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E/M High Level Office Visits-99205 and 99215

M

mskitaly09

Networker
Messages
29
Location
Greensboro, NC
I have a provider that is steadily going up on her office visits to high level visit of 99215 but the documentation does not support it. The provider has added an addendum in hopes it would help in supporting on what is billed. I recommended to use a time statement since the provider is taking a long time with these visits. The provider refuses to use a time statement and think her documentation alone is supported by the code being coded/billed. Below is an example, please review and advise if the audit finding is correct.

Auditing Finding:
Patient Type: Established patient
Provider Billed: 99215
Medical Decision Making Elements:
  1. Number of problems addresses: 1 or more chronic illnesses=MODERATE
  2. Data: 3 ordered labs=MODERATE
  3. Risk: Prescription drug management=MODERATE
Audit Finding: MDM supports code: 99214
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mskitaly09 said:
I have a provider that is steadily going up on her office visits to high level visit of 99215 but the documentation does not support it. The provider has added an addendum in hopes it would help in supporting on what is billed. I recommended to use a time statement since the provider is taking a long time with these visits. The provider refuses to use a time statement and think her documentation alone is supported by the code being coded/billed. Below is an example, please review and advise if the audit finding is correct.

Auditing Finding:
Patient Type: Established patient
Provider Billed: 99215
Medical Decision Making Elements:
  1. Number of problems addresses: 1 or more chronic illnesses=MODERATE
  2. Data: 3 ordered labs=MODERATE
  3. Risk: Prescription drug management=MODERATE
Audit Finding: MDM supports code: 99214
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Click to expand...


That addendum is really generic. It looks like something that came out of a textbook rather than something specific to the patient's encounter. It doesn't add any justification to support a level 5 for this specific patient on this specific encounter, IMO.

The rest of the note does not support a Level 5 either.

Number And Complexity of Problems Addressed: Moderate - 2 or more stable chronic illnesses.

The physician has documented all of the chronic conditions as stable. The note doesn't support High MDM:

• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
• 1 acute or chronic illness or injury that poses a threat to life or bodily function

Again, the physician documented everything as stable. Seems pretty cut and dried to me.


Risk: Moderate could be justified for prescription drug management. Nothing documented in the note supports high patient-specific risk for this encounter.

Data: I see part of a lab table towards the end - did the physician order those labs? I guess it doesn't necessarily matter because 2 of 3 elements are already Moderate.


If the physician spends a lot of time on these visits, then they're shortchanging themselves by not documenting time.

If the patient wasn't actually stable at the visit, then why didn't they clearly document what was going on with the patient and the physician's thought process to support a higher level of MDM?


Anyhow, that's my super quick review based on what you've shared here. I agree with the audit that the documentation supports a Level 4, not a Level 5.
 
It might also be helpful to educate the provider on what "risk" means in terms of MDM and E/M levels.

Risk of Complications and/or Morbidity or Mortality of Patient Management - in other words, the risk of the testing/treatment/patient management being performed or recommended at this specific encounter.

The language in the addendum you posted was only about the risk of the patient having chronic conditions. The chronic conditions were already captured in the Number and Complexity of Problems Addressed column.

What's the risk of complications from the patient management done at this encounter? Show the provider examples of what might constitute high risk for E/M leveling. For example, the AMA E/M Grid gives these examples of high risk in the risk column:

High risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis


The story the documentation is telling is that the patient has stable chronic conditions that were managed with prescription refills. (And possibly some labs ordered, but that was cut off from the page.)
 
Agree with the audit finding; 4 based on MDM and documentation. Agree with what Susan said about the story in this note. Also, agree, if the provider refuses to code by time when time is the main driver and they would meet the time requirement of the E/M, they are doing themselves a disservice. Cloned statement (which is probably in every single chart) does not fly. Red flag. The "addendum" also does not have the required initials, or date/name time of the addendum or amendment (from the snip, unless it is somewhere in the full note). You can't just copy and paste and slap on the same "addendum" to try and justify a level 5 on every visit. https://palmettogba.com/jmb/did/94dlv84552?cat=jmb-evaluation-and-management-em https://palmettogba.com/jmb/did/98efvb2528?cat=jmb-evaluation-and-management-em
"Maybe" G2211
 
sls314 said:
That addendum is really generic. It looks like something that came out of a textbook rather than something specific to the patient's encounter. It doesn't add any justification to support a level 5 for this specific patient on this specific encounter, IMO.

The rest of the note does not support a Level 5 either.

Number And Complexity of Problems Addressed: Moderate - 2 or more stable chronic illnesses.

The physician has documented all of the chronic conditions as stable. The note doesn't support High MDM:

• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
• 1 acute or chronic illness or injury that poses a threat to life or bodily function

Again, the physician documented everything as stable. Seems pretty cut and dried to me.


Risk: Moderate could be justified for prescription drug management. Nothing documented in the note supports high patient-specific risk for this encounter.

Data: I see part of a lab table towards the end - did the physician order those labs? I guess it doesn't necessarily matter because 2 of 3 elements are already Moderate.


If the physician spends a lot of time on these visits, then they're shortchanging themselves by not documenting time.

If the patient wasn't actually stable at the visit, then why didn't they clearly document what was going on with the patient and the physician's thought process to support a higher level of MDM?


Anyhow, that's my super quick review based on what you've shared here. I agree with the audit that the documentation supports a Level 4, not a Level 5.
Click to expand...
I go by the E/M guidelines, AMA MDM chart, and Codify- E/M Calculator when doing my audits. Thank you so much for your feedback.
 
amyjph said:
Agree with the audit finding; 4 based on MDM and documentation. Agree with what Susan said about the story in this note. Also, agree, if the provider refuses to code by time when time is the main driver and they would meet the time requirement of the E/M, they are doing themselves a disservice. Cloned statement (which is probably in every single chart) does not fly. Red flag. The "addendum" also does not have the required initials, or date/name time of the addendum or amendment (from the snip, unless it is somewhere in the full note). https://palmettogba.com/jmb/dYou can't just copy and paste and slap on the same "addendum" to try and justify a level 5 on every visit.id/94dlv84552?cat=jmb-evaluation-and-management-em https://palmettogba.com/jmb/did/98efvb2528?cat=jmb-evaluation-and-management-em
"Maybe" G2211
Click to expand...
Thank you for your feedback and the references.
 
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