Wiki Does this chart note qualify for E/M upcoding?

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ollielooya

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Help determining E/M level please… I have come up with 99214 and would like to know if improved documentation might elevate this to 99215 based on E/M time factor coding or am I caught in the crack by it not being the 40 minutes necessary? OR, am I back to 99214? Help, please!

HPI = comprehensive (location, timing, modifiying factors, associated signs and conditions;
ROS = 2 (Neuro), Const. OR Psych (which one would be correct?) =DETAILED
PFSH = DETAILED
PE = EPF

Summation: Comprehensive + ROS (DET) + PFSH/DETAILED = DETAILED
Examination = EPF
MDM = Moderate + (data) ??? Moderate (how many points can be found in this chart note?) + Risk (moderate) = 99214. Do I even need to be concerned about this when coding based on time?
My conclusion is that IF doctor spent more than 50% of the time in C&C and documented it as such, a 99215 could be assigned. An additional Prolonged Service Code would NOT be justified. Can I get experienced E&M coders to comment? Are there any shortcut factors here that can be immediately determined to arrive at this upper level coding? ---Suzanne, CPC-A
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The patient reports she continues to have daily pain localized to the neck region. The pain may spread to the head and is on a continuous basis. He has been using occasional Percocet. Patient denies any withdrawal symptoms and indicates his mood has been stable. The pain may spread to the vertex.

PHYSICAL EXAMINATION:
Patient is alert and oriented with fluent speech and intact verbal comprehension. Extraocular movements are intact. Pupils are equal, round and reactive to light. Fundi are sharp with flat discs, and no papilledema is noted. No postural tremor is present. There are spasms in the trapezii. There is tenderness in the cervical facet region and spasms in trapezeii.

Diagnosis List:
Chronic migraine headaches without aura
.DX: Cervical facet syndrome
.DX: Cervicogenic headaches
Reported cancer of vocal cords
Depression
Anxiety
Cerebral aneurysms

I advised the patient to follow up with a pain specialist regarding cervical facet blocks. I had a long discussion with the patient regarding the different etiologies and presentation of his headaches.
I advised him to discontinue Advil and try Naprelan. He may try muscle relaxants and samples of Amrix and Skelaxin were provided.

Patient was advised to schedule follow up in three weeks.
Total face-to-face contact time with patient was about 35 minute
(Rx list follows of past and current medication)
 
no you may not upcode the visit it would need to be in excess of 45 minutes, whenyou have the documentation to support upcoding, the the level is based on the time spent, in your case 35 minutes is less than a level 5.
 
The documentation you presented does not support level 5 E/M. If you do code level 5, when the EOB arrives the insurance payor will want documentation to support the higher level code or no pay. Then what do you do? You have already wasted time and your physician may not get paid at all.
As you were advised by other the coder with CPC-H, don't go there.
You should not code with the mindset of trying to make more money for the physician you work for. This is basic E/M. You should not overcode or undercode. The E/M is based on contributing factors and must be done correctly. Go to your CPT book and read and study the section on E/M.

Best Wishes for your success,
K
 
Hi, Kay, and thank you so much for your admonition. Believe it or not, I have been intensely studying E/M behind the scenes as well as shadowing another at work. I do not want to "upcode" just to get higher revenue, as I'm well aware of the pitfalls of those actions. I am only an apprentice, hence the questions, and am passionate about learning and of course, others will read this thread and learn too. Why else would I be on here late Saturday night studying with the CPT book and 95 and 97 guidelines in front of me? (smiles)
And yes, I will follow your advice to heed to Debra, as her answers to other questions I have submitted in the past have always yielded great assistance! Thank you again for replying.
Suzanne, CPC-A
 
SUZANNE,

You are and will be a great coder because of your passion! :) I have been where you are and it is best not to over think the situation. Go with what you have in front of you. If it is not clear to you, don't hesitate to ask the doctor. After all the doctor's revenue is based on your correct coding.

Sometimes I come across too strong, but I wouldn't post if I didn't care. I do!
I don't won't new coders to have to go through what I have in the past. It can be an 'uphill climb', with no rope, so to speak.

I know you will be successful!
K
 
Coding based on time

In order to code based on time for counseling/coordination of care, three elements MUST be present.
1) total time spent face-to-face with patient
2) amount of time spent in counseling/coordination of care (must be MORE than 50% of total time)
3) summary of subject of counseling/coordination.

Your doctor has fulfilled items 1 and 3 ... but doesn't tell us how much of the total time was spent in counseling/coordination. So you cannot bill based on time at all for this note.

As for whether this would be a level 4 or a level 5 established patient (assuming all the counseling/coordination rules were met)...
I have been told by our Compliance office that we are allowed to round up based on the difference between one level and the next. What does this mean? Average time for 99214 is 25 minutes. Average time for 99215 is 40 minutes. Difference between these two times is 15 minutes. So if you have spent eight or more minutes over the 25 minutes you can round up to the next level. This would mean that as long as you had spent 33 or more minutes in direct face-to-face time, with more than half that time spent in counsling/coordination of care, you could code this as 99215.

Frankly I'm skeptical about this approach and prefer to stick to the "average" time as being the minimal amount you need to reach ... it's sure easier to figure out.

Hope that didn't confuse the issue too much.

F Tessa Bartels, CPC, CEMC
 
Tessa, you wrote, " I have been told by our Compliance office that we are allowed to round up based on the difference between one level and the next. What does this mean? Average time for 99214 is 25 minutes. Average time for 99215 is 40 minutes. Difference between these two times is 15 minutes. So if you have spent eight or more minutes over the 25 minutes you can round up to the next level. This would mean that as long as you had spent 33 or more minutes in direct face-to-face time, with more than half that time spent in counsling/coordination of care, you could code this as 99215.

Frankly I'm skeptical about this approach and prefer to stick to the "average" time as being the minimal amount you need to reach ... it's sure easier to figure out."

Ok, let's say we have a new patient documented visit with levels of service indicating an 99205 PLUS time spent was 75 minutes? Doesn't qualify for extended service code, so where can we go with this? Do I dare ask (gulp!) if we can work it backwards by downcoding to a 99204 with an extended service code? This would seem to work, but again, am very hesitant to ask....
---Suzanne
 
Prolonged or Additional time

Just noting time, in an of itself, is not enough to qualify for either prolonged service OR coding based on counseling/coordination.

Let's just talk about prolonged service. First you code the level of E/M based on the three key elements (or 2 out of 3 if it's an established patient).

Then if you have additional or prolonged time spent with the patient (at least 30 minutes) you can add the prolonged service codes. This prolonged service time can NOT include any procedures that would be separately billable. So if the time is because you're monitoring an infusion, and you're billing the infusion, that time doesn't count for prolonged service.

The doctor really should document something on the order of : I spent an additional 35 minutes in direct patient care, exclusive of procedures.

In your example, Suzanne, you state: we have a new patient documented visit with levels of service indicating an 99205 PLUS time spent was 75 minutes (emphasis added by FTB)

If the documentation really states that the physician spent an additional 75 minutes with the patient, you most certainly can use the prolonged service codes.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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