Wiki Dnr/dni

[Jenna000]

Hello,
I have a provider that wants to bill a 99215 for discussing a code status with a 90 yr old pt that is doing well and still living relatively independently. The audit tool says decision to not to resuscitate or de-escalated care because of poor prognosis. This patient is old, but I don't see that it she has a poor prognosis, I don't not believe she should be billing a 99215 or anything close to that!

Does anyone have any guidelines on this?

Thank you in advance,
Jenna

 

[thomas7331]

Discussing DNR status is listed on the audit tool only as an indicator of a high level of risk, which is only one component that goes toward determining the MDM level and is not, by itself, sufficient to assign a 99215. Even if the MDM is determined to by high (with extensive diagnoses or data reviewed), the history and/or exam would still need to be comprehensive and supported by the medical necessity of the patient's presenting problem in order to qualify for a 99215. I'd also note that the E&M guidelines point out that the measures listed in the table of risk are "common clinical examples rather than absolute measures of risk", so in my opinion, it's not possible to take the DNR discussion out of the context of the entire note to be able to make an accurate assessment of the risk element that is reflected in the visit.

 

[Pathos]

I agree with thomas7331, suggesting that "poor prognosis" = "DNR" alone is not enough to argue for a 99215. Even if documentation supports a DNR, documentation still needs to support either a High Diagnosis/Management Options or Amount of Data. History or Examination would also need to be Complete/Comprehensive in order to bill a 99215.

I caution you to not suggest a code which cannot be supported by documentation (which sounds like you are concerned about too), and watch out for upcoding (billing a higher code than what documentation supports). I get that providers are increasingly pressured by practice managers/directors to increase revenue, however you do not want to be on the receiving end of audits that will negatively affect your practice.

Let me leave the CMS E/M guidelines for your reference.

Hope this helps, if not ask again. Happy Monday!