpful in justifying the level of care the provider would like to bill. I have two separate scenarios. Patient A is seen for a skin check, diagnosed with Benign Nevus, no data, and nothing notated but script not needed. Patient B is diagnosed with Seb. Keratosis, no data, notation of no script needed. Provider chose 99213, coder chose 99212. Discussion with provider follows and provider states they rarely see a level 2 and they spoke with their colleagues. The colleagues reminded them that if they discuss OTC medication is qualifies as a level 3....provider will start documenting in her written note that she recommends UVB/SPF 30 + with zinc and titanium..which provider does recommend just doesn't document.

I still as a coder classify the benign nevus and seb keratosis as self-limited or minor, we still have no data, and even with OTC mentioned...I'm still seeing a 99212.

I would love for others to weigh in on the nevus and seb keratosis and where you feel they fall. Provider is adamant that we do not alter coding. Provider utilizes an EMR in primary location clinic, which is bumping these up to a 99213 for established and 99203 for new patients.

Would love feedback and advice on how others handle providers who do not want their coding altered even after discussion and reasoning.
Regarding your first question, just given what you've said and without seeing the notes, I'd basically agree that these visits sound like 99212 based on the new guidelines for coding just using MDM. I think under the old guidelines, providers could get these up to 99213 because a skin check usually involved a pretty thorough exam, and combined with the history they could code a 99213 even if the MDM did not meet the level. The only thing I'd perhaps suggest is that if these patients have some history of skin cancer that is driving the need for a skin check, then that could perhaps justify the 99213 since that's a higher level of risk that just a patient coming in who's worried about a benign spot on their skin.

As to the second question about handling providers, that's a little more difficult to answer in a short post. A coder sort of has to play the diplomat in these kinds of situations. The answer is also going to vary depending on the structure of your organization. The first thing I'd ask (in as nice a way as possible) is why does the practice hire coders if the physician insists that their coding is correct and can't be altered? They're wasting their money if the pay a coder but then don't use the coder's skills. It just needlessly puts you in a difficult position. But that aside, if the physician owns or runs the practice and has the final say, then there's not a lot you can do other than to do your best to advise them and persuade them, document that you've done so in case there's ever any question, and then leave it at that. If you have a practice manager or administrator to whom the physician is accountable or will at least listen to and respect, then they should be involved in this and they may be able to mediate if you're not able to resolve your differences in opinion. Another option is to arrange for an outside auditor to review some records and to provide some education. A physician might sometimes give more credence to an experienced professional auditor than they will to their own employee. This is never an easy situation to be in but ultimately, all you can really do is to do your job to the best of your ability, say your piece, and then stand back and let the people in charge make their decisions as to how they want to proceed, for better or worse.
I agree 100% with the advice Thomas gave. It's always a dicey situation when the provider is giving pushback and it's tough as a coder. Sometimes peer audits can help, I have often enlisted the help of physician partners to assist me with their colleagues.
The advice about outside auditors is spot on. I have been in situations where internal coders, supervisors and managers are saying the exact same thing as an outside entity yet the provider only wants to take the advice of the external party.
Usually, I would advise using denials and medical record requests from payers to show slow payment and/or no payment to the provider to support yourself, but in this case you probably aren't seeing audits or denials for these lower levels.
Like Thomas said, all you can do is your best to advise, document your advice, bring concerns to your supervisor and leave it at that. Ultimately, the provider is responsible if they want to code a certain way.