Wiki E/M Documentation

[kimberlydegrazia]

Can a physican bill for a Level 4 Established Patient if a physical examination was not performed? The patient's visit was mainly for discussion of lab results and assess for change. The patient refused the physical exam for that reason. HPI and MDM is sufficient for a level 4. Please help, thank you.

 

[MikeEnos]

If the provider documents a detailed history and the MDM is moderately complext, you satisfy the requirements of a 99214 by meeting or exceeding 2 of the 3 key components.

However - when you have an encounter where discussion,counseling,coordinating care dominates (>50%) the encounter, have you provider document the total length of the encounter and select the level of service based on time spent. It's easy, just document:
A) Total length of the encounter
B) Greater than half of the time was spent counseling the patient and/or caregiver(s)
C) The content of the discussion

 

[kimberlydegrazia]

Thank you Mike.

 

[maddismom]

If it is Medicare, check with your carrier. Per Noridian, all three components MUST be performed even though you are only basing your code on two of them for an established patient. Otherwise, I would go with time based coding if it meets the criteria Mike points out.

 

[drashby]

WPS Medicare is the same as Noridian - Unless time is used, all three components must be documented. Remember though, vitals is exam. So if you meet Hx and MDM and vitals are documented the level has been met.

Deb

 

[kimberlydegrazia]

Thanks Deb.

 

[mitchellde]

In a recent transmittal from Medicare regarding the use of templets and documentation CMS stated that the overarching criteria for any visit level is Medical Necessity. This was repeated time and again through all of their examples and explanations.
How I explain this to my class is, that anyone can create a level 4 or level 5 document, but the real issue is SHOULD you have performed that level given the patient's medical necessity. There must be a match between the diagnosis and the visit level. Therefore if you are using the History and the MDM to set the level then how does that match up to the medical necessity. It could be entirely logical, and then again maybe not.

 

[nyyankees]

In a recent transmittal from Medicare regarding the use of templets and documentation CMS stated that the overarching criteria for any visit level is Medical Necessity. This was repeated time and again through all of their examples and explanations.
How I explain this to my class is, that anyone can create a level 4 or level 5 document, but the real issue is SHOULD you have performed that level given the patient's medical necessity. There must be a match between the diagnosis and the visit level. Therefore if you are using the History and the MDM to set the level then how does that match up to the medical necessity. It could be entirely logical, and then again maybe not.

Excellent point. When I was at Ortho seminars medical necessity was mentioned repeatedly for E/M levels. Do you really need a Level 4 for knee pain follow up? But where I am we are submitting the claim based on what's in the note not that a comp history was not necessary for a F/U visit. I know the RACs and IOG are looking at E/M's very closely as there is a lot of money that can be recoupped.