Does 99204 = 99214 or 99215???

tmarugg

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My physician seen a previous patient in the clinic who was last seen in 2015. He selected 99204, but the claim was denied stating new patient qualifications were not met. When I asked him about this, he stated it was an error on his part because he thought it was 2 years not 3 years when deciding new vs. established. So now I need to submit a corrected claim.

I watched an E/M leveling video on YouTube recently and now I'm wondering how do I go about selecting the correct established patient code. I don't feel like just switching to 99214 would be correct (maybe I'm overthinking it)

99204 = comprehensive history, comprehensive exam, & mdm is moderate, 45 mins
99214 = detailed history, detailed exam, & mdm is moderate, 25 mins
99215 = comprehensive history, comprehensive exam, & mdm is high, 40 mins

My gut says it should be 99215.

Thanks in advance!!!
Tammy
 

ellzeycoding

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For new patient visits, you need to meet ALL THREE key components to meet the level of care. History, Exam, and Medical Decision Making

For established patients, you only need to meet TWO of the three key components. So you could end up doing slightly less.

From a key critera requirement perspective...

99204 - (History - 4+ History of Present Illness items, 10+ Review of Systems, 3 of 3 Past/Family/Social History items), (Exam = Comprehensive), (Medical Decision Making/Risk = High)

99215 - (History - 4+ History of Present Illness items, 10+ Review of Systems, 3 of 3 Past/Family/Social History items), (Exam = Comprehensive), (Medical Decision Making/Risk = High)


So yes, they are technically the same, but for the 99215, you can do just two key components History and Exam, or History and MDM, or Exam and MDM.
 

ellzeycoding

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Also, one small difference... if coding based on time, when more than 50% of the encounter is spent counseling the patient (and documented), the requirements are slightly different

99204 = 45 minutes
99215 = 40 minutes
 

tmarugg

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For new patient visits, you need to meet ALL THREE key components to meet the level of care. History, Exam, and Medical Decision Making

For established patients, you only need to meet TWO of the three key components. So you could end up doing slightly less.

From a key critera requirement perspective...

99204 - (History - 4+ History of Present Illness items, 10+ Review of Systems, 3 of 3 Past/Family/Social History items), (Exam = Comprehensive), (Medical Decision Making/Risk = High)

99215 - (History - 4+ History of Present Illness items, 10+ Review of Systems, 3 of 3 Past/Family/Social History items), (Exam = Comprehensive), (Medical Decision Making/Risk = High)


So yes, they are technically the same, but for the 99215, you can do just two key components History and Exam, or History and MDM, or Exam and MDM.

So if for the established patient, 2 of the 3 are met, I can bill the 99215?
 

ellzeycoding

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As long as you documented and met all elements for 2 of the 3 key components, yes you can.

And make sure that the elements are relevent to the chief complaint.
 

valleycoder

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Medicare says medical necessity is the overarching criteria, not quantity of documentation. If the medical decision making is moderate, i'd stick with a 99214.
 
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