Question Data Points/Independent Vis/Test billed profee on same day

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Hello from California :cool:

Cardiology MD billed: 99214 + 93000.

List of lab results in side-header of clinic note - no mention in note of "I reviewed...".
Previously performed echo reviewed in chart, but not documented whether this MD performed/billed that previous echo or not. (would query)
EKG performed in clinic that day, read and billed by same MD.

4+ stable chronic diagnoses addressed, and nothing ordered other than the EKG which was performed and billed by MD same DOS, with 1y followup.

Audit said I should have up-coded this to a 99215 on the following grounds:

DX: 4 points (high)

Data points: 4 points (high)
EKG - 1 data point
Echo - 2 points (independent review of echo)
Labs - 1 point

Risk: Moderate


I think I misunderstand the way data points can be counted. I would not give labs a point because the MD did not document that he actually reviewed any labs.

I am confused on the EKG/echo points because I have worked under varying instructions on this topic, and I tend to agree that my prior instruction was correct: If MD bills professional fee for EKG, then they do not get a data point in their MDM as it is double dipping. Where I am even more confused is giving separate points for the echo and the EKG, as they are in the same category.

Is there an exception to give separate credit if MD performs true independent visualization as well as orders his own test in same category?
Where would I find clear direction regarding whether or not it is double dipping to bill same DOS/LOC global fee for an EKG, and then also be allowed to count data points in E/M?

Four years in and I still feel like a rookie most days! :)

Thank you so much!
 

thomas7331

True Blue
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E&M has so many grey areas and conflicting guidance between sources that if your organization does not provide you with internal guidance on how to count points and assign levels, then it's understandable how you feel. I'll just share some of my own thoughts, for what they're worth.

Regarding labs, if the MD has taken the time to copy the lab results into note, then in my mind it is self-evident that they have reviewed the information and I would not penalize them for not documenting that they reviewed them. Copying the lab results is a common practice and I've never come across a payer audit that had a problem with this. Payers these days are becoming more conscious of the administrative burdens imposed on providers and aren't going to put up a fight about extra wording in the documentation that may satisfy a coder's requirements but which adds nothing of clinical value or significance to the record itself.

You're correct that EKGs and echos both fall under the 'medicine' section, so you cannot assign separate points for each in that category (similar to labs where you cannot assign points for each different lab test) but I haven't seen anything stating that you cannot count one for the order or review and another for the independent visualization.

I don't think there is definitive guidance on whether or not you can count points for an independent visualization when the provider bills the professional component of the test. I've seen some publications that have said you can and others that say you can't, but none of these from CMS or CPT, so you may need to look at your specific payers' rules for additional guidance. My own opinion is that there is nothing wrong with counting the points because doing the interpretation and report is a different service than using that information to make a decision about the particular patient that is being treated. On the E&M level, you are reflecting the complexity of the decision making, not the work of the professional component itself. So I agree with your auditor's assignment of 4 data points here.

I'd also just add that I would absolutely not query your provider regarding whether or not they performed the previous echo. Queries are time-consuming for provider and should be saved for material deficiencies, inconsistencies and more serious errors in documentation that need to be addressed. I advise against making a query simply to clarify how many data points need to be counted - the cost of the amount of time the MD will spend on the query will likely be more than the difference in the payment between one level and the next. Since E&M is such a grey area and the financial impact in a single encounter is so low, in many cases it's best to make your decision and be prepared to defend as best you can based on your training.

Hope this helps some.
 
Last edited:

AC

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Hello from California :cool:

Cardiology MD billed: 99214 + 93000.

List of lab results in side-header of clinic note - no mention in note of "I reviewed...".
Previously performed echo reviewed in chart, but not documented whether this MD performed/billed that previous echo or not. (would query)
EKG performed in clinic that day, read and billed by same MD.

4+ stable chronic diagnoses addressed, and nothing ordered other than the EKG which was performed and billed by MD same DOS, with 1y followup.

Audit said I should have up-coded this to a 99215 on the following grounds:

DX: 4 points (high)

Data points: 4 points (high)
EKG - 1 data point
Echo - 2 points (independent review of echo)
Labs - 1 point

Risk: Moderate


I think I misunderstand the way data points can be counted. I would not give labs a point because the MD did not document that he actually reviewed any labs.

I am confused on the EKG/echo points because I have worked under varying instructions on this topic, and I tend to agree that my prior instruction was correct: If MD bills professional fee for EKG, then they do not get a data point in their MDM as it is double dipping. Where I am even more confused is giving separate points for the echo and the EKG, as they are in the same category.

Is there an exception to give separate credit if MD performs true independent visualization as well as orders his own test in same category?
Where would I find clear direction regarding whether or not it is double dipping to bill same DOS/LOC global fee for an EKG, and then also be allowed to count data points in E/M?

Four years in and I still feel like a rookie most days! :)

Thank you so much!
I totally agree with you on the data! I would just add that the final decision for me (regardless of data points) would be based on the medical necessity/complexity of the encounter.
 
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