Wiki Coding Level Limits

[mlemon]

Has anyone ever heard of coding level limits as far as Medicare patients are concerned?

I have a physician who states he was informed that Medicare only allows a certain amount of level 4 e/m codes and level 5 e/m codes during a certain time period and anything after that is a red flag for an audit.

Has anyone ever heard of anything like this?

Thanks in advance.

 

[ARCPC9491]

I think your provider may be misinterpreting.

Medicare has a profile for each provider who submits claims to Medicare. They track the E/M productivity and compare against other providers in the same specialty in your area. If it goes off the mark, at all, they send out a letter stating they need to take an E/M online course. I think it's a scare tactic -- not a true threat for an audit. Lots of my physicians have gotten those letters and I tell them to throw it away. It's not mandatory and how can they suggest a class when they haven't even looked at the records? that's rediculous. I had one physician who stopped seeing new patients all together in 2007, but evidently he did see a single 99204 -- and he got a letter stating that his level 4's are at 100%. It's all based on numbers not what the actual documentation says, they don't even look at the records.

Always, always, always code the level of evaluation and management that supports the documentation! Even if it does end up being 50 99215's in a month.

Hope that helps..

 

[RebeccaWoodward*]

I've never heard of "coding limits". With that said... Medicare creates a bell curve for each specialty. They compare this information with other regions of the same specialty. Medicare uses this bell curve to track provider coding to determine if their is a pattern of under/over coding. Statistically, this can produce unwarranted audits (or so in my opinion). Depending on the type of specialty, type of patient (i.e. geriatrics), it's plausible to have a spike in higher E/M levels due to the patient's comorbidities. However, I understand why Medicare utilizes this methodology. There are providers that will abuse the system.

Just my two cents~

 

[RNCPC0709]

I think your provider may be misinterpreting.

Medicare has a profile for each provider who submits claims to Medicare. They track the E/M productivity and compare against other providers in the same specialty in your area. If it goes off the mark, at all, they send out a letter stating they need to take an E/M online course. I think it's a scare tactic -- not a true threat for an audit. Lots of my physicians have gotten those letters and I tell them to throw it away. It's not mandatory and how can they suggest a class when they haven't even looked at the records? that's rediculous. I had one physician who stopped seeing new patients all together in 2007, but evidently he did see a single 99204 -- and he got a letter stating that his level 4's are at 100%. It's all based on numbers not what the actual documentation says, they don't even look at the records.

Always, always, always code the level of evaluation and management that supports the documentation! Even if it does end up being 50 99215's in a month.

Hope that helps..

I agree, especially with the last part. As long as your provider is documenting appropriately and the documentation supports the code, I would not be worried about this..........

*************************
PB

 

[mlemon]

Thank you for your comments! I explained that to him earlier but he insisted that he had received a memo stating something different. So I was just checking.

Thanks again!