E/M coding-99214 vs 99215

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mhink693

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We have a doctor that is trying to bill 99215 on patient visits where patient is being seen say for knee osteoarthritis. Hasn’t had PT, hasn’t had injections, but has been dealing with this for a while and is now having total knee. Doctor goes over risk. He is wanting to bill 99215 and personally I think it’s so hard for a doc to get to a 99215 in ortho with no time statement. Does anyone have any good examples of what is classified as a severe exacerbation or what is qualified as a major surgery. I feel like I get conflicting answers which makes it so hard to code.
Does anybody agree? I feel ortho is so black and white.
 
I don't feel ortho is always black and white. I have seen plenty of justified level 5s. However, I have also seen every single visit being coded as a 5 which is suspect. It depends on the documentation. If every single visit is being coded as a 5, that would be questionable. If the documentation supports it, and using MDM, there is no reason for them not to code the correct level. There could be a case where it is possible a 5. What if this was a discussion of a possible TKA with a high-risk patient who has diabetes w/ high A1C, heart problems, maybe they had a hx of CABG, they are on Eliquis, they have some other chronic conditions. They are in severe pain with knee deformity, they are using a cane. They cannot perform or participate in their normal ADLs and activities. They need a disability parking pass because now they can't walk more than a short distance. The provider gives them a course of some type of pain medication while waiting for surgery, provider does extensive data review (maybe they brought in outside XR or MRI and PCP notes?), and they have to get a workup from the cardiologist, PCP, etc. Keeping in mind, all of this is DOCUMENTED in the note with the "thinking process" you can see in the note. That could be a 5.

Go back to the AMA E/M definitions: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.

Surgery (minor or major, elective, emergency, procedure or patient risk):
Surgery—Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

Resources:
This isn't the MAC for NE, however the E/M FAQ has good info: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
This is ED focused but also has good info: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
You can check in here for E/M FAQs: https://www.kzanow.com/coding-coaches/category/Orthopaedics
This has case examples ($ webinar): https://educate.kzanow.com/products...-hospitalobservation-billing-and-em-modifiers
This is from 2021 but might have help:

Take a sample of the providers notes and use an audit sheet. How does that look? Talk with the provider about it. Can you see the thinking process on "paper"? Are they doing more but it is not being captured in the documentation? Ask them to explain why and help you understand. Did they connect the dots if the patient is more complicated. A lot of those in the age group for TKAs have a lot more going on and may be higher risk for major surgery. Ask your provider their definition of major/minor (not the global days).
 
As a practicing orthopaedic surgeon, billing a level 5 for that would be completely inappropriate unless somehow based on time.
If you're billing a 5, it's because you're sending the patient to the hospital for a life or limb-threatening condition.
If the patient walked himself into clinic with a can, it ain't a "severe exacerbation" of knee arthritis.
A knee replacement is a major surgery, period. That is black and white. Lots of examples of patient-specific risk factors too, but that's just one of the three categories, and you need two at the High level to bill a 5.

This doesn't pass the sniff test. If he persists, tell him to send it to his coding reps at AAOS - they'll tell him exactly the same thing as what I am saying now.
If he wants to bill level 5, get audited, and face clawbacks, sanctions and legal action, this would be exactly the way to do it.
 
amyjph said:
I don't feel ortho is always black and white. I have seen plenty of justified level 5s. However, I have also seen every single visit being coded as a 5 which is suspect. It depends on the documentation. If every single visit is being coded as a 5, that would be questionable. If the documentation supports it, and using MDM, there is no reason for them not to code the correct level. There could be a case where it is possible a 5. What if this was a discussion of a possible TKA with a high-risk patient who has diabetes w/ high A1C, heart problems, maybe they had a hx of CABG, they are on Eliquis, they have some other chronic conditions. They are in severe pain with knee deformity, they are using a cane. They cannot perform or participate in their normal ADLs and activities. They need a disability parking pass because now they can't walk more than a short distance. The provider gives them a course of some type of pain medication while waiting for surgery, provider does extensive data review (maybe they brought in outside XR or MRI and PCP notes?), and they have to get a workup from the cardiologist, PCP, etc. Keeping in mind, all of this is DOCUMENTED in the note with the "thinking process" you can see in the note. That could be a 5.

Go back to the AMA E/M definitions: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.

Surgery (minor or major, elective, emergency, procedure or patient risk):
Surgery—Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

Resources:
This isn't the MAC for NE, however the E/M FAQ has good info: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
This is ED focused but also has good info: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
You can check in here for E/M FAQs: https://www.kzanow.com/coding-coaches/category/Orthopaedics
This has case examples ($ webinar): https://educate.kzanow.com/products...-hospitalobservation-billing-and-em-modifiers
This is from 2021 but might have help:

Take a sample of the providers notes and use an audit sheet. How does that look? Talk with the provider about it. Can you see the thinking process on "paper"? Are they doing more but it is not being captured in the documentation? Ask them to explain why and help you understand. Did they connect the dots if the patient is more complicated. A lot of those in the age group for TKAs have a lot more going on and may be higher risk for major surgery. Ask your provider their definition of major/minor (not the global days).
Click to expand...
I agree it isn’t ALWAYS black and white, but if the patient is a normally healthy patient coming in for knee osteoarthritis with planned total knee I just don’t think that can get to a 99215 unless the patient does have other issues.
Thank you for the examples and I think that’s a great YouTube video.
 
mhink693 said:
I agree it isn’t ALWAYS black and white, but if the patient is a normally healthy patient coming in for knee osteoarthritis with planned total knee I just don’t think that can get to a 99215 unless the patient does have other issues.
Thank you for the examples and I think that’s a great YouTube video.
Click to expand...
Oh yes, as always, it depends on the documentation. If it is a straight up visit w/ decision for a TKA due to knee OA, without any of the other elements, it's not a 5. I have seen where every single visit is coded as a 5 for total joint providers simply because there was a decision for surgery. Nothing else.
 
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